This document provides an outline and overview of newer oral anticoagulants (NOACs). It discusses the types of NOACs including dabigatran, rivaroxaban, and apixaban. It describes the properties, indications, dosing, and results of clinical trials comparing each NOAC to warfarin for preventing strokes in atrial fibrillation and for treating deep vein thrombosis. The document concludes that NOACs have advantages over warfarin such as fewer drug interactions and no need for regular monitoring, though they have slightly higher risks of gastrointestinal bleeding.
Anticoagulation expanding steadily over the past few decades.
In addition to Heparins and vitamin K antagonist, other anticoagulants that directly target the enzymatic activity of thrombin and factor Xa have been developed.
there are several limitation in VKA,to over come these problem NOACs came in picture but still limited indication for NOACs currently,required further study inter and intra comparison between anticoagulants.
Anticoagulation expanding steadily over the past few decades.
In addition to Heparins and vitamin K antagonist, other anticoagulants that directly target the enzymatic activity of thrombin and factor Xa have been developed.
there are several limitation in VKA,to over come these problem NOACs came in picture but still limited indication for NOACs currently,required further study inter and intra comparison between anticoagulants.
Newer Oral Anticoagulant in Chronic Kidney DiseaseAbdullah Ansari
Kidney specific mechanisms leading to atrial fibrillation
Possible mechanism of CKD progression in atrial fibrillation
Atherosclerosis Risk in Communities (ARIC) study
Guidelines
Pulmonary embolism & deep vein thrombosis
Nephrotic syndrome
Problems with Vit K antagonists in CKD
Non Vit K oral anticoagulants
Site of action of NOACs and VKAs
Pharmacology of Direct Oral Anticoagulants
Trials for NOACs
Dose NOACs according to renal function
Laboratory monitoring of NOACs
Anticoagulant reversal of NOACs
Ponencia presentada por el Dr. Raúl Moreno Gómez en el directo online ‘Anticoagulación de cine en el paciente mayor’, realizado el 13 de febrero de 2020 en la Casa del Corazón.
Direct oral anticoagulants (DOACs) have quickly become attractive alternatives to the long‐standing standard of care in anticoagulation, vitamin K antagonist. DOACs are indicated for prevention and treatment of several cardiovascular conditions. Since the first approval in 2010, DOACs have emerged as leading therapeutic alternatives that provide both clinicians and patients with more effective, safe, and convenient treatment options in thromboembolic settings. With the expanding role of DOACs, clinicians are faced with increasingly complex decisions relating to appropriate agent, duration of treatment, and use in special populations. This review will provide an overview of DOACs and act as a practical reference for clinicians to optimize DOAC use among common challenging scenarios. Topics addressed include (1) appropriate indications; (2) use in patients with specific comorbidities; (3) monitoring parameters; (4) transitioning between anticoagulant regimens; (5) major drug interactions; and (6) cost considerations.
Direct oral anticoagulants (DOACs)—dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), edoxaban (Savaysa), and betrixaban (Bevyxxa) are anticoagulation pharmacotherapy used for the prevention of thrombosis in several cardiovascular contexts.1 DOACs are categorized into 2 main classes: oral direct factor Xa inhibitors (ie, rivaroxaban, apixaban, edoxaban, and betrixaban) and direct thrombin inhibitors (ie, dabigatran). In 2010, the US Food and Drug Administration (FDA) approved its first DOAC, dabigatran, followed by rivaroxaban, apixaban, edoxaban, and betrixaban in the following years. DOACs are relatively new agents demonstrating superiority or noninferiority to prior standards of care, anticoagulation with vitamin K antagonists (VKA; ie, warfarin), or low‐molecular‐weight heparins (LMWHs), in reducing risk of thromboembolic complications with similar or reduced bleeding risk.2, 3, 4, 5 Advantages of DOACs compared with VKAs include fewer monitoring requirements, less frequent follow‐up, more immediate drug onset and offset effects (important for periprocedural and acute bleeding management), and fewer drug and food interactions.6 As a result, DOAC prescriptions exceeded those for warfarin by 2013, with apixaban being the most frequently prescribed DOAC for patients with nonvalvular atrial fibrillation (NVAF).7
Over the past decade, DOACs have been the subject of extensive investigation in many clinical scenarios. Though guidelines and review articles have provided detailed and in‐depth analyses of the immense literature base, these can be too cumbersome and challenging to integrate into everyday clinical use
In general, FDA‐approved indications for each of the DOACs are comparable (see Table 1). Dabigatran, rivaroxaban, apixaban, and edoxaban are approved for the lowering the risk of stroke and embolism in NVAF as well as deep vein thrombosis and pulmonary embolism treatment/prophylaxis.8, 9, 10, 11 Unique indications
- Describe the basic characteristics of new oral anticoagulants (OACs)
- Recognize potential candidates for new anticoagulants for atrial fibrillation and treatment of venous thrombosis
Newer Oral Anticoagulant in Chronic Kidney DiseaseAbdullah Ansari
Kidney specific mechanisms leading to atrial fibrillation
Possible mechanism of CKD progression in atrial fibrillation
Atherosclerosis Risk in Communities (ARIC) study
Guidelines
Pulmonary embolism & deep vein thrombosis
Nephrotic syndrome
Problems with Vit K antagonists in CKD
Non Vit K oral anticoagulants
Site of action of NOACs and VKAs
Pharmacology of Direct Oral Anticoagulants
Trials for NOACs
Dose NOACs according to renal function
Laboratory monitoring of NOACs
Anticoagulant reversal of NOACs
Ponencia presentada por el Dr. Raúl Moreno Gómez en el directo online ‘Anticoagulación de cine en el paciente mayor’, realizado el 13 de febrero de 2020 en la Casa del Corazón.
Direct oral anticoagulants (DOACs) have quickly become attractive alternatives to the long‐standing standard of care in anticoagulation, vitamin K antagonist. DOACs are indicated for prevention and treatment of several cardiovascular conditions. Since the first approval in 2010, DOACs have emerged as leading therapeutic alternatives that provide both clinicians and patients with more effective, safe, and convenient treatment options in thromboembolic settings. With the expanding role of DOACs, clinicians are faced with increasingly complex decisions relating to appropriate agent, duration of treatment, and use in special populations. This review will provide an overview of DOACs and act as a practical reference for clinicians to optimize DOAC use among common challenging scenarios. Topics addressed include (1) appropriate indications; (2) use in patients with specific comorbidities; (3) monitoring parameters; (4) transitioning between anticoagulant regimens; (5) major drug interactions; and (6) cost considerations.
Direct oral anticoagulants (DOACs)—dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), edoxaban (Savaysa), and betrixaban (Bevyxxa) are anticoagulation pharmacotherapy used for the prevention of thrombosis in several cardiovascular contexts.1 DOACs are categorized into 2 main classes: oral direct factor Xa inhibitors (ie, rivaroxaban, apixaban, edoxaban, and betrixaban) and direct thrombin inhibitors (ie, dabigatran). In 2010, the US Food and Drug Administration (FDA) approved its first DOAC, dabigatran, followed by rivaroxaban, apixaban, edoxaban, and betrixaban in the following years. DOACs are relatively new agents demonstrating superiority or noninferiority to prior standards of care, anticoagulation with vitamin K antagonists (VKA; ie, warfarin), or low‐molecular‐weight heparins (LMWHs), in reducing risk of thromboembolic complications with similar or reduced bleeding risk.2, 3, 4, 5 Advantages of DOACs compared with VKAs include fewer monitoring requirements, less frequent follow‐up, more immediate drug onset and offset effects (important for periprocedural and acute bleeding management), and fewer drug and food interactions.6 As a result, DOAC prescriptions exceeded those for warfarin by 2013, with apixaban being the most frequently prescribed DOAC for patients with nonvalvular atrial fibrillation (NVAF).7
Over the past decade, DOACs have been the subject of extensive investigation in many clinical scenarios. Though guidelines and review articles have provided detailed and in‐depth analyses of the immense literature base, these can be too cumbersome and challenging to integrate into everyday clinical use
In general, FDA‐approved indications for each of the DOACs are comparable (see Table 1). Dabigatran, rivaroxaban, apixaban, and edoxaban are approved for the lowering the risk of stroke and embolism in NVAF as well as deep vein thrombosis and pulmonary embolism treatment/prophylaxis.8, 9, 10, 11 Unique indications
- Describe the basic characteristics of new oral anticoagulants (OACs)
- Recognize potential candidates for new anticoagulants for atrial fibrillation and treatment of venous thrombosis
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
2. TOPIC OUTLINE
NEWER ORAL ANTICOAGULANTS
⚫Introduction
⚫Types of NOAC s and theirproperties
⚫Advantagesof NOAC soverVKA
⚫Start-upand follow-upscheme forpatientson NOACS
⚫How to measure theanticoagulanteffect of NOACs
⚫How to deal with dosing errors and management of
bleeding complicationswhen itoccurs.
⚫How to switch between various anticoagulant
regimens.
3. SPECIAL SITUATIONS
NEWER ORAL ANTICOAGULANTS
⚫patients undergoing a planned surgical intervention or
ablation.
⚫patients undergoing an urgentsurgical intervention.
⚫patientswith AF and coronary arterydisease.
⚫NOACsvs. VKAs in AF patientswith a malignancy.
4. Introduction
NEWER ORAL ANTICOAGULANTS
⚫Vitamin K antagonists (VKAs) are the mainstay of
management of thromboembolicevents for > 5decades.
⚫Despite its unquestionable impact to prevent strokes, they
have significant limitations, such us common drug or food
interactions, and the necessity of regular monitoring to
adjust doses, inter personal variation in response.
14. Indications for NOAC s
NEWER ORAL ANTICOAGULANTS
⚫Prevention of arterial thromboembolic events in non-
valvular atrial fibrillation and VTE prophylaxis
following hipand knee-replacementsurgery –
DABIGATRAN ,RIVAROXABAN, APIXABAN.
⚫Treatmentof deepvein thrombosis - RIVAROXABAN
15. Dabigatran Etexilate
NEWER ORAL ANTICOAGULANTS
⚫Dabigatran etexilate, a prodrug of dabigatran, which
reversibly inhibits both freeand clot bound thrombin,
⚫It has an oral bioavailabilityof 6%.
⚫After oral administration, dabigatran etexilate is rapidly and
completelyconverted todabigatran byesterases.
⚫Plasma levels of dabigatran peak 2 hours after drug
administration.
⚫Dabigatran has a half-life of 14 to 17 hours, which permits
once- or twice-daily administration, and 80% of the drug is
excreted unchanged by the kidneys.
16. ⚫Coadministration of dabigatran etexilate and
amiodarone,verapamil, quinidine,dronedarone - strong P-
gp inhibitors, increases dabigatran levels.
⚫It shouls be taken with food or water to minimise
dyspepsia.
⚫If a dose is missed it should be taken within 6 hours.
NEWER ORAL ANTICOAGULANTS
18. DOSE REGIMEN
NEWER ORAL ANTICOAGULANTS
⚫foracuteVTE: 150 mgBID;
⚫for VTE prevention after knee or hip replacement
surgery (14 or 30 days, respectively): 110 mg (initial
dose) then 220 mg daily.
⚫COMMON SIDE EFFECTS –
⚫Indigestion, upsetstomach, or burning ,stomach pain
⚫Allergic reaction, including hives, rash, and itching
⚫Bleeding
19. ⚫The RE-LY (Randomized Evaluation of Long-term
anticoagulant therapY with dabigatran etexilate) phase III
trial was a prospective, randomized, open-label trial
comparing two blinded doses of dabigatran etexilate (110 or
150 mg BID) with warfarin in 18,113 patients with AF and at
least one additional risk factor (a mean CHADS score of
2.1).
NEWER ORAL ANTICOAGULANTS
20. RESULTS
NEWER ORAL ANTICOAGULANTS
⚫150 mg BID dose – superior to warfarin for reduction of
strokeand systemicembolism with similar major bleeding.
⚫110 mg BID dose – non inferior to warfarin for SSE but with
significant lower bleeding rates.
⚫ICH is significantly low with both doses .
21. RELY-ABLE
NEWER ORAL ANTICOAGULANTS
Assessed the Additional information on the long-term
effects of the two doses of dabigatran in patients
completing RE-LY by extending the follow-up of patients
on dabigatran from a mean of 2 years at the end of RE-LY
byan additional 2.3 years.
RELY-ABLE confirmed the results reported in RE-LY.
Conclusions—During 2.3 years of continued treatment
with dabigatran after RE-LY, there was a higher rate of
major bleeding with dabigatran 150 mg twice daily in
comparison with 110 mg, and similar rates of stroke and
death.
22. VTE trials
NEWER ORAL ANTICOAGULANTS
⚫RECOVER and REMEDY–
Non inferior towarfarin in VTE prevention (2.4% vs
2.1%)
Nodiffrerences in major bleeding.
23. RIVAROXABAN
NEWER ORAL ANTICOAGULANTS
⚫It has an oral bioavailabilityof 80%.
⚫Rivaroxaban has a rapid onset of action and a half-life of 7
to 11 hours.
⚫Rivaroxaban has a dual mode of elimination; one third is
cleared as unchanged drug via the kidneys, one third is
metabolized by the liver via CYP3A4-dependent and -
independent pathways with the metabolites then excreted
in the feces, and one third is metabolized in the liver with
the inactive metabolites then eliminated via the kidneys.
24. ⚫Rivaroxaban
NEWER ORAL ANTICOAGULANTS
is a substrate for P-gp, and concomitant
administration of potent inhibitors
CYP3A4, such as ketoconazole
of both P-gp and
or ritonavir, is
contraindicated because they increase plasmadrug levels.
⚫There is only a minor interaction between Rivaroxiban and
verapamil unlikedabigatran and edoxaban.
⚫Co adminstration of FLUVASTATIN or ROSUVASTATIN
with thisdrug does not need dose reduction of rivaroxiban.
27. DOSE REGIMEN-
NEWER ORAL ANTICOAGULANTS
⚫for acute VTE: 20 mg daily (15 mg twice daily for initial 21
days);
⚫for VTE prevention after knee or hip replacement surgery
(14 or 30 days, respectively): 10 mg daily
28. ROCKET AF
NEWER ORAL ANTICOAGULANTS
⚫ The ROCKET AF was a double-blinded study in which 14,264 patients
with non-valvularAF and CHADS2 scores ≥2 (mean 3.5) werestudied.
⚫ After a median follow-up of 1.93 years, rivaroxaban was noninferior to
warfarin forthepreventionof stroke orsystemicembolism.
⚫ There were no differences in the risk of major bleeding, although
intracranial and fatal bleeding occurred less frequently in the rivaroxaban
group.
⚫ Gastrointestinal bleeding and transfusion requirements were greater
with rivaroxaban.
⚫ Total mortalitywas notsignificantlydifferent between groups.
29. ⚫ATLAS : Background - Acute coronary syndromes arise
from coronary atherosclerosis with superimposed
Since factor Xa plays a central role in
the inhibition of factor Xa with low-dose
thrombosis.
thrombosis,
rivaroxaban might improve cardiovascular outcomes in
patientswith a recentacute coronary syndrome.
NEWER ORAL ANTICOAGULANTS
30. ⚫ ATLAS ACS 2-TIMI 51 trial compared rivaroxaban 2.5 mg or 5 mg
twice daily (unlike the 20 mg once-daily dose for atrial fibrillation)
with placebo in 15 526 patients following ACS.
⚫ At a mean follow-up of 13 months, the primary efficacy endpoint of
CV death, MI or stroke was 10.7% with placebo, 9.1% with
rivaroxaban 2.5 mg and 8.8% with rivaroxaban 5mg with no
interaction by ACS subtype.
⚫ Rates of definite, probable or possible stent thrombosis were 2.2%
and 2.3% with 2.5 and 5 mg rivaroxaban, respectively, vs. 2.9% with
placebo .
⚫ Rates of CV death were signifi cantly lower with rivaroxaban 2.5 mg
compared with placebo but notwith rivaroxaban 5 mg (4.0%).
NEWER ORAL ANTICOAGULANTS
31. ⚫Non-CABG major bleeds occurred in 1.8% and 2.4% with 2.5
and 5 mg rivaroxaban, respectively, compared with 0.6% with
placebo.
⚫Intracranial haemorrhage rates were 0.4% with 2.5 mg and
0.7% with 5 mg rivaroxaban vs. 0.2% with placebo.
⚫The use of rivaroxaban 2.5 mg twice daily, might be
considered in combination with aspirin and clopidogrel if
ticagrelor and prasugrel are not available for NSTEMI
patients who have high ischaemicand low bleeding risks
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32. CONCLUSION -
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⚫In patients with a recent acute coronary syndrome,
rivaroxaban reduced the risk of the composite end point of
death from cardiovascular causes, myocardial infarction, or
stroke.
⚫Rivaroxaban increased the risk of major bleeding and
intracranial hemorrhage but not the risk of fatal bleeding.
33. VTE trials
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⚫EINSTEIN DVT – non inferior to warfarin for DVT(2.1% vs
3%) with similar bleeding risk.
⚫EINSTEIN PE – non inferior to warfarin for PE with loer
bleeding risk than warfarin.
⚫EINSTEIN EXTENSION – similarresults.
34. Apixaban
NEWER ORAL ANTICOAGULANTS
⚫Apixaban is a direct, reversible, competitive, and selective
inhibitor of factor Xa and the last NOAC approved by the
FDA and EMA for the prevention of stroke and embolism
in non-valvular AF.
⚫It is well absorbed achieving peak plasma concentration in
1–4 h.
⚫It is predominantly metabolized in liver.
⚫It is a mild P- glycoprotein inhibitor.
⚫Compared to other NOACS it has least bleeding
complications and greaterefficacy
.
37. ARISTOTLE
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⚫ The Apixaban for Reduction In STroke and Other ThromboemboLic
Events in AF (ARISTOTLE) compared apixaban (5 mg BID) with dose-
adjusted warfarin in 18,201 patients with non-valvular AF (a mean
CHADS2 scoreof2.1).
⚫ After amean followup of 1.8 years, apixaban was significantly better
than warfarin, with fewer primary outcomes (overall strokes and
systemic emboli), but with no significant differences in rates of
ischaemicstrokes.
⚫ Patients treated with apixaban had significantly fewer intracranial
bleeds, but GI bleedingsweresimilar between bothgroups.
⚫ All-cause mortality was found to be significantly lower in the apixaban
group.
38. ⚫Apixaban was also compared with aspirin alone in the
AVERROES study, a double-blinded study of 5599 patients
who were not suitable candidates for VKA treatment (mean
CHADS2 score of 2).
⚫After a mean follow-up of 1.1 years, the study was
prematurely stopped due to a clear benefit in favour of
apixaban.
⚫Patients with severe renal impairment (serum
creatinine.2.5 mg/dL or CrCl ,25 mL/min) were excluded
from the ARISTOTLE and AVERROES trials.
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39. APPRAISE
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⚫The Apixaban for Prevention of Acute Ischaemic Events
(APPRAISE) 2 study assessed the effects of the oral factor
Xa inhibitor apixaban 5 mg twice daily compared with
placebo, in addition to standard-of-care antiplatelet
therapy following ACS;
⚫It was terminated early (median 8 months) due to a
markedly increased risk of severe bleeds, including
intracranial haemorrhage, without any apparent benefit in
terms of ischaemicevents
40. Edoxaban
NEWER ORAL ANTICOAGULANTS
⚫Edoxaban is another reversible factorXainhibitor, recently
approved by theFDA but not yet by the EMA.
⚫It is rapidly absorbed and reaches peak plasma
concentration within 1–2 h.
⚫Up to 50% of edoxaban is eliminated by the kidneys and
rest through multiplepathways.
⚫It is also a substrate for P-glycoprotein-concomitant
administration with quinidine, amiodarone, and verapamil
will result in a significant increase of plasma levels of
edoxaban.
⚫Therefore, in patients under concomitant use of potent
glycoprotein inhibitors , body weight < 60 kg, or moderate–
severe renal impairment (CrCl < 50 mL/min), edoxaban
dose should be reduced by 50%.
43. ENGAGE AF-TIMI
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Generation in Atrial Fibrillation–Thrombolysis
⚫The Effective Anticoagulation with Factor Xa Next
in
Myocardial Infarction (ENGAGE AF-TIMI 48) compared
the two dose regimens of edoxaban (30 and 60 mg once
daily) with warfarin in a total of 21,026 patients with non-
valvular AF.
⚫After a follow-up of 2.8 years, both regimens of edoxaban
were non-inferior to warfarin with respect to the
prevention of stroke or systemic embolism.
44. ⚫Edoxaban was associated with lower, dose-related rates of
bleeding, including major bleeding, intracranial bleeding,
and life-threatening bleeding.
⚫GI bleeding - occurred more frequently with high-dose
edoxaban but less frequently with low-dose edoxaban
compared with warfarin.
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45. ⚫Finally, the incidence rate of haemorrhagic stroke and the
rate of death from cardiovascular causes were significantly
lowerwith both edoxaban regimens.
⚫Patients with severe renal dysfunction (CrCl < 30 mL/min),
high risk of bleeding, use of dual antiplatelet, acute
coronary syndromes or coronary revascularization, and
strokes within 30 days wereexcluded.
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46. ⚫HOKUSAI VTE – in DVT it is non inferior to warfarin and
in PE it is superior to warfarin with similar bleeding risk in
both conditions.
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47. OTHER fXa inhibitors
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⚫Theseare betrixaban, YM150, and TAK442.
⚫Betrixaban has the unique features of a 15-hour half-life
and extrarenal clearance.
⚫Betrixaban and YM150 are undergoing phase II evaluation
for stroke prevention in AF, whereas TAK442 is undergoing
phase II evaluation for prevention of recurrent ischemia in
ACS patients.
48. CONCOMITANT USE OF NOAC and
DIGOXIN
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⚫Digoxin is a P-glycoprotein inhibitorand commonly
used drug in AF.
⚫But there is clinically relavent interaction between
digoxin and NOACS.
49. Comparison between new oral
anticoagulants
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⚫There no direct head-to-head comparisons between these
drugs.
⚫NOACs have been made in randomized, controlled trials,
and extrapolation from primary trial data is the best
available strategy for medical prescription.
⚫However, due to differences in trial design, in the estimated
risk for stroke in the study population, comparator
uniformity, and definitions of efficacy and safety endpoints
makecomplex direct comparisons.
50. ⚫Comparative analysis of the four NOACs confirmed that
NOACs significantly reduced the composite of stroke or
systemic embolic events by 19% compared with warfarin,
which very much depended on large reduction in
haemorrhagicstrokes.
⚫Data for all four NOACS showed that they were associated
with a 14% non-significant reduction in major bleedings.
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54. ⚫The activated partial thromboplastin time (aPTT) may
provide a qualitative assessment of the presence of
dabigatran.
⚫The prothrombin time (PT) may provide a qualitative
assessment of the presenceof factorXa inhibitors.
⚫Quantitative tests for DTI and FXa inhibitors - diluted
thrombin-timeand chromogenic assays, respectively,
⚫But they may not (yet) be routinely available in most
hospitals.
⚫Moreover, there are no data on a cut-off of these specific
tests below which elective or urgent surgery is ‘safe’, and
therefore their use in this respect cannot be recommended
at this time.
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55. When interpreting these results, consider
⚫when the lastdoseof NOACwasadministered
⚫patientcharacteristics, and renal function –
determinantsof elimination half-life
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56. ⚫DABIGATRAN –
aPTT level (i.e. 12–24 h after ingestion) of ≥2 the upper
limit of normal or
ECT ≥3 times and a dTT(Hemoclot) - .200 ng/mL after 12 h
of the last dose
is associated with a higherrisk of bleeding.
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58. Patient has a bleeding complication
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⚫Specific antidotes for NOACs are still lacking and the
strategies to reverseanticoagulanteffectare limited.
⚫Time is the best advantage of NOACs, in view of their
relativelyshort elimination half-lives.
⚫If a major bleeding complication occurs, standard
supportive measurements must be started. These include
mechanical compression, surgical haemostasis, fluid
replacement, and additional haemodynamicsupport.
59. ⚫ Haemodialysis can
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accelerate drug removal patients
in those
in life-threatening
receiving dabigatran; however, its benefit
bleeding has not beenestablished.
⚫ In contrast, dialysis is not effective for factor Xa inhibitors due to
their high plasma binding and lowerrenal clearance.
⚫ The administration of prothrombin complex concentrate (PCC) or
activated prothrombin complex (aPCC) concentrates can be
considered in life-threatening bleeding, despite the scarce evidence.
⚫ Administration of PCC could start at a dose of 25 U/kg and can be
repeated if clinically indicated.
61. ⚫Novel reversal agents in clinical development
⚫There are currently 3 NOAC-specific reversal agents in
clinical development:
(1) andexanetalfa,
(2) idarucizumab, and
(3) PER977
NEWER ORAL ANTICOAGULANTS
62. ⚫“Andexanet alfa” is a recombinant, modified human factor Xa
that is being developed as adirect factorXa reversal agent.
⚫It has been shown to rapidly attenuate the anti-FXa activity of
apixaban, rivaroxaban, edoxaban, and enoxaparin and to
restore thrombin generation in phase 2 studies in healthy
humanvolunteers.
⚫Andexanet alfa has been generally well tolerated and is
currently in phase 3 clinical trials (ANNEXA-A [apixaban] and
ANNEXA-R [rivaroxaban]).
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63. ⚫Idarucizumab” is a fully humanized antibody fragment (Fab)
that binds dabigatran with highaffinityand specificity.
⚫Idarucizumab rapidly reverses the anticoagulant effect of a
220 mg twice daily dose of dabigatran in healthy human
volunteers and is currently being evaluated in phase 3 trials.
⚫Idarucizumab has been generally well tolerated in healthy
human volunteers and is currently in clinical trials in the RE-
VERSE AD study.
NEWER ORAL ANTICOAGULANTS
64. ⚫PER977 (ciraparantag)” is a water-soluble small-molecule
nonspecific reversal agent.
⚫In preclinical testing and during testing with edoxaban in
healthy male volunteers, it rapidly reversed the effect of
multipleanticoagulants, purportedlyvia hydrogen bonding.
⚫It is currently in phase 1 to 2 clinical testing in healthy human
volunteers.
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65. Patient undergoes intervention
NEWER ORAL ANTICOAGULANTS
⚫ The most appropriate management should be individualized
depending on the NOAC used, the type of surgery, the required
anaesthetic regimen, and the patients’ characteristics,
particularly, on theirrenal function.
⚫ For patients undergoing minor interventions,NOACs can be
continued around the time of the procedure, similar to VKA-
treated patients.
⚫ Some examples include skin cancer removal, joint injection,
cataract removal, or tooth extraction in which an adequate local
haemostasis is commonlypossible.
⚫ Intervention should not be performed at peak concentrations
but 12 or 24 h after the last intake, depending on their specific
regimen dosing.
67. Managing oral antiplatelet agents in patients
requiring long-term oral anticoagulants
NEWER ORAL ANTICOAGULANTS
⚫ Approximately 6 – 8% of patients undergoing PCI have an indication for
long-term OAC with VKA or NOACs due to various conditions such as
atrial fibrillation, mechanical heartvalvesorvenous thromboembolism.
⚫ In the absence of safety and efficacy data, the use of prasugrel or ticagrelor
as partof triple therapy should beavoided.
⚫ Gastric protectionwith a proton pump inhibitor is recommended.
⚫ The dose intensity of OAC should be carefully monitored with a target INR
of 2.0 – 2.5 in patients treated with VKA & in patients treated with NOACs,
the lowest tested dose for stroke prevention should be applied (i.e.
dabigatran 110 mg twice a day, rivaroxaban 15 mg once a day, apixaban 2.5
mg twicea day)
68. ⚫new-generation DESs are recommended over BMSs in
patients requiring OACat low bleeding risk (HAS-BLED ≤2).
⚫For patients at high bleeding risk (HAS-BLED ≥3)
undergoing PCI who require OAC, the choice between a BMS
and a new-generation DES needs to be individualised.
⚫it is not known whether there are differences according to
the typeof OAC (NOACsversus VKA) orstent platform.
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70. Evaluation of Dual Therapy With Dabigatran vs. Triple
Therapy With Warfarin in Patients With AF That Undergo
a PCI With Stenting (REDUAL-PCI)
NEWER ORAL ANTICOAGULANTS
⚫ The main objective of this study is to compare a Dual
Antithrombotic Therapy (DAT) regimen of 110mg dabigatran
etexilate b.i.d. plus clopidogrel or ticagrelor (110mg DE DAT) and
150mg dabigatran etexilate b.i.d. plus clopidogrel or ticagrelor
(150mg DE-DAT) with a Triple Antithrombotic Therapy (TAT)
combination of warfarin plus clopidogrel or ticagrelor plus ASA
<= 100mg once daily (warfarin-TAT) in patients with Atrial
Fibrillation that undergo a PCI with stenting (elective or due to
an Acute Coronary Syndrome).
⚫ The study aims to show non-inferiority of each dose of DE-DAT
when compared to Warfarin-TAT in termsof safety.
⚫ Safety will be determined by comparing the rates of bleeding
events and Clinically Relevant Non MajorBleeding Events.
71. New oral anticoagulants vs.vitamin K antagonists in
atrial fibrillation patients with a malignancy –
NEWER ORAL ANTICOAGULANTS
⚫Active malignancy usually was an exclusion criterion in
NOAC trials.
⚫When anticoagulant therapy needs to be initiated in a
patient with malignancy, therapy with VKAs or heparins
should be considered over NOACs, because of the clinical
experience with these substances, the possibility of close
monitoring (for VKAs and unfractionated heparin, UFH),
and reversal options (forVKAs and UFH).
72. Patient need to switch between anticoagulant regimens
NEWER ORAL ANTICOAGULANTS
73. Conclusion
NEWER ORAL ANTICOAGULANTS
⚫New oral anticoagulants have shown to have a favourable
balance between efficacy and safetycompared with VKA s.
⚫Advantages Of NOACs include fewer interactions with
medications and no interaction with food, rapid onset, fast
clearance, and no need for laboratory monitoring.
⚫Individualized anticoagulant treatment should be based on
patients’ age, renal function, and concomitant treatments.
⚫Further research is underway to develop reliable and accessible
measures to monitor the anticoagulant effects of the new
agents, as well as antidotes with the ability to effectively reverse
anticoagulation effect.