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The annual European Society of Cardiology (ESC) congress took place on 26-29 August 2022 in Barcelona, Spain. Delegates were able to attend both virtually and in-person.
The Bayer-sponsored symposium, ‘The beginning of the end for NOACs: The extra mile’, was chaired by Professor Manesh Patel (Durham, USA) and is available to view on demand. Manesh Patel urged the audience to “think about the science around the first mile – where we prove non-vitamin K antagonist oral anticoagulants (NOACs) are effective, and the science around the extra mile, or last mile where we get these therapies to our patients.” The gap between the evidence and the realities of clinical practice remains a frequent topic, with anticoagulation being the subject of many presentations at ESC 2022.
Older patients with AF can lead active lives but the fear of frailty persists
AF, atrial fibrillation
Ensuring patients are getting the most appropriate therapies is critical: discussing anticoagulation in patients with AF, Professor Elena Arbelo (Barcelona, Spain) made the point that “age is a big driver of stroke risk, you have increasing risk of atrial fibrillation (AF), you have increasing risk of stroke, usually associated with other comorbidities… so your risk of stroke is high, but at the same time you can see that these patients also have higher bleeding risk...but the interesting thing is that these patients really benefit from stroke prevention.” She followed up, noting that unfortunately, this population with elevated bleeding risk and older age frequently receive an inappropriate dosage of anticoagulation due to perceptions that this will reduce bleeding, meaning that the patients that need it most may not receive optimal protection.
There are many types of vulnerable patients with VTE who need protection
VTE, venous thromboembolism
Moving from patients with AF who are frail, to patients with VTE who are vulnerable, Professor Cecilia Beccatini (Perugia, Italy) discussed the spectrum of vulnerability in patients with venous thromboembolism (VTE). Professor Rupert Bauersachs (Frankfurt, Germany) joined the discussion, placing particular emphasis on frail patients (patients with ≥1 of the following characteristics: age >75, creatinine clearance <50 ml/min, low body weight ≤50 kg), highlighting that consistent evidence from the EINSTEIN studies, through to real-world data, support the safety profile of rivaroxaban in this group.3
Cecilia Beccatini and Rupert Bauersachs discussed vulnerability in VTE
VTE, venous thromboembolism
Vulnerability was considered in the context of patients with cancer-associated VTE, with Rupert Bauersachs noting that the guideline-recommended NOACs provide effective VTE treatment and rivaroxaban in particular is associated with a lower perceived treatment burden and higher treatment satisfaction after switching from low molecular weight heparin (LMWH) among patients.4 Craig Coleman further demonstrated that the effectiveness, safety profile and increased persistence of rivaroxaban versus LMWH is supported by recent real-world evidence from OSCAR-US and OSCAR-UK.5,6
Cancer and cancer treatment is a heavy burden and patients should be protected from the worry of cancer-associated thrombosis as well
The management of vulnerable patients with VTE was a theme running throughout ESC 2022, being the subject of several presentations. Amol Dhamane (Lawrenceville, USA) demonstrated that patients with pancreatic cancer (N=995) were far more likely to receive LMWH (52.9%) and less likely to receive a direct-acting oral anticoagulant (DOAC) (25.7%) than patients with other cancers such as prostate (N=849; LMWH 18.8%, DOAC 54.5%) and breast (N=1197; LMWH 21.8%, DOAC 53.5%) following a VTE.7
Patients with AF and multiple comorbidities including diabetes and impaired renal function are at an increased risk of stroke compared to patients with AF alone
AF, atrial fibrillation
Professor Craig Coleman was called on to provide expert commentary on the link between chronic kidney disease (CKD), diabetes and risk in patients with AF. He illustrated that patients with diabetes and CKD experience a benefit from treatment with a NOAC, both in terms of stroke prevention and reduction in major bleeding versus vitamin K antagonists (VKAs), and the presence of these comorbidities should not dissuade clinicians from using them.8,9 The increased rate of adverse kidney outcomes in patients taking warfarin was highlighted, with data from XARENO10 (N=807) and RIVA-DM8 (N=83,182) showing that we can mitigate this issue by using a NOAC, resulting in a 60% lower likelihood of progression to stage V CKD and a 92% reduction in the likelihood of needing renal replacement therapy.
The panel discussed real-world data showing improved kidney outcomes in patients with NVAF receiving rivaroxaban vs VKA
*eGFR/CrCl 15–49 ml/min. #The primary endpoint of composite outcome of >40% decrease in eGFR from baseline, eGFR <15 ml/min, need for dialysis, renal transplant, major adverse limb event, retinopathy or death was met. (HR=0.93; 95% CI 0.91–0.95)
CI, confidence interval; CrCl, creatine clearance; HR, hazard ratio; NVAF, non-valvular atrial fibrillation; VKA, vitamin K antagonist
Other presentations at ESC 2022 also focussed on the topic of kidney disease, Giandomenico Severini (Catanzano, Italy) presented results from a prospective observational study (N=411), finding that patients with NVAF prescribed a NOAC had significant improvements (p<0.01) in multiple measurements of renal function versus VKA, despite being a higher-risk group in terms of comorbidities.11 Christopher Olesovsky (Toronto, Canada) found that the cohort captured in a retrospective database study (N=57,574) experienced a high rate of switching from warfarin to almost exclusive NOAC prescription in the period from 2012 to 2020, with those started on warfarin having a consistently lower eGFR*.12
*Disclaimer: Rivaroxaban is not indicated for primary renal benefits. Please refer to your local prescribing information for full indications and posology.
Ensuring patients derive the most benefit from anticoagulation therapy, whether they have coexisting vulnerabilities in AF, or are at a higher risk of VTE recurrence is a frequent challenge faced by clinicians. Ensuring patients are receiving the most appropriate medication at the optimal dose can help cover the extra mile, delivering the most effective treatment and protection against the complications of VTE and AF.