Safety and efficacy of interrupted dabigatran for peri-procedural anticoagulation in catheter ablation of atrial fibrillation: a systematic review and meta-analysis.

AIMS: To examine the safety (defined as bleeding risk) and efficacy (defined as prevention of thromboembolic events) of interrupted dabigatran for peri-procedural anticoagulation in catheter ablation (CA) of atrial fibrillation (AF) in comparison with warfarin. METHODS AND RESULTS: Reviewers independently searched literature databases from January 2010 through April 2013 for studies comparing the safety and efficacy of dabigatran and warfarin in CA of AF and extracted pre-defined data. The Mantel-Haenszel method was used to pool data of bleeding and thromboembolism outcomes into random and fixed effect model meta-analyses, respectively. Odds ratios (ORs), and risk difference (RD) analysis when studies reported no events in either arm, were used to generate an overall effect estimate of both outcomes. Publication bias and heterogeneity were assessed by contour funnel plot and the I(2) test, respectively. Nine citations, including 3036 patients (1073 dabigatran), met the inclusion criteria. There was no significant difference between interrupted dabigatran and warfarin therapy in CA of AF in occurrence of bleeding [dabigatran 58 (5.4%), warfarin 103 (5.2%); OR 0.92 (95% confidence interval (CI) 0.55-1.45); χ(2) = 13.03-P = 0.11; I(2) = 39%] or thromboembolism [dabigatran 5 (0.4%), warfarin 2 (0.1%); OR 2.15 (95% CI-0.58-7.98); χ(2) = 2.14, P = 0.54; I(2) = 0%; RD 0.00 (95% CI-0.00 to 0.01); χ(2) = 3.37, P = 0.81; I(2) = 0%]. Analysis of pre-defined subgroups (published articles vs. abstracts), sensitivity analyses (interrupted warfarin, USA studies, and Japanese studies) and fixed effect model analyses showed similar results. Heterogeneity was mild in the bleeding outcome analysis and zero in thromboembolism. There was no evidence of publication bias in either meta-analysis. CONCLUSION: Meta-analysis of currently available studies showed no significant difference in bleeding and thromboembolism between interrupted dabigatran and warfarin therapy in CA of AF. Dabigatran appears to be safe and effective for peri-procedural anticoagulation in CA of AF.

Efficacy of direct oral anticoagulants on the resolution of left ventricular thrombus-A case series and literature review.

BACKGROUND: Left ventricular thrombus is a frequent complication of acute myocardial infarction and a risk factor for thromboembolic complications. Warfarin has been frequently used, but has some disadvantages that limit its use. Direct oral anticoagulants, in particular Dabigatran and Rivaroxaban have been proved to be effective in preventing thromboembolism among patients with non-valvular atrial fibrillation. However, no randomized clinical trials testing the efficacy and safety of these agents in patients with existing left ventricular thrombus. Furthermore, direct oral anticoagulants are still not approved by the Food and Drug Administration in the management of left ventricular thrombus. METHOD: This study was a retrospective cohort assessing the efficacy of direct oral anticoagulants (Dabigatran or Rivaroxaban) on the resolution of left ventricular thrombus in patients taking either of these drugs during the study period from December, 2011 to December, 2016 at King Fahad Medical City. All patients' records were reviewed and all patients who were diagnosed with left ventricular thrombus were included. Patients without available echocardiogram records were excluded. The study was approved by the institutional review board of King Fahad medical city, Riyadh Saudi Arabia. RESULT: During the defined study period we found that 413 and 1218 patients were taking Dabigatran and Rivaroxaban, respectively. After filtering them based on the specialty of the prescriber, we ended up with 299 patients who have been started on Dabigatran and 448 patients who have been started on Rivaroxaban by cardiologists. Moreover, after reviewing echocardiogram reports for all of them (747 patients), we found that 11 patients were diagnosed to have left ventricular thrombus. Among those 11 patients, seven of them were treated with direct oral anticoagulants from the beginning and the remaining four patients were shifted from Warfarin to direct oral anticoagulants. All of them (7 patients) showed left ventricular thrombus resolution on follow-up echocardiogram. CONCLUSION: Use of direct oral anticoagulants showed promising results in the resolution of left ventricular thrombus in patients diagnosed with left ventricular thrombus. Further studies at multiple health care centers are needed to further evaluate the efficacy and safety of direct oral anticoagulants as compared to traditional treatment in patients with left ventricular thrombus.

Impact of Research Educational Intervention on Knowledge, Attitudes, Perceptions, and Pharmacy Practices Towards Evidence-based Medicine Among Junior Pharmacists.

Background Establishing evidence-based medicine (EBM) is important for pharmaceutical care services to be effective and for adding value to patient care. Increasing examples are illustrating that health professionals hold positive attitudes toward EBM. Nevertheless, their knowledge and skills are relatively insufficient. The objective of this study was to assess the impact of research educational intervention on knowledge, attitudes, perceptions, and pharmacy practices towards evidence-based medicine among junior pharmacists. Methods A one group pre-test/post-test quasi-experimental design was conducted on postgraduate junior pharmacy staff working or training at one of the three randomly selected tertiary care settings in Riyadh, Saudi Arabia. This study consisted of two phases. During the first phase, a structured questionnaire assessing the knowledge, perceptions, and attitudes of the participants regarding EBM, as well as basic biostatistics, epidemiology and the utilization of EBM, was administered. The second phase was scheduled to begin four weeks after the distribution of the educational materials, whereby the same questionnaire was redistributed among the same participants. Results Sixty-seven pharmacists participated in this study. The overall percentage mean score of correct responses of the study participants' knowledge was 37.0% in the pre-test compared to 44.4% in the post-test. The percentage mean score of correct responses for biostatistics and epidemiology and study design sections significantly increased after the study intervention (p < 0.001), (p = 0.02), respectively. Regarding the study participants' attitudes towards EBM, only one item, "Willingness to support the promotion of EBM implementation," was statistically significantly higher in the post-test (61, 93.8%) participants compared to participants (53, 80.3%) in the pre-test, while "Possessing sufficient skills to implement EBM principles" was the only statistically significant item for the study participants' perceptions towards EBM in the pre-test compared to the post-test, (82.1%, 92.4%), respectively. Moreover, our results showed that 74.6% of the respondents were practicing EBM before the study intervention versus 81.5% after the intervention. Conclusion The results of this study reveal that comprehensive educational intervention might improve the knowledge, attitudes, and perceptions of EBM among pharmacists and encourage them to incorporate this into their everyday clinical practice.