Methadone dosing at New York State opioid treatment programs following initial revisions to federal regulations.

INTRODUCTION: In March 2020, a temporary federal regulatory exemption for opioid treatment programs (OTPs) was issued, allowing for a greater number of take-home methadone doses than was previously permitted. In the same month, to address financial sustainability, New York State (NYS) Medicaid also transitioned to a bundle reimbursement methodology for OTPs. We examined methadone dosing schedules in NYS before and after these regulatory and financing changes. METHODS: We conducted a retrospective cohort study using NYS OTP patient data from two sources: the client data system for a baseline period (February 2020) and survey data collected after regulatory and financing changes (May 2020 to August 2021, 64 weekly surveys). We compared methadone dosing schedules over time using chi-square tests and Poisson regression. RESULT: At baseline, data were available for 78% (n=77/99) of OTPs including 90.9% (n=26,225/28,839) of their enrolled patients. During the survey period, 99 OTPs completed 93.1% (n=5901/6336) of weekly surveys, with a mean statewide weekly patient census of 38,904 (SD=1214.5). Between February and May 2020, daily dosing significantly decreased from 55.4% to 16.3% of patients (-39.1 percentage points [95%CI: -39.8 to -38.4]), although it significantly increased subsequently (3.33%/4-weeks [95%CI: 3.28, 3.39]). In addition, weekly-to-monthly dosing significantly increased from 26.9% to 54.5% of patients (27.6 percentage points [95%CI: 26.9, 28.4]), although it significantly decreased subsequently (-1.19%/4-weeks [95%CI: -1.23, -1.15]). DISCUSSION: Despite large initial changes, we found a trend toward gradual return to more restrictive dosing schedules. OTPs need further support in leveraging new opportunities to improve methadone treatment and outcomes.

Preliminary anticancer evaluation of new Pd(II) complexes bearing NNO donor ligands.

In this study we presented a novel series of NNO tridentate ligands generating imino, amido and oxo donor pocket for Pd(II) coordination. All the compounds were meticulously characterized by elemental analysis and advanced spectroscopic techniques, including FTIR, proton and carbon NMR. The synthesized compounds underwent rigorous evaluation for their potential as anti-cancer agents, utilizing the aggressive breast cancer cell lines MDA-MB (ATCC) and MCF-7 as a crucial model for assessing growth inhibition in cancer cells. Remarkably, the MTT assay unveiled the robust anti-cancer activity for all palladium complexes against MDA-MB-231 and MCF-7 cells. Particularly, complex [Pd(L1)(CH3CN)] exhibited exceptional potency with an IC50 value of 25.50 ± 0.30 µM (MDA-MB-231) and 20.76 ± 0.30 µM (MCF-7), compared to respective 27.00 ± 0.80 µM and 24.10 ± 0.80 µM for cisplatin, underscoring its promising therapeutic potential. Furthermore, to elucidate the mechanistic basis for the anti-cancer effects, molecular docking studies on tyrosine kinases, an integral target in cancer research, were carried out. The outcome of these investigations further substantiated the remarkable anticancer properties inherent to these innovative compounds. This research offers a compelling perspective on the development of potent anti-cancer agents rooted in the synergy between ligands and Pd(II) complexes and presenting a promising avenue for future cancer therapy endeavors.

A review study on green synthesis of chitosan derived schiff bases and their applications.

Chitosan is a bio-degradable, bio-compatible, non-toxic, and renewable biopolymer. The reactive amino group of chitosan has gained importance because using these amino groups can help achieve the different types of structural modification in chitosan. Chemical modification of chitosan via imine functionalization results in the formation of a chitosan Schiff base. The present review covers the green synthesis of chitosan Schiff bases using non-conventional green methods such as microwave irradiation, green solvent, ultrasound irradiation, and one-pot synthesis. These methods are energy-efficient and greener versions of the conventional condensation methods. Scientists have paid significant attention to the chitosan Schiff base because of its unique properties and versatility. These molecules display various biological applications, including antioxidant, antimicrobial, anticancer, antibacterial, and anti-fungal. In addition to biological applications, chitosan Schiff base also has other applications like corrosion inhibition, catalysis, metal ion adsorption, and as a sensor. Available literature particularly shows the different methods for the synthesis of chitosan Schiff bases and their different applications. This review gives detailed insight regarding sustainable approaches to the synthesis of chitosan derived Schiff bases and their applications in various emerging fields.

Sex Differences in Clinical Profile and Outcome After Percutaneous Coronary Intervention for Chronic Total Occlusion.

BACKGROUND: There are limited data around sex differences in the risk profile, treatments and outcomes of percutaneous coronary intervention (PCI) in chronic total occlusion (CTO) lesions in contemporary interventional practice. We investigated the impact of sex on clinical and procedural characteristics, complications and clinical outcomes in a national cohort. METHODS & RESULTS: We created a longitudinal cohort (2006-2018, n = 30,605) of patients with stable angina who underwent CTO PCI in the British Cardiovascular Intervention Society (BCIS) database. Clinical, demographic, procedural and outcome data were analysed in two groups stratified by sex: male (n = 24,651), female (n = 5954). Female patients were older (68 vs 64 years, P < 0.001), had higher prevalence of diabetes mellitus (DM), hypertension (HTN) and prior stroke. Utilization of intravascular ultrasound (IVUS), drug eluting stents (DES), radial or dual access and enabling strategies during CTO PCI were higher in male compared to female patients. Following multivariable analysis, there was no significant difference in in-patient mortality (adjusted odds ratio (OR):1.40, 95 % CI: 0.75-2.61, P = 0.29) and major cardiovascular and cerebrovascular events (MACCE) (adjusted OR: 1.01, 95 % CI: 0.78-1.29, P = 0.96). The crude and adjusted rates of procedural complications (adjusted OR: 1.37, 95 % CI: 1.23-1.52, P < 0.001), coronary artery perforation (adjusted OR: 1.60, 95 % CI: 1.26-2.04, P < 0.001) and major bleeding (adjusted OR: 2.06, 95 % CI: 1.62-2.61, P < 0.001) were higher in women compared with men. CONCLUSION: Female patients treated by CTO PCI were older, underwent lesser complex procedures, but had higher adjusted risk of procedural complications with a similar adjusted risk of mortality and MACCE compared with male patients.

Mortality in a Multiethnic Population Attending a One-Stop TIA Clinic.

INTRODUCTION: Studies indicate a 13-27% mortality rate following a transient ischaemic attack (TIA). However, outcomes following TIA/minor stroke since the introduction of rapid-access TIA clinics and prompt vascular risk factor intervention are not known. Specifically, there is paucity of data comparing outcomes between people who are diagnosed with an "acute cerebrovascular" (CV) event or an alternative non-cardiovascular diagnosis (non-CV) in a rapid-access TIA clinic. We aimed to assess the mortality in such a setting. METHODS: A retrospective observational study was undertaken at the Leicester rapid-access secondary care TIA clinic. Data included information collected at the first clinic visit (including comorbidities, and primary diagnosis, categorized as CV and non-CV) and the date of death for people dying during follow-up. RESULTS: 11,524 subjects were included with 33,164 years of follow-up data; 4,746 (41.2%) received a CV diagnosis. The median follow-up time was 2.75 years (interquartile range 1.36-4.32). The crude mortality rate was 37.3 (95% CI: 35.3-39.5) per 1,000 person-years (PTPY). The mortality rate was higher following a CV diagnosis (50.8 [47.2-54.7] PTPY) compared to a non-CV diagnosis (27.9 [25.7-30.4] PTPY), and for males, older people, those of white ethnicity, and people with orthostatic hypotension (OH). DISCUSSION: This study identified possible risk factors associated with a higher mortality in TIA clinic attendees, who may benefit from specific intervention. Future research should explore the underlying causes and the effect of specific targeted management strategies.

Performance Metrics of Substance Use Disorder Care Among Medicaid Enrollees in New York, New York.

Importance: There is limited evaluation of the performance of Medicaid managed care (MMC) private plans in covering substance use disorder (SUD) treatment. Objective: To compare the performance of MMC plans across 19 indicators of access, quality, and outcomes of SUD treatment. Design Setting and Participants: This cross-sectional study used administrative claims and mandatory assignment to plans of up to 159 016 adult Medicaid recipients residing in 1 of the 5 counties (boroughs) of New York, New York, from January 2009 to December 2017 to identify differences in SUD treatment access, patterns, and outcomes among different types of MMC plans. Data from the latest years were received from the New York State Department of Health in October 2019, and analysis began soon thereafter. Approximately 17% did not make an active choice of plan, and a subset of these (approximately 4%) can be regarded as randomly assigned. Exposures: Plan assignment. Main Outcomes and Measures: Percentage of the enrollees achieving performance measures across 19 indicators of access, process, and outcomes of SUD treatment. Results: Medicaid claims data from 159 016 adults (mean [SD] age, 35.9 [12.7] years; 74 261 women [46.7%]; 8746 [5.5%] Asian, 73 783 [46.4%] Black, and 40 549 [25.5%] White individuals) who were auto assigned to an MMC plan were analyzed. Consistent with national patterns, all plans achieved less than 50% (range, 0%-62.1%) on most performance measures. Across all plans, there were low levels of treatment engagement for alcohol (range, 0%-0.4%) and tobacco treatment (range, 0.8%-7.2%), except for engagement for opioid disorder treatment (range, 41.5%-61.4%). For access measures, 4 of the 9 plans performed significantly higher than the mean on recognition of an SUD diagnosis, any service use for the first time, and tobacco use screening. Of the process measures, total monthly expenditures on SUD treatment was the only measure for which plans differed significantly from the mean. Outcome measures differed little across plans. Conclusions and Relevance: The results of this cross-sectional study suggest the need for progress in engaging patients in SUD treatment and improvement in the low performance of SUD care and limited variation in MMC plans in New York, New York. Improvement in the overall performance of SUD treatment in Medicaid potentially depends on general program improvements, not moving recipients among plans.

Racial/Ethnic Disparities in Substance Use Treatment in Medicaid Managed Care in New York City: The Role of Plan and Geography.

OBJECTIVE: The aim was to assess the magnitude of health care disparities in treatment for substance use disorder (SUD) and the role of health plan membership and place of residence in observed disparities in Medicaid Managed Care (MMC) plans in New York City (NYC). DATA SOURCE: Medicaid claims and managed care plan enrollment files for 2015-2017 in NYC. RESEARCH DESIGN: We studied Medicaid enrollees with a SUD diagnosis during their first 6 months of enrollment in a managed care plan in 2015-2017. A series of linear regression models quantified service disparities across race/ethnicity for 5 outcome indicators: treatment engagement, receipt of psychosocial treatment, follow-up after withdrawal, rapid readmission, and treatment continuation. We assessed the degree to which plan membership and place of residence contributed to observed disparities. RESULTS: We found disparities in access to treatment but the magnitude of the disparities in most cases was small. Plan membership and geography of residence explained little of the observed disparities. One exception is geography of residence among Asian Americans, which appears to mediate disparities for 2 of our 5 outcome measures. CONCLUSIONS: Reallocating enrollees among MMC plans in NYC or evolving trends in group place of residence are unlikely to reduce disparities in treatment for SUD. System-wide reforms are needed to mitigate disparities.

A Review of the Potential Consequences of Pearl Millet (Pennisetum glaucum) for Diabetes Mellitus and Other Biomedical Applications.

Diabetes mellitus has become a troublesome and increasingly widespread condition. Treatment strategies for diabetes prevention in high-risk as well as in affected individuals are largely attributed to improvements in lifestyle and dietary control. Therefore, it is important to understand the nutritional factors to be used in dietary intervention. A decreased risk of diabetes is associated with daily intake of millet-based foods. Pearl millet is a highly nutritious grain, nutritionally comparable and even superior in calories, protein, vitamins, and minerals to other large cereals, although its intake is confined to lower income segments of society. Pearl millet contains phenolic compounds which possess antidiabetic activity. Thus, it can be used to prepare a variety of food products for diabetes mellitus. Moreover, it also has many health benefits, including combating diabetes mellitus, cancer, cardiovascular conditions, decreasing tumour occurrence, lowering blood pressure, heart disease risk, cholesterol, and fat absorption rate. Therefore, the current review addresses the role of pearl millet in managing diabetes.

A Comprehensive Review on Therapeutic Perspectives of Phytosterols in Insulin Resistance: A Mechanistic Approach.

Natural products in the form of functional foods have become increasingly popular due to their protective effects against life-threatening diseases, low risk of adverse effects, affordability, and accessibility. Plant components such as phytosterol, in particular, have drawn a lot of press recently due to a link between their consumption and a modest incidence of global problems, such as Type 2 Diabetes mellitus (T2DM), cancer, and cardiovascular disease. In the management of diet-related metabolic diseases, such as T2DM and cardiovascular disorders, these plant-based functional foods and nutritional supplements have unquestionably led the market in terms of cost-effectiveness, therapeutic efficacy, and safety. Diabetes mellitus is a metabolic disorder categoriszed by high blood sugar and insulin resistance, which influence major metabolic organs, such as the liver, adipose tissue, and skeletal muscle. These chronic hyperglycemia fallouts result in decreased glucose consumption by body cells, increased fat mobilisation from fat storage cells, and protein depletion in human tissues, keeping the tissues in a state of crisis. In addition, functional foods such as phytosterols improve the body's healing process from these crises by promoting a proper physiological metabolism and cellular activities. They are plant-derived steroid molecules having structure and function similar to cholesterol, which is found in vegetables, grains, nuts, olive oil, wood pulp, legumes, cereals, and leaves, and are abundant in nature, along with phytosterol derivatives. The most copious phytosterols seen in the human diet are sitosterol, stigmasterol, and campesterol, which can be found in free form, as fatty acid/cinnamic acid esters or as glycosides processed by pancreatic enzymes. Accumulating evidence reveals that phytosterols and diets enriched with them can control glucose and lipid metabolism, as well as insulin resistance. Despite this, few studies on the advantages of sterol control in diabetes care have been published. As a basis, the primary objective of this review is to convey extensive updated information on the possibility of managing diabetes and associated complications with sterol-rich foods in molecular aspects.

Immunohistochemical biomarkers in oral submucous fibrosis: A scoping review.

INTRODUCTION: This scoping review was done to study the immunohistochemical biomarkers involved in the pathogenesis and malignant transformation of oral submucous fibrosis (OSF), in literature published from 2010 to 2021. METHOD: The protocol was adapted from the Joanna Briggs Institute Reviewer's Manual (2017), and reported according to the PRISMA guidelines for Scoping Reviews. RESULTS: Eighty-six studies included in this review reported 84 immunohistochemical (IHC) biomarkers in OSF: 10 epithelial markers, 28 connective tissue markers, 22 proliferative markers, and 24 other biomarkers that are transcription factors, cancer stem cell markers, cell signaling markers, proteins, and enzymes. The commonly reported IHC biomarkers were alpha-smooth muscle actin (α-SMA) and E-cadherin (seven articles each) followed by vascular endothelial growth factor (VEGF) and CD34 (six articles each), p53, p63, and Ki67 (five articles each). α-SMA, Ki67, CD105, and hTERT were significantly increased in oral squamous cell carcinoma arising in a background of OSF (OSCC-OSF) compared with OSF and normal subjects. CONCLUSION: The identified surrogate IHC biomarkers reported in OSF in this scoping review require validation with long-term prospective studies to facilitate early diagnosis, for use in risk assessment, and plan appropriate treatment for OSF in clinical practice. Open Science Framework ID: osf.io/epwra.

Thyroid-Stimulating Hormone Favors Runx2-Mediated Matrix Mineralization in HOS and SaOS2 Cells: An In Vitro and In Silico Approach.

Osteoporosis is a skeletal disease that is both systemic and silent characterized by an unbalanced activity of bone remodeling leading to bone loss. Rising evidences demonstrate that thyroid stimulating hormone (TSH) has an important role in the regulation on the metabolism of bone. However, TSH regulation on human osteoblast essential transcriptional factors has not been identified. Current study examined the role of TSH on human osteoblastic Runx2 expression and their functional genes by in vitro and in slico analysis. Human osteoblast like (HOS and SaoS-2) cells were cultured with DMEM and treated with hTSH at the concentration of 0.01 ng/mL and 10 ng/mL. After treatment, osteoblastic Runx2 and IGF-1R beta expression were studied using RT-PCR and western blot analysis. TSH treatment induced osteoblastic essential transcriptional factor, Runx2 in HOS and SaOS2 cells on 48 h duration and elevated the expression of IGF-IR ß gene and Protein in SaoS-2 cells. TSH also promotes Runx2 responsive genes such as ALP, Collagen and osteocalcin in SaOS2 cells on day 2 to day 14 of 10 ng/mL of treatment and favors' matrix mineralization matrix in these cells. In addition, TSH facilitated human osteoblastic cells to mineralize their matrix confirmed by day 21 of alizarin red calcium staining. In silico study was performed to check CREB and ELK1 interaction with Runx2. Results of in silico analysis showed that TSH mediated signalling molecules such as CREB and ELK1 showed interaction with Runx2 which involve in osteobalstic gene expression and differentiation. Present findings confirm that TSH promotes Runx2 expression, osteoblastic responsive genes and bone matrix formation.

Effect of the Timing of Admission of Out of Hospital Cardiac Arrest Complicating Acute Myocardial Infarction on Management and Outcome.

There is limited data regarding the impact of time of admission on clinical outcomes of out of hospital cardiac arrest (OHCA) complicating acute myocardial infarction (AMI). We investigated the patient characteristics, management, and outcomes of OHCA complicating AMI according to the time of admission. Patients admitted with a diagnosis of AMI and OHCA between 2010 and 2017 from the Myocardial Ischemia National Audit Project (MINAP) were studied. All patients were stratified into out-of-hours (OOH) and working hours (WH) cohort according to the time of hospital admission. We used multivariable logistic regression models to evaluate the predictors of clinical outcomes and treatment strategy. 16,118 patients were admitted with AMI and OHCA. The WH cohort consisted of 5,780 patients (35.9%) and OOH cohort consisted of 10,338 patients (64.1%). The OOH cohort was younger (OOH 64 vs WH 66 years, p <0.001). A significantly higher proportion of patients had a final diagnosis of STEMI in OOH cohort (OOH 78.3% vs WH 76.6%, p = 0.012). Whilst the use of coronary angiography was lower in OOH (OOH 80.7% vs WH 82.5%, p = 0.005), PCI rates were similar (OOH 39.7% vs WH 40.5%, p = 0.4). Adjusted in-hospital mortality (OR 0.96, 95%CI 0.86 to 1.07), re-infarction (OR 0.90, 95% CI 0.72 to 1.12) and bleeding (OR 0.93, 95% CI 0.76 to 1.12) were similar in the 2 groups. In conclusion, the majority of OHCA occurred out of working hours. However, the time of hospital admission didn't affect the rate of revascularization by PCI or clinical outcomes.

Predictive validity of the New York State Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) for continuous engagement in treatment among individuals recommended for outpatient care.

BACKGROUND: The New York State (NYS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) was launched in 2015 to determine the most appropriate level of care for individuals seeking addiction treatment. However, research has not studied its predictive validity. We examined the predictive validity of the LOCADTR recommendation for outpatient treatment by determining whether those who entered a level of care (LOC) concordant with the LOCADTR recommendation differed in continuous engagement in treatment compared to those who entered a discordant LOC. METHODS: The study combined data from two NYS administrative sources, the LOCADTR database and a treatment registry. The study examined characteristics of the clients who entered concordant and discordant LOCs as well as tested for differences in continuous engagement of clients who entered discordant care compared to a propensity score-matched comparison group of clients who entered the concordant LOC. RESULTS: Among clients for whom the LOCADTR recommended the outpatient LOC, concordant clients who entered the outpatient LOC were more likely to be retained in care than discordant clients who entered the inpatient LOC (aOR = 0.53; 95% CI = 0.36, 0.77). We did not observe statistical differences in continuous engagement among clients who were recommended for outpatient and entered that LOC versus those who entered the outpatient rehabilitation LOC instead (aOR = 1.08; 95% CI = 0.90, 1.30). CONCLUSION: This study provides support for predictive validity of recommendations stemming from the LOCADTR. Clients, treatment providers, and payers benefited from a tool that provides clear guidance and predictively valid recommendations for treatment placement. The study found that clients were more likely to be retained in treatment for 6 months or longer if admitted to outpatient care, as recommended by the LOCADTR algorithm, rather than to inpatient treatment. One factor accounting for the longer engagement in outpatient care is the low level of continuity of care among patients being discharged from inpatient treatment.

A facilitation model for implementing quality improvement practices to enhance outpatient substance use disorder treatment outcomes: a stepped-wedge randomized controlled trial study protocol.

BACKGROUND: The misuse of and addiction to opioids is a national crisis that affects public health as well as social and economic welfare. There is an urgent need for strategies to improve opioid use disorder treatment quality (e.g., 6-month retention). Substance use disorder treatment programs are challenged by limited resources and a workforce that does not have the requisite experience or education in quality improvement methods. The purpose of this study is to test a multicomponent clinic-level intervention designed to aid substance use disorder treatment clinics in implementing quality improvement processes to improve high-priority indicators of treatment quality for opioid use disorder. METHODS: A stepped-wedge randomized controlled trial with 30 outpatient treatment clinics serving approximately 2000 clients with opioid use disorder each year will test whether a clinic-level measurement-driven, quality improvement intervention, called Coaching for Addiction Recovery Enhancement (CARE), improves (a) treatment process quality measures (use of medications for opioid use disorder, in-treatment symptom and therapeutic progress, treatment retention) and (b) recovery outcomes (substance use, health, and healthcare utilization). The CARE intervention will have the following components: (1) staff clinical training and tools, (2) quality improvement and change management training, (3) external facilitation to support implementation and sustainability of quality improvement processes, and (4) an electronic client-reported treatment progress tool to support data-driven decision making and clinic-level quality measurement. The study will utilize multiple sources of data to test study aims, including state administrative data, client-reported survey and treatment progress data, and staff interview and survey data. DISCUSSION: This study will provide the field with a strong test of a multicomponent intervention to improve providers' capacity to make systematic changes tied to quality metrics. The study will also result in training and materials that can be shared widely to increase quality improvement implementation and enhance clinical practice in the substance use disorder treatment system. TRIAL REGISTRATION: Trial # NCT04632238NCT04632238 registered at clinicaltrials.gov on 17 November 2020.

Managing hyperglycaemia in inpatients.

Inpatient hyperglycaemia is associated with poor patient outcomes. The majority of inpatients with diabetes are admitted with non-diabetes-related conditions and are primarily cared for by a clinician who does not specialise in diabetes. We describe common inpatient hyperglycaemia scenarios and outline strategic management approaches for the general physician, enabling better frontline care for people with diabetes.

Fasting with adrenal insufficiency: Practical guidance for healthcare professionals managing patients on steroids during Ramadan.

There are limited recommendations for fasting in many chronic diseases such as adrenal insufficiency (AI). Research in such situations highlights potential for complications and need for education for patients with AI undertaking fasting during Ramadan. This article aimed to provide up-to-date guidance for healthcare professionals to educate, discuss and manage patients with AI who are considering fasting in Ramadan and is religiously compatible. Latest guidance on this topic and the evidence base for steroid dosing are reviewed and discussed. Risk stratification for patients with AI and optimal strategies for management, including steroid dosing, are detailed. Our review highlights that patients with AI wishing to fast should undergo a thorough risk assessment ideally several months before Ramadan. 'High risk' and 'Very high risk' patients should be encouraged to explore alternative options to fasting discussed below. Prior to the commencement of Ramadan, all patients must receive up-to-date education on sick day rules, instructions on when to terminate their fast or abstain from fasting, carry steroid warning information and must have a valid intramuscular (IM) hydrocortisone pack and know how to administer this. Switching patients with AI desiring to fast from multiple daily hydrocortisone replacement to prednisolone 5 mg once daily at dawn (during Suhoor or Sehri) is recommended and discussed. Patients on fludrocortisone for AI should be advised to take their total dose at dawn. We provide practically relevant case-based scenarios to help with the application of this guidance. Future efforts need to focus on healthcare professional awareness and further research in this setting.

What is the optimal blood pressure level for patients with atrial fibrillation treated with direct oral anticoagulants?

OBJECTIVE: Limited data exist to inform blood pressure (BP) thresholds for patients with atrial fibrillation prescribed direct oral anticoagulants (DOAC) therapy in the real world setting. METHODS: SBP was measured in 9051 primary care patients in England on DOACs for atrial fibrillation with postinitiation BP levels available within the Clinical Practice Research Datalink. The incidence rate for the primary outcome of the first recorded event (defined as a diagnosis of first stroke, recurrent stroke, myocardial infarction, symptomatic intracranial bleed, or significant gastrointestinal bleed) and of secondary outcomes all-cause mortality and cardiovascular mortality were calculated by postinitiation BP groups. RESULTS: The Cox proportional hazard ratio of an event [crude and adjusted hazard ratio 1.04 (95% confidence interval (CI) 1.00-1.08), P = 0.077 and 0.071, respectively] did not differ significantly with a 10 mmHg increase in SBP. The hazard of all-cause mortality [crude hazard ratio 0.83 (95% CI 0.80-0.86), P = 0.000; adjusted hazard ratio 0.84 (95% CI 0.81-0.87), P = 0.000] and cardiovascular mortality [crude hazard ratio 0.92 (95% CI 0.85-0.99), P = 0.021; adjusted hazard ratio 0.93 (95% CI 0.86-1.00), P = 0.041] demonstrated a significant inverse relationship with a 10 mmHg increase in SBP. Patients with a SBP within 161-210 mmHg had the lowest all-cause death rate, while patients with SBP within 121-140 mmHg had the lowest cardiovascular death rate. CONCLUSION: SBP values below 161 mmHg are associated higher all-cause mortality, but lower event risk in patients with atrial fibrillation on DOAC therapy. The nadir SBP for lowest event rate was 120 mmHg, for lowest cardiovascular mortality was 130 mmHg and for lowest all-cause mortality was 160 mmHg. This demonstrates a need for a prospective interventional study of BP control after initiation of anticoagulation.