Dabigatran Might Cut Hospital Days vs Standard Anticoagulants in New AF

March 15, 2013

SAN FRANCISCO — There are more options than ever when starting anticoagulation therapy in patients with a new diagnosis of nonvalvular atrial fibrillation (AF), but some may get the patient out the hospital doors faster than others. A small retrospective study suggests that choosing one of the newer oral agents that don't call for extra steps in getting anticoagulation levels to target, the way warfarin typically does, can help cut a significant number of hours, maybe more than a day, off hospitalization time[1].

In a series of 36 patients hospitalized with newly diagnosed AF, the 18 who started on dabigatran etexilate (Pradaxa, Boehringer Ingelheim) left the hospital about a day earlier, on average, than the other half put on a standard anticoagulation regimen. The entire group had been screened to exclude those with major comorbidities or other conditions that might affect hospital length of stay (LOS), senior author Dr David A Vorchheimer (Mount Sinai Heart Institute, New York, NY) told heartwire .

As he reported at the recent American College of Cardiology 2013 Scientific Sessions , those for whom dabigatran was selected and the others who underwent standard anticoagulation were similar with respect to age, sex, and CHADS2 scores. Nor did they differ in rate or severity of in-hospital events such as bleeding, and there were no embolic complications.

Dr David A Vorchheimer

As warfarin can take days to reach therapeutic anticoagulation levels, often the patient starts on parenteral anticoagulation for bridging; in the current series, 10 patients on standard anticoagulation were bridged to warfarin with enoxaparin and seven with unfractionated heparin. One started on warfarin directly.

Adding to the process of starting warfarin, optimal dosing for a given patient typically requires titration guided by anticoagulation checks.

Neither the direct-thrombin inhibitor dabigatran nor any of the new oral factor Xa inhibitors require bridging with parenteral anticoagulation. So, Vorchheimer said, "in our small snapshot [of patients in clinical practice], it seems to make sense that if you have a drug with a shorter onset of action and a shorter time to therapeutic anticoagulation, you can get the patient out of the hospital faster."

Duration of Anticoagulation and Hospital Stay by Anticoagulation Regimen in Nonvalvular AF

End point

Standard anticoagulation, n=18 Dabigatran, n=18 p
Duration of in-hospital anticoagulation (median days) 4.0 2.0 <0.001
Hospital length of stay (mean hours) 86 60.4 <0.05
Hospital length of stay (median hours) 75.5 49.4 <0.01

"We had thought perhaps the reason that patients [on standard anticoagulation] had a longer length of stay is that they were being managed ineptly, not by experts. But the physician of record for both [groups] was a cardiologist," he said; that was the case in 94% of standard-anticoagulation patients and all of those put on dabigatran.

He also noted that use of dabigatran appeared consistent with the guidelines in that it wasn't given to patients with impaired renal function. One of the few observed significant baseline differences between the two groups was in creatinine clearance, which averaged 50 mL/min in standard-anticoagulation patients and 68 mL/min in those getting the direct thrombin inhibitor (p=0.034).

Vorchheimer and his colleagues report that they have no relevant relationships to disclose; the analysis received no industry support.

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