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Switching patients from warfarin to dabigatran therapy: To RE-LY or not to rely
International Journal of Cardiology 154 (2012) e27–e28
Contents lists available at ScienceDirect
International Journal of Cardiology j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j c a r d
Letter to the Editor
Switching patients from warfarin to dabigatran therapy: To RE-LY or not to rely☆ Fadi J. Sawaya a, Khaled M. Musallam b, Samir Arnaout b, Ali Rabah b, Jaber Sawaya b,⁎ a b
Department of Internal Medicine, Emory University School of Medicine, Atlanta, Georgia, USA Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
a r t i c l e
i n f o
Article history: Received 31 March 2011 Accepted 13 May 2011 Available online 31 May 2011 Keywords: Atrial fibrillation Dabigatran Warfarin Stroke
The RE-LY study showed that dabigatran, given at 110 mg twice daily, is non-inferior to warfarin for preventing stroke in patients with atrial fibrillation [1]. Previous vitamin K antagonist exposure was also shown not to influence the benefits of dabigatran in this setting [2]. We herein present an unfavorable outcome after shifting an eligible patient from warfarin to dabigatran therapy; thus challenging some existing comfort zones. A 78-year-old, 80-kg patient with controlled hypertension underwent angioplasty and Cypher stent implantation in the proximal Ramus artery five years ago; and has been free of coronary events since then. One year after stent placement, the patient underwent laparoscopic cholecystectomy at which time he was noted to be in sinus rhythm. One year later and on routine evaluation, he was found to be in atrial fibrillation. Transesophageal echocardiogram showed a left atrial thrombus (Fig. 1A) and the patient was started on warfarin therapy with close follow-up of prothrombin time being in the therapeutic range. Repeat echocardiogram one year later showed the left atrium to be free of thrombus (Fig. 1B). Following data from the
☆ Conflict of Interest Statement: The authors have no conflicts of interest to disclose. This study did not receive external funding. ⁎ Corresponding author at: Division of Cardiology, Department of Internal Medicine, American University of Beirut Medical Center, P.O. Box 11-0236, Riad El-Solh 1107 2020, Beirut, Lebanon. Tel.: + 961 1 350000; fax: + 961 1 370814. E-mail address: [email protected] (J. Sawaya). 0167-5273/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2011.05.026
RE-LY study, the patient was shifted to dabigatran 110 mg therapy twice daily. After eight months on dabigatran therapy, he was admitted for management of prostatic symptoms. Routine echocardiogram done during admission showed a 2.5 × 2.1 cm left atrial thrombus (Fig. 1C). The left ventricular function remained near normal. At this point, the patient was shifted back to warfarin. His CHADs score was 3, with no history of stroke. The patient’s medications over the course of treatment included amlodipine, trimetazidine, amantadine, dutasteride, tamsulosin, rosuvastatin, and esmoprazole. The patient has normal hepatic and renal functions. This case illustrates resolution of an atrial thrombus on warfarin and reappearance on dabigatran therapy. It could be inferred that in similar patients with atrial fibrillation who already formed a thrombus, it may be better to continue warfarin therapy and avoid switching to dabigatran. Large prospective studies are needed to explore special considerations for this patient population. Acknowledgement The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [3]. References [1] Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009;361:1139–51. [2] Ezekowitz MD, Wallentin L, Connolly SJ, et al. Dabigatran and warfarin in vitamin K antagonist-naive and -experienced cohorts with atrial fibrillation. Circulation 2010;122:2246–53. [3] Shewan LG, Coats AJ. Ethics in the authorship and publishing of scientific articles. Int J Cardiol 2010;144:1–2.
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F.J. Sawaya et al. / International Journal of Cardiology 154 (2012) e27–e28
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Fig. 1. (A) Transesophageal echocardiogram showing a thrombus in the left atrium (arrow) at initial assessment, off anticoagulant therapy. (B) Transthoracic echocardiogram showing disappearance of the left atrial thrombus after one year of warfarin therapy. (C) Transthoracic echocardiogram showing reappearance of a left atrial thrombus (arrow) eight months following switching from warfarin to dabigatran therapy.
Contents lists available at ScienceDirect
International Journal of Cardiology j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j c a r d
Letter to the Editor
Switching patients from warfarin to dabigatran therapy: To RE-LY or not to rely☆ Fadi J. Sawaya a, Khaled M. Musallam b, Samir Arnaout b, Ali Rabah b, Jaber Sawaya b,⁎ a b
Department of Internal Medicine, Emory University School of Medicine, Atlanta, Georgia, USA Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
a r t i c l e
i n f o
Article history: Received 31 March 2011 Accepted 13 May 2011 Available online 31 May 2011 Keywords: Atrial fibrillation Dabigatran Warfarin Stroke
The RE-LY study showed that dabigatran, given at 110 mg twice daily, is non-inferior to warfarin for preventing stroke in patients with atrial fibrillation [1]. Previous vitamin K antagonist exposure was also shown not to influence the benefits of dabigatran in this setting [2]. We herein present an unfavorable outcome after shifting an eligible patient from warfarin to dabigatran therapy; thus challenging some existing comfort zones. A 78-year-old, 80-kg patient with controlled hypertension underwent angioplasty and Cypher stent implantation in the proximal Ramus artery five years ago; and has been free of coronary events since then. One year after stent placement, the patient underwent laparoscopic cholecystectomy at which time he was noted to be in sinus rhythm. One year later and on routine evaluation, he was found to be in atrial fibrillation. Transesophageal echocardiogram showed a left atrial thrombus (Fig. 1A) and the patient was started on warfarin therapy with close follow-up of prothrombin time being in the therapeutic range. Repeat echocardiogram one year later showed the left atrium to be free of thrombus (Fig. 1B). Following data from the
☆ Conflict of Interest Statement: The authors have no conflicts of interest to disclose. This study did not receive external funding. ⁎ Corresponding author at: Division of Cardiology, Department of Internal Medicine, American University of Beirut Medical Center, P.O. Box 11-0236, Riad El-Solh 1107 2020, Beirut, Lebanon. Tel.: + 961 1 350000; fax: + 961 1 370814. E-mail address: [email protected] (J. Sawaya). 0167-5273/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2011.05.026
RE-LY study, the patient was shifted to dabigatran 110 mg therapy twice daily. After eight months on dabigatran therapy, he was admitted for management of prostatic symptoms. Routine echocardiogram done during admission showed a 2.5 × 2.1 cm left atrial thrombus (Fig. 1C). The left ventricular function remained near normal. At this point, the patient was shifted back to warfarin. His CHADs score was 3, with no history of stroke. The patient’s medications over the course of treatment included amlodipine, trimetazidine, amantadine, dutasteride, tamsulosin, rosuvastatin, and esmoprazole. The patient has normal hepatic and renal functions. This case illustrates resolution of an atrial thrombus on warfarin and reappearance on dabigatran therapy. It could be inferred that in similar patients with atrial fibrillation who already formed a thrombus, it may be better to continue warfarin therapy and avoid switching to dabigatran. Large prospective studies are needed to explore special considerations for this patient population. Acknowledgement The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [3]. References [1] Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009;361:1139–51. [2] Ezekowitz MD, Wallentin L, Connolly SJ, et al. Dabigatran and warfarin in vitamin K antagonist-naive and -experienced cohorts with atrial fibrillation. Circulation 2010;122:2246–53. [3] Shewan LG, Coats AJ. Ethics in the authorship and publishing of scientific articles. Int J Cardiol 2010;144:1–2.
e28
F.J. Sawaya et al. / International Journal of Cardiology 154 (2012) e27–e28
A
LA
B
LV
LA
C
LV
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Fig. 1. (A) Transesophageal echocardiogram showing a thrombus in the left atrium (arrow) at initial assessment, off anticoagulant therapy. (B) Transthoracic echocardiogram showing disappearance of the left atrial thrombus after one year of warfarin therapy. (C) Transthoracic echocardiogram showing reappearance of a left atrial thrombus (arrow) eight months following switching from warfarin to dabigatran therapy.