APHRS NEWSLETTER Contents 02 APHRS Summit 2019: Jakarta 04 The Use Of Direct Oral Anticoagulant For Stroke Prevention In Taiwan Patients With Non-Valvular Atrial Fibrillation 10 Shock Absorbers - The Use of Social Media in ICD Patient Support 11 Abbott: Accuracy Matters 12 APHRS 2019: Bangkok MARCH 2019 | NO.41 Chief Editor: Anil Saxena Deputy Editor: Kazuo Matsumoto Managing Editors: Hsuan-Ming Tsao David Heaven Pipin Kojodjojo Nwe Nwe Katsuhiko Imai Jae-Min Shim Toshiko Nakai Ming-Shien Wen Jacky Chan Yuanning Xu Arisara Suwanagool Preecha Uerojanaungkul
Transcript
A P H R S N E W S L E T T E R
Contents02 APHRS Summit 2019: Jakarta04 The Use Of Direct Oral Anticoagulant For Stroke Prevention In Taiwan Patients With Non-Valvular Atrial Fibrillation10 Shock Absorbers - The Use of Social Media in ICD Patient Support11 Abbott: Accuracy Matters12 APHRS 2019: Bangkok
THE APHRS SUMMIT 2019: JAKARTADr. Dicky A. Hanafy, MD; Prof. Yoga Yuniadi, MD, PhD
The APHRS Summit 2019 was held in Jakarta on 23rd -24th February 2019, hosted by the Asia Pacific Heart Rhythm Society and organized by the Indonesia Heart Rhythm Society.
The summit was an important activity of APHRS where the key board members came together to meet and discuss on the future activities of APHRS. The subcommittee chairpersons of the various subcommittees of APHRS were also discussing on their plans for their current and future activities. At the same time during the summit, the device and pharmaceutical companies were also having private meetings with the key members of the APHRS board to discuss how together we get to improve electrophysiology development in the Asia Pacific region.
During the board meeting, there was also a full day arrhythmia symposium delivered by the APHRS Board Members and Indonesian EP specialists which consists of review of the latest key topics in EP and device therapy. Topics such as Atrial Fibrillation, SVT, VT, Bradycardia, and Device Therapy were covered. The summit was well-received with more than 760 participants (2 from Australia, 1 from Vietnam, 2 from Malaysia and 755 from all over Indonesia).
A group photo of the APHRS Board Members and Subcommittee Chairpersons at the APHRS Summit 2019 in Jakarta
Front (Left to Right): Wei Hua, Shu Zhang, Jonathan Kalman, Anil Saxena, Wee Siong Teo, Shih-Ann Chen, Chu-Pak Lau, Masayasu Hiraoka, Young-Hoon Kim, Takashi Nitta, Yoga Yuniadi, Tachapong Ngarmukos, Kyoko Soejima
Back (Left to Right): Pham Tran Linh, Myung-Jin Cha, Dicky A. Hanafy, Tze-Fan Chao, Rohan Gunawardhane, Minglong Chen, Ajay Naik, Hui-Nam Pak, Chen-Chuan Cheng, Kazuo Matsumoto, Yung-Kuo Lin, Dean Boddington, Yong Seog Oh, Nwe Nwe, Chandara Mam, Martin Stiles, Saruul Tseveendee, Ngai-Yin Chan, Morio Shoda, Takeshi Aiba, Giselle Gervacio, Chi Keong Ching, Sofian Johar, Zulkeflee Muhammad, Andrew McGavigan
A view of Board Meeting
03 APHRS SUMMIT 2019: JAKARTA
Participants’ impression on venue of symposium
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Participants’ impression on symposium in general
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Participants’ willingness to recommend the meeting in the future
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Dr. Dicky A. Hanafy
Opening speech from Prof. Chu-Pak Lau, President of the APHRS (2019)
The Angklung (Indonesian traditional bamboo tube musical instrument) played by all attendees during the opening ceremony
A “Gong” beaten by Prof. Chu-Pak Lau as a sign of symposium opening
Attendees at the symposium
Prof. Shih-Ann Chen Prof. Young-Hoon Kim Dr. Tachapong Ngarmukos
The Scientific Symposium
Opening Ceremony
Participants’ Evaluation
Left to Right: Prof. Yoga Yuniadi, Dr. Myung-Jin Cha and Prof. Chen-Chuan Cheng
04 THE USE OF DIRECT ORAL ANTICOAGULANT FOR STROKE PREVENTION IN TAIWAN PATIENTS WITH NON-VALVULAR AF
THE USE OF DIRECT ORAL ANTICOAGULANT FOR STROKE PREVENTION IN TAIWAN PATIENTS WITH
1The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan 33305, Taiwan 2College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
3Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan 33305, Taiwan4Department of Public Health, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
safer alternatives to warfarin.7-10 The safety profiles showed that most DOACs caused a lower risk of ICH and major bleeding, but an increased risk of gastrointestinal bleeding compared with warfarin. Of particular note, Asians may receive greater benefit from DOACs compared with non-Asians as they carry a higher risk of ICH and have a greater difficulty maintaining the therapeutic range of INR when taking warfarin.4, 11 The post-hoc analyses from four pivotal NOACs trials indicated that DOACs may be more effective and safer in Asians than in non-Asians.12, 13
The use of direct oral anticoagulants (DOACs) among NVAF Patients in Taiwan’s real-world practice The National Health Insurance (NHI) system in Taiwan is a mandatory universal health insurance program which provides comprehensive medical care coverage to all Taiwanese. As of 2016, there were > 23 million enrollees and a > 99% coverage rate of the entire population. DOAC is covered by NHI for NVAF patients with CHA2DS2-VASc ≥ 2 and it is estimated that at least 50,000 patients have the experience of DOACs in Taiwan from June 01, 2012 to December 31, 2016 (Figure 1). The result indicated that three DOACs (apixaban, rivaroxaba, and dabigatran) were all associated with lower risks of thromboembolism and major bleeding compared with warfarin, and the phase III results of DOACs trials in Asian subgroup all translated well into Taiwan’s real world practice14 (Figure 2-4). Recent study also demonstrated that after the introduction of DOACs in Taiwan, the
The use of warfarin in Asians with non-valvular atrial fibrillation (NVAF) Atrial fibrillation (AF) is the most common cardiac arrhythmia with a global prevalence of 2% to 3%, which significantly increases the risk of embolic stroke and death.1 Oral anticoagulants, like vitamin K antagonists (e.g., warfarin), is a commonly used anticoagulant to prevent possible thromboembolic events in AF patients. Previous studies indicated that warfarin significantly reduces the risk of embolic stroke and mortality, while it also doubles the risk of intracranial hemorrhage at the same time.2,
3 Furthermore, Asian patients with non-valvular AF (NVAF) are at an unacceptably higher risk of intracranial hemorrhage (ICH) while taking warfarin, even when the international normalized ratio (INR) is ideally maintained in the target range of 2 to 3.4
The reasons why Asian patients are more prone to warfarin related major bleeding compared to non-Asians was partially explained by the variations of genetic polymorphisms for VKA metabolism, multiple drug-food interaction, and use of herbal medicine among Asians.5, 6
The use of direct oral anticoagulants (DOACs) in Asians with NVAF Unlike warfarin, direct oral anticoagulants (DOACs) —namely dabigatran, rivaroxaban, apixaban, and edoxaban—do not require routine monitoring and have fewer potential drug–drug or drug–food interactions. Furthermore, several large trials have indicated that DOACs have non-inferior or improved efficacy compared with warfarin and are
05 THE USE OF DIRECT ORAL ANTICOAGULANT FOR STROKE PREVENTION IN TAIWAN PATIENTS WITH NON-VALVULAR AF
It is the largest Asian-specific cohort taking DOACs around the world
Figure 1The population of Taiwanese with non-valvular atrial fibrillation (NVAF) taking direct oral anticoagulants (DOACs) from June 01, 2012 to December 31, 2016
Apixaban
Dabigatran
Rivaroxaban
Warfarin
05000 2000010000
n = 5,843
n = 20,079
n = 27,777
n = 19,375
110mg BID88%
2.5mg62%
5mg BID38%
150mg BID12%
2012/06/01-2016/12/31
Yi-Hsin Chan, Lai-Chu See and Chi-Tai Kuo. JAHA. 2018;7:e008150
10mg QD40%
15mg QD54%
20mg QD6%
2500015000 30000
3623
17760
11029
19375
14971 1777
2319
2220
The phase III resullt of ARISTOTLE (East Asia) ‘translates’ well into Taiwan’s real world practice
Figure 2The phase III results of DOACs trial (apixaban) in Asian subgroup translated well into Taiwan’s real world practice
ARISTOTLE East Asia
Apixaban N = 988Warfarin N = 1,005
Mean CHA2DS2-VASc = 3.3
* P < 0.05 vs. warfarin * P < 0.05 vs. warfarin
The Taiwan Cohort
Apixaban N = 5,843Warfarin N = 19,375
Mean CHA2DS2-VASc = 3.9
1 1
2 2
3 3
4 4
5 5
Incid
ence
rate
(per
100
PYs
)
Incid
ence
rate
(per
100
PYs
)
6 6
0 0IS/SE IS/SE
2.52 2.26Apixaban
HR = 0.74
HR = 1.17HR = 0.76
HR = 0.53*
HR = 0.41*
HR = 0.45*
HR = 0.55*
HR = 0.36*
Warfarin0.45 0.520.67 0.702.02 1.52
3.39 3.550.39 0.611.88 1.413.84 3.25
AMI AMIICH ICHALL MAJOR BLEEDING
ALL MAJOR BLEEDING
Goto et al., Am Heart J 2014;168:303-9Yi-Hsin Chan, Lai-Chu See and Chi-Tai Kuo. JAHA. 2018;7:e008150
The phase III resullt of ROCKET-AF (East Asia) ‘translates’ well into Taiwan’s real world practice
Figure 3The phase III results of DOACs trial (rivaroxaban) in Asian subgroup translated well into Taiwan’s real world practice
ROCKET-AF East Asia
Rivaroxaban N = 468Warfarin N = 464
Mean CHA2DS2-VASc = 4.4
* P < 0.05 vs. warfarin* P < 0.05 vs. warfarin
The Taiwan Cohort
Rivaroxaban N = 27,777Warfarin N = 19,375
Mean CHA2DS2-VASc = 3.9
1 1
2 2
3 3
4 4
5 5
Incid
ence
rate
(per
100
PYs
)
Incid
ence
rate
(per
100
PYs
)
6 6
0 0IS/SE IS/SE
2.63 3.00Rivaroxaban
HR = 0.78
HR = 1.00HR = 0.68
HR = 0.63
HR = 0.57*
HR = 0.51*
HR = 0.81*
HR = 0.24*
Warfarin0.99 0.430.59 0.743.44 1.97
3.38 3.550.99 0.612.46 1.415.14 3.25
AMI AMIICH ICHALL MAJOR BLEEDING
ALL MAJOR BLEEDING
Wong et al., Stroke. 2014;45:1739-1747Yi-Hsin Chan, Lai-Chu See and Chi-Tai Kuo. JAHA. 2018;7:e008150
The phase III resullt of RE-LY (Asia) ‘translates’ well into Taiwan’s real world practice
Figure 4The phase III results of DOACs trial (dabigatran) in Asian subgroup translated well into Taiwan’s real world practice
RE-LY Asia
(110 mg)
Dabigatran N = 923Warfarin N = 926
* P < 0.05 vs. warfarin* P < 0.05 vs. warfarin
The Taiwan Cohort
(110mg: 88%)
Dabigatran N = 20,079Warfarin N = 19,375
Mean CHA2DS2-VASc = 3.7
1 1
2 2
3 3
4 4
5 5
Incid
ence
rate
(per
100
PYs
)
Incid
ence
rate
(per
100
PYs
)
6 6
0 0IS/SE IS/SE
2.50 2.90Dabigatran
HR = 0.81
HR = 0.88 HR = 0.78
HR = 0.57*
HR = 0.65*
HR = 0.50*
HR = 0.82*
HR = 0.23*
Warfarin0.51 0.520.23 0.702.22 2.12
3.06 3.550.58 0.611.10 1.413.82 3.25
AMI AMIICH ICHALL MAJOR BLEEDING
ALL MAJOR BLEEDING
Hori et al. Stroke. 2013;44:1891-1896Yi-Hsin Chan, Lai-Chu See and Chi-Tai Kuo. JAHA. 2018;7:e008150
initiation rate of oral anticoagulants (OAC) in newly diagnosed patients with NVAF significantly increased from 13.6% to 35.6%. A lower risk of ischemic stroke and mortality was temporally associated with the increasing prescription rates of OACs.15
There are some interesting phenomenons for the DOAC prescription in Taiwan. We had observed a high prevalence of low-dose DOACs prescription among the large Asian cohort, with an approximately 62%, 88%, and 94% of patients taking low-dose apixaban (2.5 mg twice daily), rivaroxaban (15/10 mg once daily), and dabigatran (110 mg twice daily), respectively. The smaller body size of Asians as compared with non-Asians, fear of the iatrogenic bleeding events caused by DOACs, and multiple underlying comorbidities including chronic kidney diseases (CKD) in Asian patients render physicians reluctant to prescribe standard-dose DOACs for their patients. Another case is for the rivaroxaban in Taiwan’s real-world practice. Taiwan and Japan are the only two countries where low-dose rivaroxaban (15/10 mg once daily according to the J-ROCKET AF trial) has been approved for stroke prevention in NVAF patients. The 94% prescription of rivaroxaban 15/10 mg indicated that most physicians chose to follow the regimen of J-ROCKET AF (15/10 mg) rather than the ROCKET AF (20/15 mg) in Taiwan’s real-world practice. Interesting, our results indicated that the J-ROCKET AF (15/10 mg) regimen was associated with lower risks of thromboembolism and major bleeding compared with warfarin (INR target of 2 to 3) in Taiwan’s real-world practice (Figure 5).16
The concern of renal safety among NVAF Patients taking oral anticoagulants Another issue is the renal safety among patient with NVAF taking OAC. It is estimated that as high as 20.5% of all patients taking warfarin have experienced at least one episode of warfarin-related nephropathy (WRN) during their treatment course, with most cases occurring within 1 year after the initiation of treatment. The mechanisms underlying WRN are complicated and multifactorial but supra-
therapeutic doses of warfarin with an INR of > 3.0 may result in glomerular hemorrhage and consequent tubular injury caused by obstructive tubular RBC casts and heme-induced free radical injury. Warfarin also facilitates renal vascular calcification and the consequent decline in renal function via inhibition of the activation of matrix G1a protein and growth arrest specific gene 6 (GAS-6).17 Whether the DOACs with its anticoagulant mechanism independent from the Vitamin K related cascade, is associated with a lower risk of acute kidney injury (AKI) in patients with NVAF remains unknown. Our previous study indicated that use of warfarin carried a significantly higher annual risk of AKI than that of dabigatran especially for those with high CHA2DS2-VASc score (Figure 6).18 We also evaluated the risk of AKI in NVAF Asians taking other DOACs including apixaban, dabigatran, rivaroxaban as compared with warfarin. The results also confirmed that three DOACs were all associated with a significantly lower risk of AKI compared with warfarin for both CKD-free and CKD cohorts. The annual incidence of AKI for all NOACs and warfarin increased gradually as the increment of CHA2DS2-VASc for both CKD-free and CKD cohorts after propensity score weighting.19 Our results were supported by previous study showing that DAOCs were associated with lower risks of several renal outcomes including more than 30% decline of eGFR, doubling of serum creatinine, and the risk of AKI.20
Several concurrent medications may increase the risk of major bleeding among NVAF Patients taking DOACsPolypharmacy among patients taking DOAC may increase plasma levels and the risk of bleeding. Particular attention has been paid to medications such as CYP3A4 inhibitors or P-glycoprotein competitors that share common metabolic pathways with NOACs. However, current knowledge of drug-drug interactions associated with NOACs mainly comes from limited pharmacokinetic measurement, whereas the evidence of large clinical data was lacking. This nationwide population-based cohort study in Taiwan tested the concurrent use of 12 commonly prescribed medications that share
06 THE USE OF DIRECT ORAL ANTICOAGULANT FOR STROKE PREVENTION IN TAIWAN PATIENTS WITH NON-VALVULAR AF
The effectiveness/safety of Japan-dose rivaroxaban 15/10 mg in Taiwan’s real world practice (after baseline co-morbidities adjustment)
Dabigatran showed a lower risk of acute kidney injury than warfarin for high CHA2DS2-VASc score in CKD(-) and CKD(+) cohorts
Figure 5The J-ROCKET AF (15/10 mg once daily) regimen was associated with lower risks of thromboembolism and major bleeding compared with warfarin (INR target of 2 to 3) in Taiwan’s real-world practice
Figure 6Dabigatran showed a lower risk of acute kidney injury than warfarin for high CHA2DS2-VASc score in chronic kidney disease free (CKD(-)) and CKD(+) cohorts in Taiwan’s real-world practice
Hsin-Fu Lee*, Yi-Hsin Chan*, Chi-Tai Kuo, and Lai-Chu See, IJC 2018, Jun 15;261:78-83
Yi-Hsin Chan, Lai-Chu See and Chi-Tai Kuo. JACC. 2016;68(21):2272-2283.
07 THE USE OF DIRECT ORAL ANTICOAGULANT FOR STROKE PREVENTION IN TAIWAN PATIENTS WITH NON-VALVULAR AF
Concurrent use of amiodarone, fluconaole, rifampin, and phenytoin was associated with increased risk of major bleeding in patients taking DOACs
Figure 7Concurrent use of amiodarone, fluconazole, rifampin, and phenytoin was associated with increased risk of major bleeding in patients taking DOACs in Taiwan’s real-world practice
Shang-Hung Chang et al......and Chang-Fu Kuo. JAMA. 2017 Oct 3;318(13):1250-1259
metabolic pathways with DOACs, which demonstrated that concurrent use of amiodarone, fluconazole, rifampin, and phenytoin was associated with increased risk of major bleeding in patients taking DOAC, whereas some combinations not recommended by the ESC guidelines were not associated with major bleeding.21
ConclusionIn conclusion, consistent with the RCT evidence of the four DOACs in the post-hoc analysis of Asian subgroups, DOACs appear to preserve the superior efficacy and safety profile over warfarin in Taiwan’s real-world practice. DOACs may be a safer alternative to warfarin in Asians with NVAF in terms of the risk of anticoagulant-related AKI. Several concurrent medications may be associated with increased risk of major bleeding in Asians with NVAF taking DOAC. Further prospective and randomized controlled validation of our results in a future study is warranted.
References1. Chiang CE, Wu TJ, Ueng KC, Chao TF, Chang KC, Wang CC, Lin YJ, Yin WH, Kuo JY, Lin WS, Tsai CT, Liu YB, Lee KT, Lin LJ, Lin LY, Wang KL, Chen YJ, Chen MC, Cheng CC, Wen MS, Chen WJ, Chen JH, Lai WT, Chiou CW, Lin JL, Yeh SJ, Chen SA. 2016 guidelines of the taiwan heart rhythm society and the taiwan society of cardiology for the management of atrial fibrillation. Journal of the Formosan Medical Association = Taiwan yi zhi. 2016;115:893-9522. Hart RG, Pearce LA, Aguilar MI. Meta-analysis: Antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Annals of internal medicine. 2007;146:857-8673. Lip GY, Edwards SJ. Stroke prevention with aspirin, warfarin and ximelagatran in patients with non-valvular atrial fibrillation: A systematic review and meta-analysis. Thrombosis research. 2006;118:321-3334. Shen AY, Yao JF, Brar SS, Jorgensen MB, Chen W. Racial/ethnic differences in the risk of intracranial hemorrhage among patients with atrial fibrillation. Journal of the American College of Cardiology. 2007;50:309-3155. Gaikwad T, Ghosh K, Shetty S. Vkorc1 and cyp2c9 genotype distribution in asian countries. Thrombosis research. 2014;134:537-5446. Ho CW, Ho MH, Chan PH, Hai JJ, Cheung E, Yeung CY, Lau KK, Chan KH, Lau CP, Lip GY, Leung GK, Tse HF, Siu CW. Ischemic stroke and intracranial hemorrhage with aspirin, dabigatran, and warfarin: Impact of quality of anticoagulation control. Stroke. 2015;46:23-30
08 THE USE OF DIRECT ORAL ANTICOAGULANT FOR STROKE PREVENTION IN TAIWAN PATIENTS WITH NON-VALVULAR AF
7. Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, Pogue J, Reilly PA, Themeles E, Varrone J, Wang S, Alings M, Xavier D, Zhu J, Diaz R, Lewis BS, Darius H, Diener HC, Joyner CD, Wallentin L, Committee R-LS, Investigators. Dabigatran versus warfarin in patients with atrial fibrillation. The New England journal of medicine. 2009;361:1139-11518. Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, Hacke W, Breithardt G, Halperin JL, Hankey GJ, Piccini JP, Becker RC, Nessel CC, Paolini JF, Berkowitz SD, Fox KA, Califf RM, Investigators RA. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. The New England journal of medicine. 2011;365:883-8919. Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM, Hanna M, Al-Khalidi HR, Ansell J, Atar D, Avezum A, Bahit MC, Diaz R, Easton JD, Ezekowitz JA, Flaker G, Garcia D, Geraldes M, Gersh BJ, Golitsyn S, Goto S, Hermosillo AG, Hohnloser SH, Horowitz J, Mohan P, Jansky P, Lewis BS, Lopez-Sendon JL, Pais P, Parkhomenko A, Verheugt FW, Zhu J, Wallentin L, Committees A, Investigators. Apixaban versus warfarin in patients with atrial fibrillation. The New England journal of medicine. 2011;365:981-99210. Giugliano RP, Ruff CT, Braunwald E, Murphy SA, Wiviott SD, Halperin JL, Waldo AL, Ezekowitz MD, Weitz JI, Spinar J, Ruzyllo W, Ruda M, Koretsune Y, Betcher J, Shi M, Grip LT, Patel SP, Patel I, Hanyok JJ, Mercuri M, Antman EM, Investigators EA-T. Edoxaban versus warfarin in patients with atrial fibrillation. The New England journal of medicine. 2013;369:2093-210411. Oh S, Goto S, Accetta G, Angchaisuksiri P, Camm AJ, Cools F, Haas S, Kayani G, Koretsune Y, Lim TW, Misselwitz F, van Eickels M, Kakkar AK, Investigators G-A. Vitamin k antagonist control in patients with atrial fibrillation in asia compared with other regions of the world: Real-world data from the garfield-af registry. International journal of cardiology. 2016;223:543-54712. Wang KL, Lip GY, Lin SJ, Chiang CE. Non-vitamin k antagonist oral anticoagulants for stroke prevention in asian patients with nonvalvular atrial fibrillation: Meta-analysis. Stroke; a journal of cerebral circulation. 2015;46:2555-256113. Lip GY, Wang KL, Chiang CE. Non-vitamin k antagonist oral anticoagulants (noacs) for stroke prevention in asian patients with atrial fibrillation: Time for a reappraisal. Int J Cardiol. 2015;180:246-25414. Chan YH, See LC, Tu HT, Yeh YH, Chang SH, Wu LS, Lee HF, Wang CL, Kuo CF, Kuo CT. Efficacy and safety of apixaban, dabigatran, rivaroxaban, and warfarin in asians with nonvalvular atrial fibrillation. J Am Heart Assoc. 2018;715. Tze-Fan Chao C-EC, Yenn-Jiang Lin , Shih-Lin Chang , Li-Wei Lo , Yu-Feng Hu , Ta-Chuan Tuan , Jo-Nan Liao , Fa-Po Chung , Tzeng-Ji Chen , Gregory Y.H. Lip , and Shih-Ann Chen. Evolving changes of the use of oral anticoagulants and outcomes in patients with newly diagnosed atrial fibrillation in taiwan. Circulation. 2018;138:1485–148716. Lee HF, Chan YH, Tu HT, Kuo CT, Yeh YH, Chang SH, Wu LS, See LC. The effectiveness and safety of low-dose rivaroxaban in asians with non- valvular atrial fibrillation. Int J Cardiol. 2018;261:78-8317. Narasimha Krishna V, Warnock DG, Saxena N, Rizk DV. Oral anticoagulants and risk of nephropathy. Drug Saf. 2015;38:527-53318. Chan YH, Yeh YH, See LC, Wang CL, Chang SH, Lee HF, Wu LS, Tu HT, Kuo CT. Acute kidney injury in asians with atrial fibrillation treated with dabigatran or warfarin. J Am Coll Cardiol. 2016;68:2272-228319. Chan YH, Yeh YH, Hsieh MY, Chang CY, Tu HT, Chang SH, See LC, Kuo CF, Kuo CT. The risk of acute kidney injury in asians treated with apixaban, rivaroxaban, dabigatran, or warfarin for non-valvular atrial fibrillation: A nationwide cohort study in taiwan. Int J Cardiol. 2018;265:83-8920. Yao X, Tangri N, Gersh BJ, Sangaralingham LR, Shah ND, Nath KA, Noseworthy PA. Renal outcomes in anticoagulated patients with atrial fibrillation. J Am Coll Cardiol. 2017;70:2621-263221. Chang SH, Chou IJ, Yeh YH, Chiou MJ, Wen MS, Kuo CT, See LC, Kuo CF. Association between use of non-vitamin k oral anticoagulants with and without concurrent medications and risk of major bleeding in nonvalvular atrial fibrillation. JAMA. 2017;318:1250-1259
09 THE USE OF DIRECT ORAL ANTICOAGULANT FOR STROKE PREVENTION IN TAIWAN PATIENTS WITH NON-VALVULAR AF
Thank You for Your Contribution in 2018!
Koichiro Kumagai (Japan), EP Ablation Subcommittee Chair (2018)
Chern-En Chiang (Taiwan), Practice Guideline Subcommittee Chair (2018)
Amit Vora (India), APHRS Country Representative (2018)
Muhammad Munawar (Indonesia), APHRS Country Representative (2018)
Seil Oh (Korea), APHRS Country Representative (2018)
Azmat Hayat (Pakistan), APHRS Country Representative (2018)
Susitha Amarasinghe (Sri Lanka), APHRS Country Representative (2018)
Buncha Sunsaneewitayakul (Thailand), APHRS Country Representative (2018)
Quoc Khanh Pham (Vietnam), APHRS Country Representative (2018)
10 SHOCK ABSORBERS
SHOCK ABSORBERS - THE USE OF SOCIAL MEDIA IN ICD PATIENT SUPPORT
Karen de Bruijn, Nelson Hospital, New Zealand.
I am a senior cardiac physiologist at Nelson Hospital in the South Island of New Zealand, in charge of the pacemaker/ICD service in the Nelson/Marlborough district. Our relatively small ICD population (160) comes from the city of Nelson, neighbouring town of Blenheim and surrounding rural areas. We see them annually in hospital clinics as well as most having home monitoring.It was one of our more unstable patients, with a history of working in health initiatives in the UK, who helped organise our inaugural ICD Support Group meeting and coined the name “Shock Absorbers”. It was invaluable to have an “ICD Wearer” (as he calls himself) on the team so that the meeting could involve the wishes and needs from a patient perspective. It was a well attended meeting but half of the ICD population had to drive several hundred kilometres to attend as the two main centres are separated by hills and a 2-hour drive.The biggest city in the South Island, Christchurch, has a long established and well-run support group that includes some great speakers and input from their team of EP docs and physiologists. Some people in our region with ICDs regularly travel to Christchurch from Blenheim and Nelson to attend their meetings but it is a 4-5hr drive for our patients to attend. After our inaugural meeting, the wife of an ex-ICD patient, who has since had cardiac transplant, suggested we set up a Facebook group for those with ICDs and their spouses, whanau (family), parents of young people with ICDS and other loved ones. I then set up the Shock Absorbers Facebook group.Social media is not for young people anymore and the younger ones are often horrified that their parents and grandparents want to “friend” them on Facebook. Older people are much more savvy on computers now and most of our ICD people, even the older ones, are already on Facebook.The “Shock Absorbers” Facebook group is a closed group, meaning that the group admin has to approve any new members and only group members can read or post on the page, thereby giving a secure environment to share health issues that you may not want to share with your regular Facebook friends and family.I co-administrate the group with Adele Clayton who is both an ICD patient and Arrhythmia Nurse Specialist at North Shore Hospital (Auckland NZ).
“Shock Absorbers” was started as a support group for Nelson/ Marlborough people but has extended to other parts of New Zealand, and even Australia, the USA and UK. The group now has 250 members. The members also include health professionals working with ICDs.
What does it achieve?Many will read but not post, but we have a few who are regular posters and activity has increased as new members join and tell their story and ask questions. If anyone has a specific problem, they will ask on the Facebook page and will get answers and comment from other ICD wearers, family, or one of the techs/nurses/ cardiologists on the site As an ICD tech, I try to answer the questions in a general and non-specific way so as to educate others with a similar problem, or suggest they talk to their ICD clinic for more individualised advice. I also try to keep the site alive with educational and topical posts that are relevant to our ICD group.The other advantage of a social media group is that it allows people with ICDs to get around the hospital confidentiality and communicate with each other. If they don’t want to share on the group page, they can private message each other or arrange to meet in real life. It is a real advantage that it brings people together who are geographically separated, even within our own large catchment of Nelson/ Marlborough.We have the Facebook link if you would like pass it on to your ICD patients.https://www.facebook.com/groups/ShockAbsorbers/
