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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O’Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary. J Am Coll Cardiol 2021; 77:450-500. [DOI: 10.1016/j.jacc.2020.11.035] [Citation(s) in RCA: 272] [Impact Index Per Article: 90.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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52
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Abstract
Atrial fibrillation (AF) is the most common cardiac arrythmia and a major cause of stroke, heart failure, sudden death, and cardiovascular morbidity. AF increases risk of thromboembolic stroke via stasis in the left atrium and subsequent embolization to the brain. In patients with acute ischemic stroke, it is essential that clinicians undertake careful investigation to search for AF. In these patients, up to 23.7% eventually are found to have underlying AF. Oral anticoagulation is effective in prevention of strokes secondary to AF, reducing overall stroke numbers by approximately 64%. Left atrial appendage occlusion is promising for prevention of stroke in AF.
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Affiliation(s)
- Hani Essa
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK
| | - Andrew M Hill
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK; Department of Medicine for Older People, St Helens and Knowsley Teaching Hospitals NHS Trust, Marshalls Cross Road, St Helens, Liverpool WA9 3DA, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Sondra Skovvej, 15, Aalborg 9000, Denmark.
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53
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Sedaghat M, Lima BS, Bouzari R, Shadlou S. Gastrointestinal Bleeding Associated With Warfarin and Rivaroxaban Therapy in Atrial Fibrillation Cases with Concomitant Coagulopathy. Cardiovasc Hematol Disord Drug Targets 2021; 21:123-127. [PMID: 33390152 DOI: 10.2174/1871529x20999201231210044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 10/23/2020] [Accepted: 11/13/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND There is inadequate information on the risk of gastrointestinal (GI) bleeding in patients who are under rivaroxaban and warfarin therapy in Iran. Determining the risk of GI bleeding in patients receiving these two drugs can help to select a more appropriate anti-coagulation prophylaxis in high-risk patients. OBJECTIVE The aim of this study was to compare the incidence of GI bleeding in patients with atrial fibrillation (AF) and concomitant bleeding risk factors receiving either warfarin or rivaroxaban. METHODS In this observational study, 200 patients with AF and bleeding risk factors who referred to Imam Hossein Hospital (Tehran, Iran) were included. The patients were under treatment with either warfarin or rivaroxaban. The incidence of GI bleeding was compared between the two groups monthly for one year. RESULTS GI bleedings were observed in 61% and 34% of patients treated with warfarin and rivaroxaban, respectively (P = 0.001).Melena was the most common type of GI bleeding in both groups. History of hypertension, history of stroke, consumption of anti-platelet drugs, NSAID consumption, and history of alcohol consumption were associated with more frequent GI bleeding only in warfarin group. CONCLUSION The incidence of GI bleeding was lower in AF patients who received rivaroxaban compared to those treated with warfarin. Also, GI bleeding risk does not change according to the consumption of other anti-coagulant drugs and underlying history of hypertension or stroke in patients received rivaroxaban. Therefore, rivaroxaban is suggested as the choice of prophylaxisin patients with AF and concomitant coagulopathy.
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Affiliation(s)
- Meghdad Sedaghat
- Department of Internal Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Behnam Safarpour Lima
- Department of Neurology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reihanesadat Bouzari
- Department of Neurology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sarvenaz Shadlou
- Department of Internal Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Gokcal E, Horn MJ, Gurol ME. The role of biomarkers and neuroimaging in ischemic/hemorrhagic risk assessment for cardiovascular/cerebrovascular disease prevention. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:345-357. [PMID: 33632452 DOI: 10.1016/b978-0-12-819814-8.00021-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Stroke prevention in patients with atrial fibrillation is arguably one of the fastest developing areas in preventive medicine. The increasing use of direct oral anticoagulants and nonpharmacologic methods such as left atrial appendage closure for stroke prevention in these patients has increased clinicians' options for optimal care. Platelet antiaggregants are also commonly used in other ischemic cardiovascular and or cerebrovascular conditions. Long term use of oral anticoagulants for atrial fibrillation is associated with elevated risks of major bleeds including especially brain hemorrhages, which are known to have extremely poor outcomes. Neuroimaging and other biomarkers have been validated to stratify brain hemorrhage risk among older adults. A thorough understanding of these biomarkers is essential for selection of appropriate anticoagulant or left atrial appendage closure for stroke prevention in patients with atrial fibrillation. This article will address advances in the stratification of ischemic and hemorrhagic stroke risk among patients with atrial fibrillation and other conditions.
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Affiliation(s)
- Elif Gokcal
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Mitchell J Horn
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - M Edip Gurol
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States.
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55
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Domínguez-Erquicia P, Raposeiras-Roubín S, Abbu-Assi E, Cespón-Fernández M, Alonso-Rodríguez D, Camacho-Freire SJ, Cubelos-Fernández N, López-Masjuán Ríos Á, Melendo-Viu M, Íñiguez-Romo A. Incidence, predictors of bleeding and prognosis of bleeding in anticoagulated nonagenarian patients with atrial fibrillation. Int J Cardiol 2020; 327:217-222. [PMID: 33220362 DOI: 10.1016/j.ijcard.2020.11.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/02/2020] [Accepted: 11/12/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND The prevalence of atrial fibrillation (AF) increases with age. The prescription of anticoagulation in very elderly patients is controversial and sometimes underused. Our objective is to report the incidence and predictors of major bleeding in anticoagulated nonagenarian patients with non valvular atrial fibrillation (NVAF). METHODS We analyzed a large multicentre registry of anticoagulated nonagenarian patients diagnosed with NVAF from three health areas of Spain, between 2013 and 2017. Predictors of major bleeding were studied with a competing risk analysis and the impact of major bleeding with a time-dependent mortality analysis. RESULTS The incidence rate of major bleeding was 5 per100 person-year (95% Confidence Interval [CI]: 4.59-6.35), similar in the group of patients with vitamin K antagonists (VKAs) and direct oral anticoagulants (DOAC). In the VKAs group we found as predictors of major bleeding: previous admission for bleeding (sub-distribution hazard ratio [sHR] 3.25, 95% CI: 1.48-7.13), creatinine (sHR 1.38, 95% CI: 1.16-1.64,) and control out-of-range INR (sHR 1.90, 95% CI: 1.02-3.55). In DOAC group, male sex (sHR 1.92, 95% CI: 1.18-3.13) and the history of previous admission for bleeding (sHR 2.60, 95% CI 1.33-5.06) were found as a predictor. The HAS-BLED was not associated with major bleeding. Major bleeding was associated with increased mortality in both VKAs and DOAC groups without significant differences. CONCLUSIONS We found an incidence rate of major bleeding with relative low values, similar in those treated with VKAs and those treated with DOAC, with different predictors of major bleeding in each group. Major bleeding was associated with increased mortality, with no significant difference by oral anticoagulation therapy (OAT).
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Affiliation(s)
- Pablo Domínguez-Erquicia
- Cardiology Department, University Hospital Álvaro Cunqueiro, Vigo, Spain; Health Research Institute Galicia Sur, Vigo, Spain
| | - Sergio Raposeiras-Roubín
- Cardiology Department, University Hospital Álvaro Cunqueiro, Vigo, Spain; Health Research Institute Galicia Sur, Vigo, Spain.
| | - Emad Abbu-Assi
- Cardiology Department, University Hospital Álvaro Cunqueiro, Vigo, Spain; Health Research Institute Galicia Sur, Vigo, Spain
| | - María Cespón-Fernández
- Cardiology Department, University Hospital Álvaro Cunqueiro, Vigo, Spain; Health Research Institute Galicia Sur, Vigo, Spain
| | | | | | | | | | - María Melendo-Viu
- Cardiology Department, University Hospital Álvaro Cunqueiro, Vigo, Spain
| | - Andrés Íñiguez-Romo
- Cardiology Department, University Hospital Álvaro Cunqueiro, Vigo, Spain; Health Research Institute Galicia Sur, Vigo, Spain
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Páramo JA. Prediction and treatment of bleeding in patients under anticoagulant treatment. Med Clin (Barc) 2020; 156:20-25. [PMID: 33218693 DOI: 10.1016/j.medcli.2020.06.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/17/2020] [Accepted: 06/17/2020] [Indexed: 10/23/2022]
Abstract
Major bleeding is a common complication of anticoagulant treatment. Risk assessment tools are relevant in the management of patients with atrial fibrillation and venous thromboembolism. The combination of clinical, biological and genetic markers is incorporated to build predictive scores to help in the decision process about intensity and duration of treatment. The optimal management of bleeding involves the application of predictive scores in combination with anticoagulant reversal strategies.
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Affiliation(s)
- José A Páramo
- Servicio de Hematología, Clínica Universidad de Navarra, IdiSNA, CIBERCV, Pamplona, Navarra, España.
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57
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Nicol C, Lacut K, Pan-Petesch B, Lippert E, Ianotto JC. Hemorrhage in Essential Thrombocythemia or Polycythemia Vera: Epidemiology, Location, Risk Factors, and Lessons Learned from the Literature. Thromb Haemost 2020; 121:553-564. [PMID: 33186994 DOI: 10.1055/s-0040-1720979] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Hemorrhage is a well-known complication of essential thrombocythemia (ET) and polycythemia vera (PV), but evidence-based data on its management and prevention are lacking to help inform clinicians. In this review, appropriate published data from the past 15 years regarding bleeding epidemiology, classification, location, and risk factors are presented and discussed. Research was conducted using the Medline database. The bleeding classifications were heterogeneous among the collected studies. The median incidences of bleeding and major bleeding were 4.6 and 0.79% patients/year, in ET patients and 6.5 and 1.05% patients/year in PV patients, respectively. The most frequent location was the gastrointestinal tract. Bleeding accounted for up to 13.7% of deaths, and cerebral bleeding was the main cause of lethal hemorrhage. Thirty-nine potential risk factors were analyzed at least once, but the results were discrepant. Among them, age >60 years, bleeding history, splenomegaly, myeloproliferative neoplasm subtype, and platelet count should deserve more attention in future studies. Among the treatments, aspirin seemed to be problematic for young patients with ET (especially CALR-mutated ET patients) and anagrelide was also identified as a bleeding inducer, especially when associated with aspirin. Future studies should analyze bleeding risk factors in more homogeneous populations and with common bleeding classifications. More tools are needed to help clinicians manage the increased risk of potentially lethal bleeding events in these diseases.
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Affiliation(s)
- Christophe Nicol
- Service d'Hématologie Clinique, Institut de Cancéro-Hématologie, CHRU de Brest, Bretagne, France
| | - Karine Lacut
- Département de Médecine Interne et Pneumologie, CHRU de Brest, Bretagne, France.,GETBO, Groupe d'Etude de la Thrombose de Bretagne Occidentale, CHRU de Brest, Brest, Bretagne, France
| | - Brigitte Pan-Petesch
- Service d'Hématologie Clinique, Institut de Cancéro-Hématologie, CHRU de Brest, Bretagne, France.,GETBO, Groupe d'Etude de la Thrombose de Bretagne Occidentale, CHRU de Brest, Brest, Bretagne, France
| | - Eric Lippert
- Laboratoire d'Hématologie, CHRU de Brest, Bretagne, France.,FIM, France Intergroupe des Néoplasies Myéloprolifératives, France
| | - Jean-Christophe Ianotto
- Service d'Hématologie Clinique, Institut de Cancéro-Hématologie, CHRU de Brest, Bretagne, France.,GETBO, Groupe d'Etude de la Thrombose de Bretagne Occidentale, CHRU de Brest, Brest, Bretagne, France.,FIM, France Intergroupe des Néoplasies Myéloprolifératives, France
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58
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Jiang M, Zhou Y, Chen J, Zhang W, Sun Z, Qin M, Liu Y, Liu G. Effects of Herba Erigerontis injection on pharmacodynamics and pharmacokinetics of warfarin in rats in vivo. Basic Clin Pharmacol Toxicol 2020; 128:386-393. [PMID: 33155415 DOI: 10.1111/bcpt.13531] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 12/25/2022]
Abstract
Herba Erigerontis injection (HEI) is an aqueous solution derived from whole plants of Erigeron breviscapus, which may be co-administered with warfarin to treat cardiovascular and cerebrovascular disorders. This research was conducted to make sure whether HEI would affect anticoagulation of warfarin to guarantee reasonable medication. The pharmacodynamic study was designed to measure prothrombin time (PT) and activated partial thromboplastin time (APTT) values, and international normalized ratio (INR) values were calculated. For pharmacokinetic study, ultra performance liquid chromatography-tandem mass spectrometer (UPLC-MS/MS) technology was applied to measure plasma concentrations of warfarin enantiomers. The influence of HEI on plasma protein binding rate of warfarin was assessed by ultrafiltration. Pharmacodynamic study demonstrated that both HEI alone and co-administered with warfarin could increase PT and INR values significantly (P < .01), whereas the APTT values were unaffected (P > .05). Pharmacokinetic study manifested that Cmax , AUC and t1/2 prolonged significantly (P < .01) for R/S-warfarin in presence of HEI. Low (3.6 mL/kg), medium (7.2 mL/kg) and high (10.8 mL/kg) doses of HEI could decrease plasma protein binding rate of warfarin significantly (P < .01). The results mean that HEI can potentiate the anticoagulant response of warfarin through both pharmacodynamics and pharmacokinetics.
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Affiliation(s)
- Meiting Jiang
- Department of Pharmacy, The Second Affiliated Hospital, Harbin Medical University, The Heilongjiang Key Laboratory of Drug Research, Harbin, P.R. China
| | - Yangxu Zhou
- Department of Pharmacy, The Second Affiliated Hospital, Harbin Medical University, The Heilongjiang Key Laboratory of Drug Research, Harbin, P.R. China
| | - Jiayu Chen
- Department of Pharmacy, The Second Affiliated Hospital, Harbin Medical University, The Heilongjiang Key Laboratory of Drug Research, Harbin, P.R. China
| | - Wenlong Zhang
- Department of Pharmacy, The Second Affiliated Hospital, Harbin Medical University, The Heilongjiang Key Laboratory of Drug Research, Harbin, P.R. China
| | - Zhidan Sun
- Department of Pharmacy, The Second Affiliated Hospital, Harbin Medical University, The Heilongjiang Key Laboratory of Drug Research, Harbin, P.R. China
| | - Mengnan Qin
- Department of Pharmacy, The Second Affiliated Hospital, Harbin Medical University, The Heilongjiang Key Laboratory of Drug Research, Harbin, P.R. China
| | - Yan Liu
- Department of Pharmacy, The Second Affiliated Hospital, Harbin Medical University, The Heilongjiang Key Laboratory of Drug Research, Harbin, P.R. China
| | - Gaofeng Liu
- Department of Pharmacy, The Second Affiliated Hospital, Harbin Medical University, The Heilongjiang Key Laboratory of Drug Research, Harbin, P.R. China
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Abstract
Older adults with atrial fibrillation are at the highest risk of ischaemic stroke yet are the least likely to be prescribed anticoagulant therapy, adhere to this therapy, and maintain long-term persistence with this therapy. The reasons for this under treatment are multifactorial and include patient-driven factors, physician-driven factors, medical system complexities, and current unknowns regarding the biology and natural history of AF. Understanding these challenges to stroke prevention and addressing identified barriers to medication adherence and persistence in this vulnerable age group will improve outcomes related to AF.
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Affiliation(s)
- Elaine M Hylek
- Department of Medicine 72 East Concord Street, Boston University School of Medicine, Boston, MA 02118, USA
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60
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Intracerebral hemorrhage outcomes in patients using direct oral anticoagulants versus vitamin K antagonists: a meta-analysis. Clin Neurol Neurosurg 2020; 198:106146. [PMID: 32823187 DOI: 10.1016/j.clineuro.2020.106146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 08/07/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND The objective of this paper is to assess the clinical outcomes between non-traumatic intracerebral hemorrhage(ICH) in patients using direct oral anticoagulants(DOAC) versus vitamin K antagonists(VKA) for non-valvular atrial fibrillation. We also evaluated the predictors of the poor post-ICH outcomes. METHODS We have performed pooled meta-analysis to assess long-term clinical outcomes in patients with DOAC-ICH as compared to those with VKA-ICH. A systematic literature search was conducted by searching the full-text English literature in PubMed, EMBASE, and Cochrane databases for observational studies reporting outcomes on interest. MOOSE guidelines were used to collect data till December 31, 2019 and random effects analysis was carried out to account for heterogeneity. For outcomes, risk ratios(RR) and the mean differences were pooled using a random-effects model and weighted mean differences (WMDs), respectively. RESULTS Seventeen studies met the inclusion criteria (n = 25,354 patients; DOAC-ICH arms = 5,631; VKA-ICH arm = 19,273). Patients with DOAC-ICH had smaller hematoma volumes (WMD=-9.59; 95%CI=-15.33--3.85; I2 = 68.6%) and reduced mortality rate at discharge (RR = 0.82; 95%CI = 0.71-0.96; I2 = 9.4%). There was no significant difference between the two groups in rate of hematoma expansion (RR = 0.79; 95%CI = 0.56-1.11; I2 = 50.9%), unfavorable functional outcome(Modified Rankin Scale) at discharge (RR = 0.82; 95%CI = 0.56-1.18; I2 = 80.2%), unfavorable outcome at 3-months (RR = 0.77; 95%CI = 0.56-1.06; I2 = 63.9), and mortality at 3-months (RR = 0.90; 95%CI = 0.73-1.10; I2 = 35∙8%). Multivariate meta-regression revealed that the average age of patient population had a significantly negative correlation with(RR=-0.202; p = 0.017) hematoma expansion. CONCLUSION We conclude that use of DOAC is associated with reduced hematoma volume and mortality rate at discharge. Age is a predictor of the poor outcome of hematoma expansion.
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61
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Hota S, Ng M, Hilliard D, Burgess J. Thromboelastogram-Guided Resuscitation for Patients with Traumatic Brain Injury on Novel Anticoagulants. Am Surg 2020. [DOI: 10.1177/000313481908500839] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Traumatic brain injuries in patients on antithrombotic agents carry significant morbidity. Initial therapy is centered around reversal of these agents. The thromboelastogram (TEG) maps the clotting cascade to guide reversal. A retrospective chart review was conducted for 118 patients presenting with a traumatic brain injury while on antithrombotics. Patients were divided between those who received a TEG on arrival and those who did not. The primary endpoint was overall mortality. Secondary endpoints included blood product utilization, and outcomes associated with specific novel anticoagulants. Mortality in the control group was 20.3 per cent compared with 18.5 per cent in the TEG group ( P = 0.81). For less severe injuries, the control group mortality was 3.8 per cent and the TEG group mortality was 8.7 per cent ( P = 0.64). For more severe injuries, mortality in the control versus TEG groups were 31.6 per cent and 25.8 per cent, respectively ( P = 0.73). Blood product utilization was significantly lower in the TEG group ( P = 0.002). Overall mortality was not significantly different between the groups. However, when stratified by severity of injury, mortality was reduced in the TEG-guided group in severely injured patients. Blood product utilization was significantly reduced with TEG-guided reversal. Trauma centers can improve the utilization of blood products in reversal of antithrombotics with the use of TEG.
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Affiliation(s)
- Salini Hota
- Department of Surgery, Eastern Virginia Medical School, Norfolk, Virginia and
| | - Matthew Ng
- Department of Surgery, Eastern Virginia Medical School, Norfolk, Virginia and
| | - Dashaunda Hilliard
- Healthcare Analytics and Delivery Science Institute, Eastern Virginia Medical School, Norfolk, Virginia
| | - Jessica Burgess
- Department of Surgery, Eastern Virginia Medical School, Norfolk, Virginia and
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Birkemeyer R, Müller A, Wahler S, von der Schulenburg JM. A cost-effectiveness analysis model of Preventicus atrial fibrillation screening from the point of view of statutory health insurance in Germany. HEALTH ECONOMICS REVIEW 2020; 10:16. [PMID: 32519034 PMCID: PMC7282133 DOI: 10.1186/s13561-020-00274-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 05/19/2020] [Indexed: 05/04/2023]
Abstract
BACKGROUND With atrial fibrillation (AF) the risk of stroke is 4.2-fold increased to a comparable population without AF. This risk decreases by up to 70% if AF is detected early enough and effective stroke preventive measures are taken as recommended by international guidelines. Long-term studies found large number of subjects with undiagnosed AF. Preventicus Heartbeats" is a hands-on screening tool for use on smartphone to diagnose AF with high sensitivity and specificity. The aim of this study is to research the cost-effectiveness of systematic screening for AF with this smartphone application. METHOD Employing a Markov model we analysed the cost-effectiveness of the "Preventicus Heartbeats" screening for Germany, i.e. from the perspective of German statutory sick funds. RESULTS For a cohort of 10,000 insured 75-year-old the use of the diagnostic app could avoid 60 strokes in the remaining lifetime thereof 32 strokes in the next four years. Former models have applied similar cohorts. The same cohort showed an increase in quality-adjusted life years (QALY) in the remaining lifetime of 165 QALYs in the scenario with screening versus. without screening and a decrease in discounted lifetime costs (including risk compensation effects) of €129 per participant (€148 for male, €114 for female participants). CONCLUSIONS The modelling demonstrates the health benefits and economic effects of an implementation of a systematic screening on AF with "Preventicus Heartbeats", given the perspective of the German payer, the statutory health care system.
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Affiliation(s)
| | - Alfred Müller
- Analytic Services GmbH, Jahnstr. 34c, 80469, Munich, Germany
| | - Steffen Wahler
- St. Bernward GmbH, Friedrich-Kirsten-Straße 40, 22391, Hamburg, Germany.
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63
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Escobar C, Borrás X, Bover Freire R, González-Juanatey C, Morillas M, Muñoz AV, Gómez-Doblas JJ. A Delphi consensus on the management of oral anticoagulation in patients with non-valvular atrial fibrillation in Spain: ACOPREFERENCE study. PLoS One 2020; 15:e0231565. [PMID: 32479502 PMCID: PMC7263623 DOI: 10.1371/journal.pone.0231565] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 03/26/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To evaluate the level of agreement between cardiologists regarding the management of oral anticoagulation (OAC) in patients with non-valvular atrial fibrillation (NVAF) in Spain. MATERIALS AND METHODS A two-round Delphi study was performed using an online survey. In round 1, panel members rated their level of agreement with the questionnaire items on a 9-point Likert scale. Item selection was based on acceptance by ≥66.6% of panellists and the agreement of the scientific committee. In round 2, the same panellists evaluated those items that did not meet consensus in round 1. RESULTS A total of 238 experts participated in round 1; of these, 217 completed the round 2 survey. In round 1, 111 items from 4 dimensions (Thromboembolic and bleeding risk evaluation for treatment decision-making: 18 items; Choice of OAC: 39 items; OAC in specific cardiology situations: 12 items; Patient participation and education: 42 items) were evaluated. Consensus was reached for 92 items (83%). Over 80% of the experts agreed with the use of DOACs as the initial anticoagulant treatment when OAC is indicated. Panellists recommended the use of DOACs in patients at high risk of thromboembolic complications (CHA2DS2-VASc ≥3) (83%), haemorrhages (HAS-BLED ≥3) (89%) and poor quality of anticoagulation control (SAMe-TT2R2 >2) (76%), patients who fail to achieve an optimal therapeutic range after 3 months on VKA treatment (93%), and those who are to undergo cardioversion (80%). Panellists agreed that the efficacy and safety profile of each DOAC (98%), the availability of a specific reversal agent (72%) and patient's preference (85%) should be considered when prescribing a DOAC. A total of 97 items were ultimately accepted after round 2. CONCLUSIONS This Delphi panel study provides expert-based recommendations that may offer guidance on clinical decision-making for the management of OAC in NVAF. The importance of patient education and involvement has been highlighted.
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Affiliation(s)
- Carlos Escobar
- Cardiology Department, Hospital Universitario La Paz, Madrid, Spain
- * E-mail:
| | - Xavier Borrás
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Ramón Bover Freire
- Cardiology Department, Hospital Clínico San Carlos, CIBERCV, Madrid, Spain
| | | | - Miren Morillas
- Cardiology Department, Hospital de Galdakao, Galdakao, Bizkaia, Spain
| | | | - Juan José Gómez-Doblas
- Cardiology Department, Hospital Universitario Virgen de la Victoria, CIBERCV, Málaga, Spain
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64
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Hu C, Liu C, Wang Y, Ding T, Sun K, Tian S. The Timing of Symptomatic Pulmonary Embolism in Patients With Nonwarfarin Anticoagulants Following Elective Primary Total Joint Arthroplasty. J Arthroplasty 2020; 35:1703-1707. [PMID: 32046872 DOI: 10.1016/j.arth.2020.01.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 01/10/2020] [Accepted: 01/11/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The purpose of this study is to investigate the incidence and timing of postoperative, symptomatic pulmonary embolism (PE) in patients receiving nonwarfarin treatment following primary total joint arthroplasty (TJA), to clarify the appropriate duration of postoperative VTE prophylaxis. METHODS We retrospectively reviewed the medical records of 11,148 patients who underwent primary TJA, including total knee arthroplasty and total hip arthroplasty at our institution between January 2012 and March 2019. The median postoperative day of diagnosis of symptomatic PE and the interquartile range for day of diagnosis were determined. Multivariate Cox proportional hazards modeling was used to test the difference of timing for PE based on demographics and comorbidities. RESULTS The overall 90-day rate of symptomatic PE was 0.71%. The median day of diagnosis for symptomatic PE was 3 days postoperatively (interquartile range, 2-7 days). Factors showed statistical significance on multivariate analysis in association with earlier timing of PE occurrence in patients with atrial fibrillation, diabetes mellitus, coronary heart disease, and history of stroke. CONCLUSION The vast majority of symptomatic PE occurs in the early postoperative period after TJA, and atrial fibrillation, diabetes mellitus, coronary heart disease, and history of stroke were independent factors affecting the timing of symptomatic PE.
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Affiliation(s)
- Chuan Hu
- Department of Orthopaedic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chuan Liu
- Department of Medical Oncology, The First Hospital of China Medical University, Shenyang, China
| | - Yuanhe Wang
- Department of Orthopaedic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Tao Ding
- Department of Articular Surgery, The Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Kang Sun
- Department of Orthopaedic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Shaoqi Tian
- Department of Orthopaedic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
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Kim KS, Song JW, Soh S, Kwak YL, Shim JK. Perioperative management of patients receiving non-vitamin K antagonist oral anticoagulants: up-to-date recommendations. Anesth Pain Med (Seoul) 2020; 15:133-142. [PMID: 33329805 PMCID: PMC7713812 DOI: 10.17085/apm.2020.15.2.133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/05/2020] [Indexed: 01/12/2023] Open
Abstract
Indications of non-vitamin K antagonist oral anticoagulants (NOACs), consisting of two types: direct thrombin inhibitor (dabigatran) and direct factor Xa inhibitor (rivaroxaban, apixaban, and edoxaban), have expanded over the last few years. Accordingly, increasing number of patients presenting for surgery are being exposed to NOACs, despite the fact that NOACs are inevitably related to increased perioperative bleeding risk. This review article contains recent clinical evidence-based up-to-date recommendations to help set up a multidisciplinary management strategy to provide a safe perioperative milieu for patients receiving NOACs. In brief, despite the paucity of related clinical evidence, several key recommendations can be drawn based on the emerging clinical evidence, expert consensus, and predictable pharmacological properties of NOACs. In elective surgeries, it seems safe to perform high-bleeding risk surgeries 2 days after cessation of NOAC, regardless of the type of NOAC. Neuraxial anesthesia should be performed 3 days after cessation of NOACs. In both instances, dabigatran needs to be discontinued for an additional 1 or 2 days, depending on the decrease in renal function. NOACs do not require a preoperative heparin bridge therapy. Emergent or urgent surgeries should preferably be delayed for at least 12 h from the last NOAC intake (better if > 24 h). If surgery cannot be delayed, consider using specific reversal agents, which are idarucizumab for dabigatran and andexanet alfa for rivaroxaban, apixaban, and edoxaban. If these specific reversal agents are not available, consider using prothrombin complex concentrates.
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Affiliation(s)
- Kwang-Sub Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Wook Song
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sarah Soh
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Lan Kwak
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae-Kwang Shim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
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Cerebral Microbleeds and Chronic Kidney Disease in Acute Ischemic Stroke Patients with Atrial Fibrillation. J Stroke Cerebrovasc Dis 2020; 29:104650. [PMID: 32024601 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 12/27/2019] [Accepted: 01/06/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Cerebral microbleeds (CMBs) are associated with the risk of intracerebral hemorrhage in stroke patients with atrial fibrillation (AF). We investigated the association between CMBs and chronic kidney disease (CKD) in patients with acute ischemic stroke and AF. METHODS We retrospectively examined consecutive patients with acute ischemic stroke and AF who underwent brain gradient-echo T2*-weighted magnetic resonance imaging. The number and distribution (lobar, deep or infratentorial, and mixed) of CMBs were assessed. Kidney function was assessed according to the estimated glomerular filtration rate (eGFR), which was calculated using a modified version of the Modification of Diet in Renal Disease equation. RESULTS Of the 357 included patients, 105 (29.4%) had CMBs. CKD (eGFR < 60 mL/min/1.73 m2) was found in 131 (36.7%) patients. Patients with CKD showed a higher prevalence of any form of CMB (41.2% versus 22.6%, P < .001), deep or infratentorial CMBs (19.9% versus 9.3%, P < .01), and mixed CMBs (14.5% versus 5.3%, P < .01) than those without CKD. After adjusting for age and other confounding factors, CKD was found to be independently associated with the presence of any form of CMB (odds ratio 1.89, P = .02) and mixed CMBs (odds ratio 3.10, P < .01). Moreover, moderate to severe CKD (eGFR < 45 mL/min/1.73 m2) was independently associated with the presence of multiple CMBs (odds ratio 2.31, P = .04). CONCLUSIONS CMBs and CKD are common in acute ischemic stroke patients with AF, and CKD may be a risk factor for CMBs. Further longitudinal studies are needed to evaluate whether maintaining kidney function can prevent the development of CMBs.
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Zhao S, Hong X, Cao J, Zhang J, Ma P. Current Evidence for Pharmacologic Reversal Using Direct Oral Anticoagulants: What's New? Am J Cardiovasc Drugs 2020; 20:117-123. [PMID: 31440983 DOI: 10.1007/s40256-019-00366-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Direct oral anticoagulants are increasingly used in clinical practice and have addressed many of the issues related to vitamin K antagonists. However, the lack of reversal in life-threatening situations raises concerns regarding patient safety. Thus, current research is aimed at developing reversal agents that can safely neutralize the effects of anticoagulants. We present the design and mechanisms of action of and the animal models, clinical trials, and current evidence supporting the use of these emerging reversal agents. Idarucizumab is approved in many countries, and andexanet alfa has been approved by the US FDA, whereas others are in clinical trials. In view of the results of clinical studies to date, the problems of safety, price and accessibility remain. Therefore, these antidotes are a significant step towards improving the field of urgent and emergency reversal. From a practical perspective, post-market surveillance will be crucial to monitor the safety and effectiveness of these agents.
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Affiliation(s)
- Shujuan Zhao
- Department of Pharmacy, People's Hospital of Henan Province, Zhengzhou, 450003, Henan, China
| | - Xuejiao Hong
- Department of Pharmacy, People's Hospital of Henan Province, Zhengzhou, 450003, Henan, China
| | - Jingjing Cao
- Department of Pharmacy, People's Hospital of Henan Province, Zhengzhou, 450003, Henan, China
| | - Jing Zhang
- Department of Cardiovascular Medicine, People's Hospital of Henan Province, Zhengzhou, 450003, Henan, China
| | - Peizhi Ma
- Department of Pharmacy, People's Hospital of Henan Province, Zhengzhou, 450003, Henan, China.
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68
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Kezerle L, Tsadok MA, Berliner Senderey A, Hoshen M, Leventer‐Roberts M, Reges O, Leibowitz M, Haim M. Use of oral anticoagulation therapy in the first 3 months after the diagnosis of atrial fibrillation in Israel: A population‐based study. J Cardiovasc Electrophysiol 2020; 31:1356-1363. [DOI: 10.1111/jce.14452] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 03/10/2020] [Accepted: 03/16/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Louise Kezerle
- Cardiac Electrophysiology and Pacing, Cardiology Department, Soroka Medical CenterBen‐Gurion University of the NegevBeer Sheva Israel
| | - Meytal A. Tsadok
- Clalit Research InstituteChief Physician's Office, Clalit Health ServicesTel Aviv Israel
| | - Adi Berliner Senderey
- Clalit Research InstituteChief Physician's Office, Clalit Health ServicesTel Aviv Israel
| | - Moshe Hoshen
- Clalit Research InstituteChief Physician's Office, Clalit Health ServicesTel Aviv Israel
| | - Maya Leventer‐Roberts
- Clalit Research InstituteChief Physician's Office, Clalit Health ServicesTel Aviv Israel
| | - Orna Reges
- Clalit Research InstituteChief Physician's Office, Clalit Health ServicesTel Aviv Israel
- Department of Health Systems ManagementAriel University Israel
| | - Morton Leibowitz
- Clalit Research InstituteChief Physician's Office, Clalit Health ServicesTel Aviv Israel
| | - Moti Haim
- Cardiac Electrophysiology and Pacing, Cardiology Department, Soroka Medical CenterBen‐Gurion University of the NegevBeer Sheva Israel
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69
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Ding WY, Harrison S, Gupta D, Lip GYH, Lane DA. Stroke and Bleeding Risk Assessments in Patients With Atrial Fibrillation: Concepts and Controversies. Front Med (Lausanne) 2020; 7:54. [PMID: 32154260 PMCID: PMC7047213 DOI: 10.3389/fmed.2020.00054] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 02/05/2020] [Indexed: 12/20/2022] Open
Abstract
Risk assessments are an important element in the management of patients with atrial fibrillation (AF). In this review, we aim to discuss the concepts and controversies surrounding the various risk factors for stroke and bleeding in AF. Indeed, there are a variety of clinical, electrical, biological, and genetic markers to guide stroke and bleeding risk assessments in AF. The more common factors have been used to formulate risk stratification scores. Some risk factors have shown promise, but others remain less well-defined. Our aim is to discuss concepts and controversies surrounding current evidence of risk factors for stroke and bleeding assessments in AF.
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Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, United Kingdom
| | - Stephanie Harrison
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, United Kingdom
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, United Kingdom
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Wang CY, Pham PN, Kim S, Lingineni K, Schmidt S, Diaby V, Brown J. Predicting Cost-Effectiveness of Generic vs. Brand Dabigatran Using Pharmacometric Estimates Among Patients with Atrial Fibrillation in the United States. Clin Transl Sci 2020; 13:352-361. [PMID: 32053288 PMCID: PMC7070788 DOI: 10.1111/cts.12719] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 09/18/2019] [Indexed: 11/30/2022] Open
Abstract
Generic entry of newer anticoagulants is expected to decrease the costs of atrial fibrillation management. However, when making switches between brand and generic medications, bioequivalence concerns are possible. The objectives of this study were to predict and compare the lifetime cost‐effectiveness of brand dabigatran with hypothetical future generics. Markov microsimulations were modified to predict the lifetime costs and quality‐adjusted life years of patients on either brand or generic dabigatran from a US private payer perspective. Event rates for generics were predicted using previously developed pharmacokinetic‐pharmacodynamic models. The analyses showed that generic dabigatran with lower‐than‐brand systemic exposure were dominant. Meanwhile, generic dabigatran with extremely high systemic exposure was not cost‐effective compared with the brand reference. Cost‐effectiveness of generic medications cannot always be assumed as shown in this example. Combined use of pharmacometric and pharmacoeconomic models can assist in decision making between brand and generic pharmacotherapies.
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Affiliation(s)
- Ching-Yu Wang
- Department of Pharmaceutical Outcomes and Policy, Center for Drug Evaluation & Safety, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - Phuong N Pham
- Department of Pharmaceutical Outcomes and Policy, Center for Drug Evaluation & Safety, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - Sarah Kim
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology, University of Florida College of Pharmacy, Orlando, Florida, USA
| | - Karthik Lingineni
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology, University of Florida College of Pharmacy, Orlando, Florida, USA
| | - Stephan Schmidt
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology, University of Florida College of Pharmacy, Orlando, Florida, USA
| | - Vakaramoko Diaby
- Department of Pharmaceutical Outcomes and Policy, Center for Drug Evaluation & Safety, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - Joshua Brown
- Department of Pharmaceutical Outcomes and Policy, Center for Drug Evaluation & Safety, University of Florida College of Pharmacy, Gainesville, Florida, USA
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Ajmeri AN, Zaheer K, McCorkle C, Amro A, Mustafa B. Treating Venous Thromboembolism Post Intracranial Hemorrhage: A Case Report. Cureus 2020; 12:e6746. [PMID: 32133268 PMCID: PMC7034755 DOI: 10.7759/cureus.6746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Venous thromboembolism (VTE) is a significant issue occurring due to genetic, acquired and circumstantial risk factors. Treatment is according to the clinical situation and judgment for long term anticoagulation based on individual risk. Anticoagulation after a history of a hemorrhagic stroke poses a therapeutic dilemma. We present a case of a 68-year-old male who presented with right-sided chest pain and shortness of breath. Workup included a CT that was positive for multiple right-sided pulmonary emboli (PE). The patient has a past medical history of Factor V Leiden Mutation, recurrent PE, and deep vein thrombosis (DVT). Two months prior he was diagnosed with a 1.3-cm intracranial hemorrhage (ICH) from multiple cavernous angiomas. At that time his warfarin was discontinued and an inferior vena cave (IVC) filter was placed. Facing the recent ICH and now multiple and recurrent PE, it was decided to resume anticoagulation based on ICH location. ICH from a deep source is likely a better characteristic that favors a resumption of anticoagulation. Our case will highlight that IVC filters cannot be solely relied upon in patients that are at high risk for thrombotic events with underlying genetic thrombophilia.
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Affiliation(s)
- Aman N Ajmeri
- Internal Medicine, Marshall University, Joan C. Edwards School of Medicine, Huntington, USA
| | - Kamran Zaheer
- Internal Medicine, Marshall University, Joan C. Edwards School of Medicine, Huntington, USA
| | - Colin McCorkle
- Internal Medicine, Marshall University, Joan C. Edwards School of Medicine, Huntington, USA
| | - Ahmed Amro
- Cardiology, Marshall University, Joan C. Edwards School of Medicine, Huntington, USA
| | - Bisher Mustafa
- Internal Medicine, Marshall University, Joan C. Edwards School of Medicine, Huntington, USA
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Nielsen PB, Skjøth F, Søgaard M, Kjældgaard JN, Lip GYH, Larsen TB. Non-Vitamin K Antagonist Oral Anticoagulants Versus Warfarin in Atrial Fibrillation Patients With Intracerebral Hemorrhage. Stroke 2020; 50:939-946. [PMID: 30869568 PMCID: PMC6430592 DOI: 10.1161/strokeaha.118.023797] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose— Recurrent bleeding associated with oral anticoagulants (OACs) causes a dilemma in patients with atrial fibrillation (AF) sustaining an intracerebral hemorrhage. Treatment recommendations guiding clinical practice on optimal OAC agent selection in this population are lacking. This study aimed to investigate the comparative effectiveness and safety of non–vitamin K antagonist OAC (NOAC) versus warfarin in patients with AF sustaining an intracerebral hemorrhage. Methods— We conducted a nationwide observational cohort study including patients with AF sustaining an intracerebral hemorrhage and who subsequently claimed an OAC prescription. Contrasts of 1-year risks for ischemic stroke and intracerebral hemorrhage risks were obtained and evaluated by inverse probability treatment weighted absolute risk reduction and risk ratios. Results— Among 622 AF patients with intracerebral hemorrhage, 274 claimed a warfarin prescription and 348 a NOAC prescription. Mean age was 76 years (39% females); 72% had an index nonsevere event and 28% moderate to severe index event according to the Scandinavian Stroke Severity scale. The 1-year ischemic stroke risk was 7.85% for warfarin and 4.01% for NOACs, with a weighted absolute risk reduction of 3.78% (95% CI, −0.15% to 7.71%); the weighted risk ratio was 0.52 (0.27–1.00). For recurrent intracerebral hemorrhage, the risk was 7.00% for warfarin and 5.07% for NOACs. The absolute risk reduction was 1.93% (−2.02% to 5.87%), with an a weighted risk ratio of 0.72 (0.38–1.38). Conclusions— NOACs were associated with a nonsignificant lower risk of ischemic stroke and recurrent intracerebral hemorrhage compared with warfarin. The results add to current recommendations of selecting a NOAC agent for stroke prophylaxis treatment in patients with AF, including those with sustaining an intracerebral hemorrhage.
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Affiliation(s)
- Peter Brønnum Nielsen
- From the Department of Cardiology (P.B.N., M.S., J.N.K., T.B.L.), Aalborg University Hospital, Denmark.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Denmark (P.B.N., F.S., M.S., J.N.K., G.Y.H.L., T.B.L.)
| | - Flemming Skjøth
- Unit of Clinical Biostatistics (F.S.), Aalborg University Hospital, Denmark.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Denmark (P.B.N., F.S., M.S., J.N.K., G.Y.H.L., T.B.L.)
| | - Mette Søgaard
- From the Department of Cardiology (P.B.N., M.S., J.N.K., T.B.L.), Aalborg University Hospital, Denmark.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Denmark (P.B.N., F.S., M.S., J.N.K., G.Y.H.L., T.B.L.)
| | - Jette Nordstrøm Kjældgaard
- From the Department of Cardiology (P.B.N., M.S., J.N.K., T.B.L.), Aalborg University Hospital, Denmark.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Denmark (P.B.N., F.S., M.S., J.N.K., G.Y.H.L., T.B.L.)
| | - Gregory Y H Lip
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Denmark (P.B.N., F.S., M.S., J.N.K., G.Y.H.L., T.B.L.).,Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom (G.Y.H.L.)
| | - Torben Bjerregaard Larsen
- From the Department of Cardiology (P.B.N., M.S., J.N.K., T.B.L.), Aalborg University Hospital, Denmark.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Denmark (P.B.N., F.S., M.S., J.N.K., G.Y.H.L., T.B.L.)
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73
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Miki K, Natori Y, Kai Y, Yamada T, Mori M, Noguchi N, Koga H. Absence of Microbleeds Reduces the Risk for Recurrent Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2019; 29:104585. [PMID: 31883791 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104585] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 11/04/2019] [Accepted: 11/28/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Many known risk factors, including hypertension and hyperlipidemia cause intracerebral hemorrhage (ICH). Recently, microbleeds have been identified as one of the factors leading to ICH. While some patients have been found to have recurrent ICH, risk factors for recurrent ICH are scarcely reported. We conducted an observational study on the risk-factors of recurrent ICH, comparing stroke patients with a single hemorrhagic episode and those with recurrent ICH. METHODS A retrospective analysis of a single-center database was performed to analyze the clinical presentation and characteristics of patients with a single and recurrent ICH. From January 2016 to December 2017, a total of 317 patients were analyzed based on suspected factors including patients' sex, age, medical history, antiplatelet therapy use, and presence of microbleeds on images. RESULTS Of the 317 patients, 36 patients (11.4%) developed a second episode of cerebral hemorrhage. Brain magnetic resonance imaging (MRI) of the patients without microbleeds, predicted reduced risk of recurrence. This is the first report strongly associating the presence of microbleeds with the possibility of a recurrent ICH. Other factors under study did not show an apparent association with recurrent ICH probably because of the high statistical significance obtained with the presence of microbleeds. CONCLUSION Our findings revealed that the absence of microbleeds on images is a factor that strongly predicts a reduced risk for recurrent ICH and that the detection of microbleeds on MRI performed in patients with a single hemorrhagic episode, is useful in defining further therapeutic management. These findings may benefit physicians treating stroke patients.
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Affiliation(s)
- Kenji Miki
- Department of Neurosurgery, Aso Iizuka hospital, Iizuka, Fukuoka, Japan.
| | - Yoshihiro Natori
- Department of Neurosurgery, Aso Iizuka hospital, Iizuka, Fukuoka, Japan
| | - Yasutoshi Kai
- Department of Neurosurgery, Aso Iizuka hospital, Iizuka, Fukuoka, Japan
| | - Tetsuhisa Yamada
- Department of Neurosurgery, Aso Iizuka hospital, Iizuka, Fukuoka, Japan
| | - Megumu Mori
- Department of Neurosurgery, Aso Iizuka hospital, Iizuka, Fukuoka, Japan
| | - Naoki Noguchi
- Department of Neurosurgery, Aso Iizuka hospital, Iizuka, Fukuoka, Japan
| | - Hidenobu Koga
- Crinical Research Support Office, Aso Iizuka hospital, Iizuka, Fukuoka, Japan
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Pandor A, Horner D, Davis S, Goodacre S, Stevens JW, Clowes M, Hunt BJ, Nokes T, Keenan J, de Wit K. Different strategies for pharmacological thromboprophylaxis for lower-limb immobilisation after injury: systematic review and economic evaluation. Health Technol Assess 2019; 23:1-190. [PMID: 31851608 PMCID: PMC6936165 DOI: 10.3310/hta23630] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Thromboprophylaxis can reduce the risk of venous thromboembolism (VTE) during lower-limb immobilisation, but it is unclear whether or not this translates into meaningful health benefit, justifies the risk of bleeding or is cost-effective. Risk assessment models (RAMs) could select higher-risk individuals for thromboprophylaxis. OBJECTIVES To determine the clinical effectiveness and cost-effectiveness of different strategies for providing thromboprophylaxis to people with lower-limb immobilisation caused by injury and to identify priorities for future research. DATA SOURCES Ten electronic databases and research registers (MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Database of Abstracts of Review of Effects, the Cochrane Central Register of Controlled Trials, Health Technology Assessment database, NHS Economic Evaluation Database, Science Citation Index Expanded, ClinicalTrials.gov and the International Clinical Trials Registry Platform) were searched from inception to May 2017, and this was supplemented by hand-searching reference lists and contacting experts in the field. REVIEW METHODS Systematic reviews were undertaken to determine the effectiveness of pharmacological thromboprophylaxis in lower-limb immobilisation and to identify any study of risk factors or RAMs for VTE in lower-limb immobilisation. Study quality was assessed using appropriate tools. A network meta-analysis was undertaken for each outcome in the effectiveness review and the results of risk-prediction studies were presented descriptively. A modified Delphi survey was undertaken to identify risk predictors supported by expert consensus. Decision-analytic modelling was used to estimate the incremental cost per quality-adjusted life-year (QALY) gained of different thromboprophylaxis strategies from the perspectives of the NHS and Personal Social Services. RESULTS Data from 6857 participants across 13 trials were included in the meta-analysis. Thromboprophylaxis with low-molecular-weight heparin reduced the risk of any VTE [odds ratio (OR) 0.52, 95% credible interval (CrI) 0.37 to 0.71], clinically detected deep-vein thrombosis (DVT) (OR 0.40, 95% CrI 0.12 to 0.99) and pulmonary embolism (PE) (OR 0.17, 95% CrI 0.01 to 0.88). Thromboprophylaxis with fondaparinux (Arixtra®, Aspen Pharma Trading Ltd, Dublin, Ireland) reduced the risk of any VTE (OR 0.13, 95% CrI 0.05 to 0.30) and clinically detected DVT (OR 0.10, 95% CrI 0.01 to 0.94), but the effect on PE was inconclusive (OR 0.47, 95% CrI 0.01 to 9.54). Estimates of the risk of major bleeding with thromboprophylaxis were inconclusive owing to the small numbers of events. Fifteen studies of risk factors were identified, but only age (ORs 1.05 to 3.48), and injury type were consistently associated with VTE. Six studies of RAMs were identified, but only two reported prognostic accuracy data for VTE, based on small numbers of patients. Expert consensus was achieved for 13 risk predictors in lower-limb immobilisation due to injury. Modelling showed that thromboprophylaxis for all is effective (0.015 QALY gain, 95% CrI 0.004 to 0.029 QALYs) with a cost-effectiveness of £13,524 per QALY, compared with thromboprophylaxis for none. If risk-based strategies are included, it is potentially more cost-effective to limit thromboprophylaxis to patients with a Leiden thrombosis risk in plaster (cast) [L-TRiP(cast)] score of ≥ 9 (£20,000 per QALY threshold) or ≥ 8 (£30,000 per QALY threshold). An optimal threshold on the L-TRiP(cast) receiver operating characteristic curve would have sensitivity of 84-89% and specificity of 46-55%. LIMITATIONS Estimates of RAM prognostic accuracy are based on weak evidence. People at risk of bleeding were excluded from trials and, by implication, from modelling. CONCLUSIONS Thromboprophylaxis for lower-limb immobilisation due to injury is clinically effective and cost-effective compared with no thromboprophylaxis. Risk-based thromboprophylaxis is potentially optimal but the prognostic accuracy of existing RAMs is uncertain. FUTURE WORK Research is required to determine whether or not an appropriate RAM can accurately select higher-risk patients for thromboprophylaxis. STUDY REGISTRATION This study is registered as PROSPERO CRD42017058688. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Abdullah Pandor
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel Horner
- Emergency Department, Salford Royal NHS Foundation Trust, Salford, UK
| | - Sarah Davis
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - John W Stevens
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Mark Clowes
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Beverley J Hunt
- Haemostasis Research Unit, King's College London, London, UK
| | - Tim Nokes
- Department of Haematology, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Jonathan Keenan
- Department of Haematology, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Kerstin de Wit
- Department of Medicine, Hamilton General Hospital, Hamilton, ON, Canada
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75
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Shah SJ, Singer DE, Fang MC, Reynolds K, Go AS, Eckman MH. Net Clinical Benefit of Oral Anticoagulation Among Older Adults With Atrial Fibrillation. Circ Cardiovasc Qual Outcomes 2019; 12:e006212. [PMID: 31707823 PMCID: PMC7117790 DOI: 10.1161/circoutcomes.119.006212] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 10/16/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND While guidelines recommend anticoagulation for all atrial fibrillation (AF) patients ≥75 years, evidence for the net clinical benefit (NCB) of anticoagulant in older adults is sparse. We sought to determine the association between age and NCB of anticoagulation in older adults with AF. METHODS AND RESULTS We examined adults ≥75 years with incident AF in the Anticoagulation and Risk Factors in Atrial Fibrillation-Cardiovascular Research Network cohort. Using a Markov state transition model, we estimated the lifetime NCB of warfarin and apixaban relative to no treatment in quality-adjusted life years (QALYs). In the decision model, each month patients face a chance of stroke, hemorrhage, or death from a competing cause; the likelihood of each is a function of individual patients' stroke risk, hemorrhage risk, and life expectancy. We defined minimal clinically relevant lifetime benefit as 0.10 QALYs. In a sensitivity analysis, we examined the effect of competing risks of death on NCB using 2 models, one including competing risks and the second without competing risks. We included 14 946 patients, with a median age of 81 years and median CHA2DS2-VASc score of 4. In the main analysis, after age 87, NCB associated with warfarin decreased below 0.10 lifetime QALYs while NCB associated with apixaban did not decrease below 0.10 lifetime QALYs until after age 92. In sensitivity analyses, over a 3-year horizon, removing competing risks of death resulted in higher NCB (at 90 years, median difference using warfarin 0.010 QALYs [95% CI, 0.009-0.013], median difference using apixaban 0.025 QALYs [95% CI, 0.024-0.026]). CONCLUSIONS The NCB of anticoagulation decreases with advancing age. The competing risk of death diminishes the NCB of anticoagulation for older patients with AF. Physicians should consider competing mortality risks when recommending anticoagulants to older adults with AF.
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Affiliation(s)
- Sachin J Shah
- University of California, San Francisco (S.J.S., M.C.F., A.S.G.)
| | - Daniel E Singer
- Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.)
| | - Margaret C Fang
- University of California, San Francisco (S.J.S., M.C.F., A.S.G.)
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA (K.R.)
| | - Alan S Go
- University of California, San Francisco (S.J.S., M.C.F., A.S.G.)
- Division of Research, Kaiser Permanente Northern California, Oakland, CA (A.S.G.)
| | - Mark H Eckman
- University of Cincinnati College of Medicine, OH (M.H.E.)
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76
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[What are the indications and options for vascular reperfusion in the acute phase of pulmonary embolism?]. Rev Mal Respir 2019; 38 Suppl 1:e53-e58. [PMID: 31585780 DOI: 10.1016/j.rmr.2019.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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77
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Prothrombin Complex Concentrates for Perioperative Vitamin K Antagonist and Non-vitamin K Anticoagulant Reversal. Anesthesiology 2019; 129:1171-1184. [PMID: 30157037 DOI: 10.1097/aln.0000000000002399] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Vitamin K antagonist therapy is associated with an increased bleeding risk, and clinicians often reverse anticoagulation in patients who require emergency surgical procedures. Current guidelines for rapid anticoagulation reversal for emergency surgery recommend four-factor prothrombin complex concentrate and vitamin K coadministration. The authors reviewed the current evidence on prothrombin complex concentrate treatment for vitamin K antagonist reversal in the perioperative setting, focusing on comparative studies and in the context of intracranial hemorrhage and cardiac surgery. The authors searched Cochrane Library and PubMed between January 2008 and December 2017 and retrieved 423 English-language papers, which they then screened for relevance to the perioperative setting; they identified 36 papers to include in this review. Prothrombin complex concentrate therapy was consistently shown to reduce international normalized ratio rapidly and control bleeding effectively. In comparative studies with plasma, prothrombin complex concentrate use was associated with a greater proportion of patients achieving target international normalized ratios rapidly, with improved hemostasis. No differences in thromboembolic event rates were seen between prothrombin complex concentrate and plasma, with prothrombin complex concentrate also demonstrating a lower risk of fluid overload events. Overall, the studies the authors reviewed support current recommendations favoring prothrombin complex concentrate therapy in patients requiring vitamin K antagonist reversal before emergency surgery.
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78
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The Impact of Infection and Elevated INR in LVAD-Associated Intracranial Hemorrhage: A Case-Crossover Study. ASAIO J 2019; 65:545-549. [DOI: 10.1097/mat.0000000000000887] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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79
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Nadeem S, Abbas S, Jalal A. The effect of oral progesterone for the treatment of abnormal uterine bleeding in women taking warfarin following prosthetic valve replacement. Pak J Med Sci 2019; 35:887-892. [PMID: 31372112 PMCID: PMC6659061 DOI: 10.12669/pjms.35.4.907] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Objectives: To evaluate the effect of oral progesterone for the treatment of abnormal uterine bleeding in patients taking warfarin after prosthetic valve replacement. Methods: A total of 85 women of reproductive age, who were on warfarin due to prosthetic valve replacement were enrolled in the study. After detailed evaluation, their menstrual bleeding was quantified using Pictorial Bleeding Evaluation Chart. The patients were then prescribed an oral progesterone (Norethisterone) 5mg three times daily. The first follow up was done after one-month then at 3-months and at six months. The improvement in PBAC score was recorded at each visit. Data was entered and analyzed using SPSS (version 23.0). The mean ± Standard Deviation were calculated for quantitative variables while qualitative variables were presented in frequency table. The normality of data was checked using Kolmogorov-Smirnov test. Due lack of normal distribution of data in various groups, the Wilcoxon Sign Rank test was used to test the significance before and after treatment. The p-value of <0.05 was taken as statistically significant. Results: The mean age of the patients was 30.13±7.69 years. The mean PBAC score was 162.8 ± 24.86 before initiation of treatment while at the end of the treatment it was 105.48 ± 8.38. Forty-six (54.1%) patients had continuous per vaginal bleeding, 33 (38.8%) had menorrhagia, 4 (4.7%) had inter-menstrual bleeding and 2 (2.4%) had menorrhagia along with polymenorrhea. The mean dose of warfarin taken by the patients was 5.85 ± 2.69 mg. The median parity of the patients was 2. The Wilcoxon Sign Rank test showed p-value of <0.00001 for comparison of the pre-treatment PCBA values with those of one, three and six-months after the treatment. The Friedman’s test also had a p-value of <0.00001. This confirmed that the post treatment bleeding was significantly less than pretreatment bleeding. Conclusion: The warfarin induced abnormal uterine bleeding can be controlled effectively and safely with low dose of oral progesterone.
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Affiliation(s)
- Shafaq Nadeem
- Shafaq Nadeem, FCPS (Gynecology & Obstetrics), Department of Cardiac Surgery, The Clinic for Women with Cardiac Diseases, Faisalabad Institute of Cardiology, Faisalabad, Pakistan
| | - Shahid Abbas
- Shahid Abbas, FCPS (Cardiology), Department of Cardiology, Faisalabad Institute of Cardiology, Faisalabad, Pakistan
| | - Anjum Jalal
- Anjum Jalal FRCS, FCPS (Cardiac Surgery), FRCS-CTh, Department of Cardiac Surgery, Faisalabad Institute of Cardiology, Faisalabad, Pakistan
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80
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Exploring the effect of factor Xa inhibitors on rotational thromboelastometry: a case series of bleeding patients. J Thromb Thrombolysis 2019; 47:272-279. [PMID: 30506352 DOI: 10.1007/s11239-018-1785-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Direct oral anticoagulants (DOACs) have become the standard for thromboembolic risk management. In cases of major bleeding, trauma, or urgent surgery, accurate monitoring of DOAC activity is desirable; however, there is often no rapid, readily available test. We therefore explored the degree to which DOAC activity correlated with two coagulation assays: rotational thromboelastometry (ROTEM) and a standard coagulation assay in bleeding patients. We conducted a retrospective review of patients who experienced bleeding while on DOAC therapy from 2015 to 2017 at a Level 1 trauma center. ROTEM (EXTEM-clotting time {CT} in seconds), activated partial thromboplastin time (aPTT) (in seconds), prothrombin time (PT) (in seconds), DOAC specific drug test (anti-Xa and Hemoclot in ng/mL), and relevant clinical parameters were recorded. Descriptive statistics (median, range) and Spearman correlation coefficients were estimated. Differences between correlations were tested using Williams' t test. Twelve cases were reviewed (13 separate bleeding episodes). Sixteen measurements of DOAC activity, EXTEM-CT, and PT were obtained. The correlations with rivaroxaban activity were 0.96 and 0.86 (p = 0.2062) for PT and EXTEM-CT, respectively. The correlations with apixaban activity were 0.63 and 0.56 (p = 0.7175) for PT and EXTEM-CT, respectively. Analyses were not conducted for dabigatran due to limited data. Although not statistically significant, PT appears to have a higher correlation with direct Xa inhibitor activity than EXTEM-CT. Further research with larger samples is necessary to clarify the differences between ROTEM and standard assays in detecting DOAC activity.
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81
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Left atrial appendage closure in atrial fibrillation patients with prior major bleeding or ineligible for oral anticoagulation. Neth Heart J 2019; 27:613-620. [PMID: 31187455 PMCID: PMC6890920 DOI: 10.1007/s12471-019-1295-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Aims Oral anticoagulation (OAC) reduces the ischaemic stroke risk in patients with atrial fibrillation (AF), but in turn leads to an increased risk of adverse bleeding events. Alternatively, left atrial appendage closure (LAAC) using a mechanical device might overcome these bleeding complications. However, evidence regarding LAAC in patients at high bleeding risk is scarce. This study evaluates the clinical features of AF patients with previous bleeding that underwent LAAC. Methods In this retrospective cohort study patients with previous major bleeding or a bleeding predisposition scheduled for transcatheter LAAC were included. The frequency and type of previous bleeding events and prevalence of bleeding and ischaemic stroke during follow-up were evaluated. Results A total of 73 patients (58% male, age 72.1 ± 7.2 years; CHA2DS2-VASc 4.5 [3.0–5.0]; HAS-BLED 4.0 [3.0–4.0]; 46% paroxysmal AF) were included. Previous bleeding occurred from intracranial (n = 50, 69%), gastro-intestinal (n = 13, 18%) or multiple (n = 16, 22%) foci. After OAC discontinuation due to bleeding, 19% suffered subsequent stroke. LAAC was successful in 96% of patients. During a median of almost 3 years’ follow-up recurrent major bleeding occurred in 4 patients (5.5%) despite OAC discontinuation in 93.2%. A total of 6 ischaemic strokes were observed, resulting in an annualised stroke rate of 2.9% compared to a calculated expected stroke rate of 6.7%. Conclusions Percutaneous LAAC may provide an alternative strategy to long-term OAC therapy in AF patients with a high bleeding risk. During follow-up, both ischaemic stroke and recurrent bleeding rates were lower than expected based on the CHA2DS2-VASc and HAS-BLED scores respectively.
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82
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Ostermann H, von Heymann C. Prothrombin complex concentrate for vitamin K antagonist reversal in acute bleeding settings: efficacy and safety. Expert Rev Hematol 2019; 12:525-540. [PMID: 31159607 DOI: 10.1080/17474086.2019.1624520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Introduction: Current guidelines recommend the administration of prothrombin complex concentrate in combination with vitamin K for normalization of coagulation in patients presenting with vitamin K antagonist-associated major bleeding, but until recently no adequately powered comparative trials had been conducted to support these recommendations. In this article, the authors review the evidence from studies assessing prothrombin complex concentrate treatment in these patients. Areas covered: A PubMed search (spanning January 1900 to September 2018) was conducted using the following search terms: prothrombin complex concentrate* AND (warfarin or (vitamin K antagonist*)), and papers relevant to major hemorrhagic events were identified; results from studies that used a randomized controlled trial (RCT) or a prospective design are presented here. Overall, the identified studies support the current guideline recommendations and indicate that prothrombin complex concentrates have at least similar safety profiles to other treatment options, such as fresh frozen plasma and recombinant activated factor VII. Expert opinion: It is hoped that the results from studies discussed here will inform future guideline updates; however, local clinical practice may also occasionally act as a barrier to adoption of guideline recommendations. There is an urgent need for further RCTs/prospective trials directly comparing PCC and plasma administration in acute bleeding settings.
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Affiliation(s)
- Helmut Ostermann
- a Department of Hematology/Oncology , Ludwig-Maximilians-Universität München , Munich , Germany
| | - Christian von Heymann
- b Department of Anesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy , Vivantes Klinikum im Friedrichshain , Berlin , Germany
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83
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Anticoagulation Therapy in Patients with Liver Cirrhosis is Associated With an Increased Risk of Variceal Hemorrhage. Am J Med 2019; 132:758-766. [PMID: 30660572 DOI: 10.1016/j.amjmed.2019.01.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 01/08/2019] [Accepted: 01/08/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVE The belief that cirrhotic patients are "auto-anticoagulated" often results in anticoagulation therapy being withheld in these patients. We aimed to understand patterns of use of anticoagulation and to determine the risk of bleeding complications in cirrhotic patients. METHODS We retrospectively analyzed 320 cirrhotic patients treated with anticoagulation therapy from July 15, 2014 to January 30, 2018. We performed bivariate and multivariate analyses to identify risk factors for clinically relevant bleeding. We conducted a separate analysis using propensity score matching to compare bleeding rates of a noncirrhotic cohort group on anticoagulation to anticoagulated patients with cirrhosis. RESULTS Nonalcoholic steatohepatitis (47%) was the most common cause of cirrhosis, and 49% were classified as Child-Pugh class B, a mean model for end-stage liver disease score of 14 and Charlson comorbidity index of 7. Anticoagulation was initiated for atrial fibrillation/atrial flutter in 56% of patients; warfarin was used in 57% of patients and concomitant use of antiplatelet therapy in 25%. Bleeding occurred in 18%, with upper gastrointestinal bleeding (53%) being the most common source. In the propensity-matched cohort, bleeding rates were higher in cirrhotics than in control patients who were matched for baseline characteristics. In multivariate analysis of the cirrhotic patients, the presence of esophageal varices was associated with higher odds of clinically relevant bleeding. CONCLUSION Anticoagulated cirrhotic patients who have esophageal varices are at an increased risk of bleeding. We recommend that patients with cirrhosis and esophageal varices who require anticoagulation have their varices managed carefully prior to initiation of anticoagulation.
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84
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Wasay M, Khan M, Rajput HM, Farooq S, Memon MI, AlRukn SA, Malik A, Abd-Allah F, Shoaib RF, Shahid R, Nishat S, Awan S. New Oral Anticoagulants versus Warfarin for Cerebral Venous Thrombosis: A Multi-Center, Observational Study. J Stroke 2019; 21:220-223. [PMID: 31161765 PMCID: PMC6549061 DOI: 10.5853/jos.2019.00150] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 03/10/2019] [Indexed: 01/25/2023] Open
Affiliation(s)
- Mohammad Wasay
- Department of Neurology, Aga Khan University, Karachi, Pakistan
| | - Maria Khan
- Department of Neurology, Rashid Hospital, Dubai, United Arab Emirates
| | - Haris Majid Rajput
- Department of Neurology, Pakistan Institute of Medical Sciences, Islamabad, Pakistan
| | - Salman Farooq
- Department of Neurology, Aga Khan University, Karachi, Pakistan
| | | | | | - Abdul Malik
- Department of Medicine, Liaquat College of Medicine and Dentistry, Karachi, Pakistan
| | | | - Raja Farhat Shoaib
- Department of Neurology, Shifa International University and Hospital, Islamabad, Pakistan
| | - Rizwana Shahid
- Department of Neurology, Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Sadia Nishat
- Department of Neurology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Safia Awan
- Department of Medicine, Aga Khan University, Karachi, Pakistan
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85
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Sulzgruber P, Wassmann S, Semb AG, Doehner W, Widimsky P, Gremmel T, Kaski JC, Savarese G, Rosano GMC, Borghi C, Kjeldsen K, Torp-Pedersen C, Schmidt TA, Lewis BS, Drexel H, Tamargo J, Atar D, Agewall S, Niessner A. Oral anticoagulation in patients with non-valvular atrial fibrillation and a CHA2DS2-VASc score of 1: a current opinion of the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy and European Society of Cardiology Council on Stroke. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2019; 5:171-180. [DOI: 10.1093/ehjcvp/pvz016] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 04/17/2019] [Accepted: 05/15/2019] [Indexed: 12/26/2022]
Abstract
Abstract
Oral anticoagulation in patients presenting with non-valvular atrial fibrillation and a CHA2DS2-VASc score of 1 (CHA2DS2-VASc of 2 in women) remains a challenging approach in clinical practice. Therapeutic decisions need to balance the individual benefit of reducing thromboembolic risk against the potential harm due to an increase in bleeding risk in this intermediate risk patient population. Within the current opinion statement of the European Society of Cardiology working group of cardiovascular pharmacotherapy and the European Society of Cardiology council on stroke the currently available evidence on the anti-thrombotic management in patients presenting with a CHA2DS2-VASc of 1 is summarized. Easily applicable tools for a personalized refinement of the individual thromboembolic risk in patients with atrial fibrillation and a CHA2DS2-VASc score of 1 that guide clinicians through the question whether to anticoagulate or not are provided.
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Affiliation(s)
- Patrick Sulzgruber
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Sven Wassmann
- Cardiology Pasing, Institutstraße 14, 81241 Munich, Germany
- University of the Saarland, Kirrberger Straße 100, 66424 Homburg, Saar, Germany
| | - Anne Grete Semb
- Department of Rheumatology, Preventive Cardio-Rheuma Clinic, Diakonhjemmet Hospital, Diakonveien 12, 0370 Oslo, Norway
| | - Wolfram Doehner
- Department of Cardiology (Virchow Klinikum), German Centre for Cardiovascular Research (DZHK), Oudenarder Straße 16, 13316 Berlin, Germany
- BIH Center for Regenerative Therapies (BCRT), Charité Universitaetsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Petr Widimsky
- Cardiocenter, Third Faculty of Medicine, Charles University, Opletalova 38, 110 00 Staré Město, Prague, Czech Republic
| | - Thomas Gremmel
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
- Department of Internal Medicine, Cardiology and Nephrology, Landesklinikum Wiener Neustadt, Corvinusring 3-5, 2700 Wiener Neustadt, Austria
| | - Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St George’s, University of London, Cranmer Terrace, Tooting, London SW17 0RE, UK
| | - Gianluigi Savarese
- Cardiology Division, Department of Medicine, Karolinska Institute, Karolinska University Hospital, Eugeniavägen 3, 171 76 Solna, Stockholm, Sweden
| | - Giuseppe M C Rosano
- Centre for Clinical and Basic Research, Department of Medical Sciences, IRCCS San Raffaele Pisana, Rome, Italy
| | - Claudio Borghi
- Atherosclerosis Research Unit, Medical and Surgical Sciences Department, Sant’Orsola-Malpighi Hospital, University of Bologna, Via Zamboni, 33, 40126 Comune di Bologna BO, Italy
| | - Keld Kjeldsen
- Department of Cardiology, Copenhagen University Hospital (Hvidovre-Amager), Blegdamsvej 9, 2100 Copenhagen, Denmark
- Department of Health Science and Technology, The Faculty of Medicine, Aalborg University, Fredrik Bajers Vej 5, 9100 Aalborg, Denmark
| | - Christian Torp-Pedersen
- Department of Health Sciences and Technology, Aalborg University, Fredrik Bajers Vej 5, 9100 Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, Fredrik Bajers Vej 5, 9100 Aalborg, Denmark
| | - Thomas Andersen Schmidt
- Emergency Department, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Basil S Lewis
- Lady Davis Carmel Medical Center, Mikhal St 7, 3436212 Haifa, Israel
- Technion-Israel Institute of Technology, Ruth and Bruce Rappaport School of Medicine, Efron St 1, 3436212 Haifa, Israel
| | - Heinz Drexel
- VIVIT Research, Landeskrankenhaus Feldkirch, Carinagasse 47, 6800 Feldkirch, Austria
- Private University of the Principality of Liechtenstein, Dorfstrasse 24. FL-9495 Triesen, Principality of Liechtenstein
| | - Juan Tamargo
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense, Avda. de Séneca, 2 Ciudad Universitaria, 28040 Madrid, Spain
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital and Institute of Clinical Medicine, Oslo University, Klaus Torgírds vei 3, 0372 Oslo, Norway
| | - Stefan Agewall
- Department of Cardiology, Oslo University Hospital and Institute of Clinical Medicine, Oslo University, Klaus Torgírds vei 3, 0372 Oslo, Norway
| | - Alexander Niessner
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
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Cost-Effectiveness of Bridging Anticoagulation Among Patients with Nonvalvular Atrial Fibrillation. J Gen Intern Med 2019; 34:583-590. [PMID: 30623388 PMCID: PMC6445930 DOI: 10.1007/s11606-018-4796-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 06/14/2018] [Accepted: 11/28/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Bridging anticoagulation is commonly prescribed to patients with atrial fibrillation during initiation and interruption of warfarin. Guidelines recommend bridging patients at high risk of stroke, while a recent randomized trial demonstrated overall harm in a population at comparatively low risk of ischemic stroke. Theory suggests that patients at high risk of stroke and low risk of hemorrhage may benefit from bridging, but data informing patient selection are scant. OBJECTIVE To estimate the utility and cost-effectiveness of bridging anticoagulation among patients with nonvalvular atrial fibrillation, stratified by thromboembolic and hemorrhagic risk DESIGN: Cost-effectiveness analysis with lifelong time horizon, from the perspective of a third-party payer MAIN MEASURES: Quality-adjusted life years (QALYs) per bridged patient; US dollars per QALY gained KEY RESULTS: Unselected patients with nonvalvular atrial fibrillation may be harmed by bridging anticoagulation. Hospital admission for bridging is almost never cost-effective, and generally harmful. Among patients carefully selected by both thromboembolic and hemorrhagic risks, outpatient bridging can be beneficial and cost-effective. Results were sensitive to how effectively heparin products reduce stroke risk. CONCLUSIONS Outpatient bridging anticoagulation can be beneficial and cost-effective for a subset of patients with nonvalvular atrial fibrillation during interruption or initiation of warfarin. Admission for bridging should be avoided.
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Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care 2019; 23:98. [PMID: 30917843 PMCID: PMC6436241 DOI: 10.1186/s13054-019-2347-3] [Citation(s) in RCA: 699] [Impact Index Per Article: 139.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/06/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. RESULTS Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.
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Affiliation(s)
- Donat R. Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic
- Centre for Research and Development, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic, Sokolska 581, CZ-50005 Hradec Kralove, Czech Republic
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, CZ-50003 Hradec Kralove, Czech Republic
- Department of Anaesthesia, Pain Management and Perioperative Medicine, QE II Health Sciences Centre, Dalhousie University, Halifax, 10 West Victoria, 1276 South Park St, Halifax, NS B3H 2Y9 Canada
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Beverley J. Hunt
- King’s College and Departments of Haematology and Pathology, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, SI-3000 Celje, Slovenia
| | - Marc Maegele
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Giuseppe Nardi
- Department of Anaesthesia and ICU, AUSL della Romagna, Infermi Hospital Rimini, Viale Settembrini, 2, I-47924 Rimini, Italy
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Charles-Marc Samama
- Hotel-Dieu University Hospital, 1, place du Parvis de Notre-Dame, F-75181 Paris Cedex 04, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
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88
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Tiili P, Putaala J, Mehtälä J, Khanfir H, Niiranen J, Korhonen P, Raatikainen P, Lehto M. Poor Quality of Warfarin Treatment Increases the Risk of All Types of Intracranial Hemorrhage in Atrial Fibrillation. Circ J 2019; 83:540-547. [DOI: 10.1253/circj.cj-18-0975] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Paula Tiili
- Department of Cardiology, Heart and Lung Center, Helsinki University Hospital, University of Helsinki
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital, University of Helsinki
| | | | | | - Jussi Niiranen
- Department of Cardiology, Heart and Lung Center, Helsinki University Hospital, University of Helsinki
| | | | - Pekka Raatikainen
- Department of Cardiology, Heart and Lung Center, Helsinki University Hospital, University of Helsinki
| | - Mika Lehto
- Department of Cardiology, Heart and Lung Center, Helsinki University Hospital, University of Helsinki
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89
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Almutairi MMA, Xu G, Shi H. Iron Pathophysiology in Stroke. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1173:105-123. [PMID: 31456207 DOI: 10.1007/978-981-13-9589-5_6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Ischemic and hemorrhagic stroke are the common types of stroke that lead to brain injury neurological deficits and mortality. All forms of stroke remain a serious health issue, and there is little successful development of drugs for treating stroke. Incomplete understanding of stroke pathophysiology is considered the main barrier that limits this research progress. Besides mitochondria and free radical-producing enzymes, labile iron is an important contributor to oxidative stress. Although iron regulation and metabolism in cerebral stroke are not fully understood, much progress has been achieved in recent years. For example, hepcidin has recently been recognized as the principal regulator of systemic iron homeostasis and a bridge between inflammation and iron regulation. This review discusses recent research progress in iron pathophysiology following cerebral stroke, focusing molecular regulation of iron metabolism and potential treatment targets.
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Affiliation(s)
- Mohammed M A Almutairi
- Department of Pharmacology and Toxicology, School of Pharmacy, University of Kansas, Lawrence, KS, 66045, USA.,Department of Pharmacology and Toxicology, School of Pharmacy, King Saud University, Riyadh, 11451, Saudi Arabia
| | - Grace Xu
- Department of Anesthesiology, School of Medicine, University of Kansas, Kansas City, KS, 66160, USA
| | - Honglian Shi
- Department of Pharmacology and Toxicology, School of Pharmacy, University of Kansas, Lawrence, KS, 66045, USA.
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90
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Abstract
Atrial fibrillation (AF) is associated with a substantially higher risk of thromboembolism, particularly stroke events, resulting in significant morbidity and mortality. Oral anticoagulation (OAC), while effective in reducing embolic events in AF patients, is associated with an increased bleeding risk. Thus, not all patients with AF are candidates for OAC and some are only candidates for OAC in the short term. Of the available nonpharmacologic strategies for the management of AF, left atrial appendage occlusion (LAAO) has emerged as a potential approach for reducing the risk of systemic thromboembolism in AF patients eligible for OAC. LAAO can be achieved either surgically or percutaneously using an epicardial, endocardial, or a combined approach. Although available data are limited, currently available LAAO devices, and those being developed, have shown promise in reducing bleeding risk in AF patients because of the reduced overall need for anticoagulation, while maintaining efficacy in preventing thromboembolism. The optimal device will reduce both embolic and hemorrhagic strokes, and other bleeds, with a high implant success rate and a low complication rate. Until that time, anticoagulation remains the gold standard that these devices strive to surpass, and thus LAAO devices are currently indicated in patients with relative contraindication to OAC therapy.
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91
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Reversing anti–factor Xa agents and the unmet needs in trauma patients. Blood 2018; 132:2441-2445. [DOI: 10.1182/blood-2018-06-850396] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 10/09/2018] [Indexed: 12/14/2022] Open
Abstract
AbstractAndexanet alfa, a reversing agent for anticoagulants that inhibit factor Xa, has recently been licensed in the United States. We discuss the impact of this licensure on current practice and review in detail the problems of a neglected and growing clinical area: reversing the anticoagulation effect of factor Xa inhibitors in bleeding trauma patients. We identify areas of practice that need research so that care of bleeding trauma patients receiving direct factor Xa inhibitors can be improved.
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92
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Huang CW, Lee MJ, Hsu CY, Chou KJ, Fang HC, Wang LJ, Chen CL, Huang CK, Chen HY, Lee PT. Clinical outcomes associated with anti-coagulant therapy in patients with renal infarction. QJM 2018; 111:867-873. [PMID: 30215794 DOI: 10.1093/qjmed/hcy205] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients with renal infarction are vulnerable to thromboembolic complications with poor outcomes. There is limited report concerning the effect of anti-coagulant therapy in this population. AIM To assess the impact of anti-coagulant therapy on outcomes in patients with renal infarction. DESIGN A retrospective cohort study of 101 renal infarction patients was conducted. METHODS The association between anti-coagulant therapy, all-cause mortality, thromboembolic complications and renal outcome was evaluated. Demographic data and comorbidities were collected for analysis. Anti-coagulant therapy was treated as a time-dependent variable. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using multi-variate Cox proportional hazards models. RESULTS Fifty-seven (56.4%) patients with renal infarction received anti-coagulant therapy during the study period. The all-cause mortality rate was 7.56 per 100 patient-years. Age (HR 1.05, 95% CI 1.02-1.08) was a risk factor for all-cause mortality and anti-coagulant therapy was associated with a 92% improved survival (HR 0.08, 95% CI 0.02-0.34). Twelve (11.9%) thromboembolic events occurred following renal infarction. Current smoking (HR 10.37, 95% CI 1.60-67.43) had an adverse effect and anti-coagulant therapy (HR 0.14, 95% CI 0.03-0.73) had a significant protective impact on thromboembolic complications. There was no significant association between anti-coagulant therapy and long-term renal outcome in renal infarction patients including the monthly change in the estimated glomerular filtration rate (eGFR), the incidence of eGFR reduction of more than 50% and end-stage renal disease. CONCLUSION Anti-coagulant therapy in patients with renal infarction was associated with better survival and reduced thromboembolic complications.
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Affiliation(s)
- Chien-Wei Huang
- Division of Nephrology, Department of Medicine, Kaohsiung Veterans General Hospital, and National Yang-Ming University, School of Medicine, Taiwan
| | - M-J Lee
- Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - C-Y Hsu
- Division of Nephrology, Department of Medicine, Kaohsiung Veterans General Hospital, and National Yang-Ming University, School of Medicine, Taiwan
| | - K-J Chou
- Division of Nephrology, Department of Medicine, Kaohsiung Veterans General Hospital, and National Yang-Ming University, School of Medicine, Taiwan
| | - H-C Fang
- Division of Nephrology, Department of Medicine, Kaohsiung Veterans General Hospital, and National Yang-Ming University, School of Medicine, Taiwan
| | - L-J Wang
- Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - C-L Chen
- Division of Nephrology, Department of Medicine, Kaohsiung Veterans General Hospital, and National Yang-Ming University, School of Medicine, Taiwan
| | - C-K Huang
- Division of Nephrology, Department of Medicine, Kaohsiung Veterans General Hospital, and National Yang-Ming University, School of Medicine, Taiwan
| | - H-Y Chen
- Division of Nephrology, Department of Medicine, Kaohsiung Veterans General Hospital, and National Yang-Ming University, School of Medicine, Taiwan
| | - P-T Lee
- Division of Nephrology, Department of Medicine, Kaohsiung Veterans General Hospital, and National Yang-Ming University, School of Medicine, Taiwan
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93
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Perez AJ, Grant GA. Common Conditions Requiring Long-Term Anticoagulation in Neurosurgical Patients. Neurosurg Clin N Am 2018; 29:529-535. [PMID: 30223965 DOI: 10.1016/j.nec.2018.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Long-term anticoagulant therapy prevents thrombosis. Management of neurosurgical patients with conditions such as atrial fibrillation, mechanical heart valves, and other prothrombotic states necessitates application of a strategy to mitigate hemorrhagic complications of anticoagulation. Development of direct oral anticoagulants, which include the direct thrombin and factor X inhibitors, yields new considerations to be had, in particular, the introduction of reversal agents. This article reviews the more common chronic clinical entities that require the use of prolonged anticoagulant therapy with special consideration for neurosurgical patients. It also includes a discussion of established treatment strategies across available treatment options.
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Affiliation(s)
- Augustus J Perez
- Pediatric Neurosurgery, Department of Neurosurgery, Stanford University Medical Center, 300 Pasteur Drive Room R211, MC 5325, Stanford, CA 94305, USA
| | - Gerald A Grant
- Department of Neurosurgery, Stanford University Medical Center, 300 Pasteur Drive Room R211, MC 5327, Stanford, CA 94305, USA.
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94
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Han S, Park GM, Kim YG, Hwang KW, Roh JH, Won KB, Ann SH, Kim SJ, Lee SG. Effect of atrial fibrillation in Asian patients undergoing percutaneous coronary intervention with drug-eluting stents for stable coronary artery disease: Results from a Korean nationwide study. Medicine (Baltimore) 2018; 97:e13488. [PMID: 30508978 PMCID: PMC6283148 DOI: 10.1097/md.0000000000013488] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 11/07/2018] [Indexed: 11/25/2022] Open
Abstract
Although the prevalence of atrial fibrillation (AF) and percutaneous coronary intervention (PCI) are increasing in Asia, there is a paucity of data concerning the effect of AF in Asian patients undergoing PCI with drug-eluting stents (DESs). Furthermore, the majority of previous studies investigating the effect of AF on prognosis following PCI have exclusively evaluated patients with myocardial infarction (MI). We aimed to evaluate the effect of AF on clinical outcomes of Asian patients undergoing PCI with DES for coronary artery disease (CAD) excluding acute MI.From national health insurance claims data in South Korea, a total of 45,288 patients aged 18 years or older without a known history of CAD, who underwent PCI with DES for the diagnosis of CAD excluding acute MI between 2011 and 2015, were enrolled. Based on the presence or absence of a history of AF at baseline, patients were categorized into the AF group (n = 1715, 3.8%) and no-AF group (n = 43,573, 96.2%). Outcomes including all-cause death, the composite outcome of all-cause death/MI/coronary revascularization, and stroke were compared between 2 groups using a propensity-score-matched analysis.After propensity-score matching, 1709 matched pairs were obtained. During the follow-up period (mean, 2.2 years), the incidence of all-cause death (hazard ratio [HR] 1.117, 95% confidence interval [CI] 0.885-1.411, P = .35) and the composite outcome of all-cause death/MI/coronary revascularization (HR 1.004, 95% CI 0.846-1.192, P = .97) were not significantly different between 2 groups. However, the incidence of stroke was significantly increased in the AF group (HR 1.983, 95% CI 1.474-2.667, P < .001).In Asian patients undergoing PCI for stable CAD, a history of AF was not associated with mortality, but was associated with increased risk of stroke.
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Affiliation(s)
- Seungbong Han
- Department of Applied Statistics, Gachon University, Seongnam
| | - Gyung-Min Park
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan
| | - Yong-Giun Kim
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan
| | - Ki Won Hwang
- Division of Cardiology, Pusan National University Yangsan Hospital, Pusan National University of Medicine, Yangsan
| | - Jae-Hyung Roh
- Department of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Ki-Bum Won
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan
| | - Soe Hee Ann
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan
| | - Shin-Jae Kim
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan
| | - Sang-Gon Lee
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan
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95
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Tsivgoulis G, Wilson D, Katsanos AH, Sargento-Freitas J, Marques-Matos C, Azevedo E, Adachi T, von der Brelie C, Aizawa Y, Abe H, Tomita H, Okumura K, Hagii J, Seiffge DJ, Lioutas VA, Traenka C, Varelas P, Basir G, Krogias C, Purrucker JC, Sharma VK, Rizos T, Mikulik R, Sobowale OA, Barlinn K, Sallinen H, Goyal N, Yeh SJ, Karapanayiotides T, Wu TY, Vadikolias K, Ferrigno M, Hadjigeorgiou G, Houben R, Giannopoulos S, Schreuder FHBM, Chang JJ, Perry LA, Mehdorn M, Marto JP, Pinho J, Tanaka J, Boulanger M, Al-Shahi Salman R, Jäger HR, Shakeshaft C, Yakushiji Y, Choi PMC, Staals J, Cordonnier C, Jeng JS, Veltkamp R, Dowlatshahi D, Engelter ST, Parry-Jones AR, Meretoja A, Mitsias PD, Alexandrov AV, Ambler G, Werring DJ. Neuroimaging and clinical outcomes of oral anticoagulant-associated intracerebral hemorrhage. Ann Neurol 2018; 84:694-704. [PMID: 30255970 DOI: 10.1002/ana.25342] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 09/13/2018] [Accepted: 09/14/2018] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Whether intracerebral hemorrhage (ICH) associated with non-vitamin K antagonist oral anticoagulants (NOAC-ICH) has a better outcome compared to ICH associated with vitamin K antagonists (VKA-ICH) is uncertain. METHODS We performed a systematic review and individual patient data meta-analysis of cohort studies comparing clinical and radiological outcomes between NOAC-ICH and VKA-ICH patients. The primary outcome measure was 30-day all-cause mortality. All outcomes were assessed in multivariate regression analyses adjusted for age, sex, ICH location, and intraventricular hemorrhage extension. RESULTS We included 7 eligible studies comprising 219 NOAC-ICH and 831 VKA-ICH patients (mean age = 77 years, 52.5% females). The 30-day mortality was similar between NOAC-ICH and VKA-ICH (24.3% vs 26.5%; hazard ratio = 0.94, 95% confidence interval [CI] = 0.67-1.31). However, in multivariate analyses adjusting for potential confounders, NOAC-ICH was associated with lower admission National Institutes of Health Stroke Scale (NIHSS) score (linear regression coefficient = -2.83, 95% CI = -5.28 to -0.38), lower likelihood of severe stroke (NIHSS > 10 points) on admission (odds ratio [OR] = 0.50, 95% CI = 0.30-0.84), and smaller baseline hematoma volume (linear regression coefficient = -0.24, 95% CI = -0.47 to -0.16). The two groups did not differ in the likelihood of baseline hematoma volume < 30cm3 (OR = 1.14, 95% CI = 0.81-1.62), hematoma expansion (OR = 0.97, 95% CI = 0.63-1.48), in-hospital mortality (OR = 0.73, 95% CI = 0.49-1.11), functional status at discharge (common OR = 0.78, 95% CI = 0.57-1.07), or functional status at 3 months (common OR = 1.03, 95% CI = 0.75-1.43). INTERPRETATION Although functional outcome at discharge, 1 month, or 3 months was comparable after NOAC-ICH and VKA-ICH, patients with NOAC-ICH had smaller baseline hematoma volumes and less severe acute stroke syndromes. Ann Neurol 2018;84:702-712.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - Duncan Wilson
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, United Kingdom, New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Aristeidis H Katsanos
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
| | - João Sargento-Freitas
- Department of Neurology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Cláudia Marques-Matos
- Department of Neurology, São João University Hospital Center, Porto, Portugal.,Department of Clinical Neurosciences and Mental Health, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Elsa Azevedo
- Department of Neurology, São João University Hospital Center, Porto, Portugal.,Department of Clinical Neurosciences and Mental Health, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Tomohide Adachi
- Department of Neurology and General Internal Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | | | - Yoshifusa Aizawa
- Department of Research and Development, Tachikawa Medical Center, Nagaoka, Japan
| | - Hiroshi Abe
- Department of Research and Development, Tachikawa Medical Center, Nagaoka, Japan
| | - Hirofumi Tomita
- Department of Cardiology and Department of Hypertension and Stroke Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Ken Okumura
- Advanced Arrhythmia Therapeutic Branch, Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Joji Hagii
- Hirosaki Stroke and Rehabilitation Center, Hirosaki, Japan
| | - David J Seiffge
- Stroke Center and Neurology, University Hospital and University of Basel, Basel, Switzerland
| | | | - Christopher Traenka
- Stroke Center and Neurology, University Hospital and University of Basel, Basel, Switzerland
| | | | - Ghazala Basir
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada
| | - Christos Krogias
- Department of Neurology, St Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Vijay K Sharma
- Division of Neurology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Robert Mikulik
- International Clinical Research Center and Neurology Department, St Anne's Hospital and Masaryk University, Brno, Czech Republic
| | - Oluwaseun A Sobowale
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Kristian Barlinn
- Department of Neurology, Dresden Neurovascular Center, Dresden, Germany
| | - Hanne Sallinen
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - Shin-Joe Yeh
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taiwan
| | - Theodore Karapanayiotides
- Second Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | | | - Marc Ferrigno
- Department of Neurology, Lille University, INSERM U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, Lille, France
| | | | - Rik Houben
- Department of Neurology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Sotirios Giannopoulos
- Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Floris H B M Schreuder
- Department of Neurology, Maastricht University Medical Center, Maastricht, the Netherlands.,Department of Neurology, Donders Institute for Brain, Cognition, and Behavior, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jason J Chang
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - Luke A Perry
- Department of Neurosciences, Eastern Health, Melbourne, Victoria, Australia
| | - Maximilian Mehdorn
- Department of Neurosurgery, Georg August University of Göttingen, Göttingen, Germany
| | - João-Pedro Marto
- Neurology Department, Egas Moniz Hospital, West Lisbon Hospital Center, Lisbon, Portugal.,CEDOC, Nova Medical School, New University of Lisbon, Lisbon, Portugal
| | - João Pinho
- Department of Neurology, Braga Hospital, Braga, Portugal
| | - Jun Tanaka
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Marion Boulanger
- Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Hans R Jäger
- Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, Institute of Neurology, University College London, London, United Kingdom
| | - Clare Shakeshaft
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, United Kingdom, New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Yusuke Yakushiji
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Philip M C Choi
- Department of Neurosciences, Eastern Health, Melbourne, Victoria, Australia
| | - Julie Staals
- Department of Neurology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Charlotte Cordonnier
- Department of Neurology, Lille University, INSERM U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, Lille, France
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taiwan
| | - Roland Veltkamp
- Division of Brain Sciences, Department of Stroke Medicine, Imperial College London, United Kingdom
| | - Dar Dowlatshahi
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada
| | - Stefan T Engelter
- Stroke Center and Neurology, University Hospital and University of Basel, Basel, Switzerland.,Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Basel, Switzerland
| | - Adrian R Parry-Jones
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Atte Meretoja
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland.,Department of Medicine and Neurology at Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Panayiotis D Mitsias
- Department of Neurology, Henry Ford Hospital, Detroit, MI.,Department of Neurology, School of Medicine, University of Crete, Crete, Greece
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, United Kingdom
| | - David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, United Kingdom, New Zealand Brain Research Institute, Christchurch, New Zealand
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96
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Shah SJ, Eckman MH, Aspberg S, Go AS, Singer DE. Effect of Variation in Published Stroke Rates on the Net Clinical Benefit of Anticoagulation for Atrial Fibrillation. Ann Intern Med 2018; 169:517-527. [PMID: 30264130 DOI: 10.7326/m17-2762] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Stroke rates in patients with nonvalvular atrial fibrillation (AF) who are not receiving anticoagulant therapy vary widely across published studies; the resulting effect on the net clinical benefit of anticoagulation in AF is unknown. OBJECTIVE To determine the effect of variation in published AF stroke rates on the net clinical benefit of anticoagulation. DESIGN Markov model decision analysis. Warfarin was the base case, and non-vitamin K antagonist oral anticoagulants (NOACs) were modeled in a secondary analysis. SETTING Community-dwelling adults. PATIENTS 33 434 adults with incident AF. MEASUREMENTS Quality-adjusted life-years (QALYs). RESULTS Of the 33 434 patients, 27 179 had a CHA2DS2-VASc (congestive heart failure, hypertension, age, diabetes, stroke, and vascular disease) score of 2 or more. The population benefit of warfarin anticoagulation for these patients was least using stroke rates from the ATRIA (AnTicoagulation and Risk Factors In Atrial Fibrillation) study and greatest using those from the Danish National Patient Registry (6290 QALYs [95% CI, ±2.3%] vs. 24 110 QALYs [CI, ±1.9%]; P < 0.001). The optimal CHA2DS2-VASc score threshold for anticoagulation was 3 or more using stroke rates from ATRIA, 2 or more using those from the Swedish AF cohort study, 1 or more using those from the SPORTIF (Stroke Prevention using ORal Thrombin Inhibitor in atrial Fibrillation) study, and 0 or more using those from the Danish National Patient Registry. Accounting for lower rates of NOAC-associated intracranial hemorrhage decreased optimal CHA2DS2-VASc score thresholds, but these thresholds still varied widely. LIMITATION Measured benefit may not generalize to other populations. CONCLUSION Variation in published AF stroke rates for patients not receiving anticoagulant therapy results in multifold variation in the net clinical benefit of anticoagulation. Guidelines should better reflect the uncertainty in current thresholds of stroke risk score for recommending anticoagulation. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Sachin J Shah
- University of California, San Francisco, San Francisco, California (S.J.S.)
| | - Mark H Eckman
- University of Cincinnati College of Medicine, Cincinnati, Ohio (M.H.E.)
| | - Sara Aspberg
- Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden (S.A.)
| | - Alan S Go
- University of California, San Francisco, San Francisco, and Kaiser Permanente Northern California, Oakland, California (A.S.G.)
| | - Daniel E Singer
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (D.E.S.)
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97
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Himmler S, Müller M, Ostwald D, Seddik A, Basic E, Hradetzky E. Long-term health benefits of stroke prevention with apixaban versus vitamin K antagonist warfarin in patients with non-valvular atrial fibrillation in Germany: a population-based modelling study. Expert Rev Pharmacoecon Outcomes Res 2018; 19:223-230. [DOI: 10.1080/14737167.2019.1522501] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
| | | | | | | | - Edin Basic
- Health Technology Assessment & Outcomes Research, Pfizer Deutschland GmbH, Berlin, Germany
| | - Eva Hradetzky
- Medical Affairs Internal Medicine, Pfizer Pharma GmbH, Berlin, Germany
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98
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Deng L, Xiao Y, Hong H. Withdrawal of oral anticoagulants 3 months after successful radiofrequency catheter ablation in patients with atrial fibrillation: A meta-analysis. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:1391-1400. [PMID: 30192009 DOI: 10.1111/pace.13494] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 07/17/2018] [Accepted: 07/20/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND The best anticoagulation therapy for atrial fibrillation (AF) after radiofrequency catheter ablation (RFCA) remains a challenge. METHODS A systematic search of PubMed, Ovid, and Cochrane Library was conducted identifying at clinical trials which evaluated the differences between thromboembolism (TE) and hemorrhage in an off-oral anticoagulants (OACs) treatment group (the observation group) and an on-OACs treatment group (the control group), at 3 months after successful RFCA. Meta-analysis was performed using RevMan 5.3 software, and the fixed effect model was used as a relevant statistical model. χ2 test and I2 were used to test for the presence of heterogeneity. Subgroup analysis and sensitivity analysis were also performed. RESULTS The results showed no significant differences between two groups in TE (relative risk [RR] 0.82, 95% confidence interval [CI], 0.51-1.33, P = 0.42), and only mild heterogeneity (P = 0.22, I2 = 29%). No significant differences in TE between two subgroups were found according to < 3 years and ≥ 3 years follow-up analyses (RR 0.58, 95% CI, 0.26-1.28, P = 0.18; RR 1.00, 95% CI, 0.54-1.85, P = 1.00). Furthermore, there was a lower risk of TE in the observation subgroup (< 60 years) compared to the control group (RR 0.31, 95% CI, 0.12-0.78, P = 0.01). Also, there were no significant differences in TE between two subgroups (≥ 60 years, RR 1.24, 95% CI, 0.67-2.28, P = 0.49). The risk of hemorrhage in the observation group was significantly lower compared to the control group (RR 0.05, 95%CI, 0.02-0.14, P < 0.00001). CONCLUSIONS The withdrawal of OACs 3 months after successful radiofrequency catheter ablation for patients with AF may be safe and feasible. It needs to be tested by randomized controlled trial.
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Affiliation(s)
- Liyu Deng
- Department of Geriatrics, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Ying Xiao
- Department of Geriatrics, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Huashan Hong
- Department of Geriatrics, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
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99
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Altintas O, Niftaliyev E, Asil T. The relationship between brain microbleeds and homeostatic markers in the treatment of ischemic stroke. Neurol Res 2018; 40:1048-1053. [DOI: 10.1080/01616412.2018.1517111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- O. Altintas
- Neurology Clinic, Avcilar Hospital, Istanbul, Turkey
| | - E. Niftaliyev
- Neurology Clinic, Gence International Hospital, Ganja, Azerbaijan
| | - T. Asil
- Neurology Clinic, Memorial Hospital, Istanbul, Turkey
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100
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Folli C, Casiraghi C, Braham S, Rovellini A, Monzani V. Major hemorrhages in patients treated with oral anticoagulants: choice of management in the emergency room. Eur J Intern Med 2018; 55:e25-e26. [PMID: 30031598 DOI: 10.1016/j.ejim.2018.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 07/12/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Christian Folli
- High-Intensity Care Internal Medicine, IRCCS Ca' Granda Maggiore Hospital Foundation, Milan, Italy
| | - Chiara Casiraghi
- High-Intensity Care Internal Medicine, IRCCS Ca' Granda Maggiore Hospital Foundation, Milan, Italy
| | - Simon Braham
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, IRCCS Ca' Granda Maggiore Hospital Foundation, Milan, Italy
| | - Angelo Rovellini
- High-Intensity Care Internal Medicine, IRCCS Ca' Granda Maggiore Hospital Foundation, Milan, Italy
| | - Valter Monzani
- High-Intensity Care Internal Medicine, IRCCS Ca' Granda Maggiore Hospital Foundation, Milan, Italy.
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