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Patel P, Nigam N, Sengupta N. Lower gastrointestinal bleeding in patients with coronary artery disease on antithrombotics and subsequent mortality risk. J Gastroenterol Hepatol 2018; 33:1185-1191. [PMID: 29156506 DOI: 10.1111/jgh.14048] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 11/06/2017] [Accepted: 11/08/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Lower gastrointestinal bleeding (LGIB) is a common complication for patients with coronary artery disease (CAD) due to the use of antithrombotic medications. Limited data exist describing which patients are at increased risk for mortality. AIM This study aims to (i) determine whether patients on dual antiplatelet therapy (DAPT) or triple therapy are at higher risk of 90-day and 6-month mortality compared with patients on aspirin alone and (ii) evaluate risk factors for mortality in patients with CAD on antithrombotics hospitalized with LGIB. METHODS We conducted a retrospective cohort study of patients hospitalized with LGIB and CAD while on aspirin at a single academic medical center from 2007 to 2015. Patients were identified using a validated, machine-learning algorithm and classified by use of aspirin, DAPT, or triple therapy. Univariate and multivariate Cox proportional hazards were used to determine mortality associated risk factors. RESULTS Seven hundred sixteen patients were identified with LGIB and CAD. Four hundred seventy-two (65.9%) patients were on aspirin monotherapy, 179 (25%) on aspirin and thienopyridine (DAPT), and 65 (9.1%) on aspirin, thienopyridine, and systemic anticoagulant (triple therapy). On univariate analysis, triple therapy use was associated with increased risk of 90-day (hazard ratio [HR] 3.12, 95% confidence interval [CI] 1.52-5.92, P = 0.003) and 6-month (HR 2.46, 95%CI 1.29-4.35, P = 0.008) mortality. Holding anticoagulation was associated with higher mortality at 90 days (HR 2.30, 95%CI 1.27-4.07, P = 0.007). On multivariate analysis, after adjusting for confounding variables, the use of triple therapy remained associated with higher 90-day mortality (HR 3.23, 95%CI 1.56-6.16, P = 0.003). CONCLUSION Triple therapy is associated with mortality at 90 days and at 6 months post discharge.
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Affiliation(s)
- Parita Patel
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Neha Nigam
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Neil Sengupta
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medical Center, Chicago, Illinois, USA
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Pisters R, Elvan A, Crijns HJGM, Hemels MEW. Optimal long-term antithrombotic management of atrial fibrillation: life cycle management. Neth Heart J 2018; 26:311-320. [PMID: 29722003 PMCID: PMC5968005 DOI: 10.1007/s12471-018-1118-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Optimal antithrombotic management of atrial fibrillation equals balancing between prevention of arterial thromboembolism, predominantly ischaemic stroke, and haemorrhagic complications. Over time different antithrombotic agents and strategies have been developed. At present, non-vitamin K antagonist oral anticoagulants (NOACs) are the first-line therapy for stroke prevention in patients with non-valvular atrial fibrillation (i.e. without a mechanical valve prosthesis or rheumatic heart disease). Considering the impact of the suboptimal adoption of recommended oral anticoagulant therapy, as experienced with the previous first-line vitamin K antagonists, this review focuses on adequate use of NOACs. As such, we address the most important and clinically challenging issues in the antithrombotic life cycle management for long-term stroke prevention in atrial fibrillation.
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Affiliation(s)
- R Pisters
- Department of Cardiology, Rijnstate Arnhem, Arnhem, The Netherlands
| | - A Elvan
- Department of Cardiology, Isala Hospital Zwolle, Zwolle, The Netherlands
| | - H J G M Crijns
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - M E W Hemels
- Department of Cardiology, Rijnstate Arnhem, Arnhem, The Netherlands. .,Department of Cardiology, Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands.
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Proietti M, Romiti GF, Romanazzi I, Farcomeni A, Staerk L, Nielsen PB, Lip GYH. Restarting oral anticoagulant therapy after major bleeding in atrial fibrillation: A systematic review and meta-analysis. Int J Cardiol 2018; 261:84-91. [PMID: 29572080 DOI: 10.1016/j.ijcard.2018.03.053] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 03/12/2018] [Indexed: 01/27/2023]
Abstract
BACKGROUND Use of oral anticoagulant (OAC) therapy in atrial fibrillation (AF) is associated with an inherited risk of bleeding. Benefits and risks of OAC restarting after a major bleeding are still uncertain. We aimed to assess effectiveness and safety of restarting OAC in AF patients after a major bleeding event. METHODS We performed a systematic review and meta-analysis of all studies reporting data about AF patients that sustained a major bleeding, reporting data on restarting or not restarting OAC therapy. RESULTS A total of seven studies were included, involving 5685 patients. No significant difference was found in "any stroke" occurrence between OAC restarters and non-restarters (odds ratio [OR]: 0.75, 95% confidence interval [CI]: 0.37-1.51), with a significant 46% relative risk reduction (RRR) (p < 0.00001) for "any thromboembolism" in OAC restarters, with consistent results when the index bleeding event was an intracranial or gastrointestinal bleeding. A significantly higher risk of recurrent major bleeding was seen (OR: 1.85, 95% CI: 1.48-2.30), but no difference in risk for recurrence of index event. OAC restarters had a 10.8% absolute risk reduction for all-cause death (OR: 0.38, 95% CI: 0.24-0.60); p < 0.00001). Net clinical benefit (NCB) analysis demonstrated that restarting OAC therapy after a major bleeding was significantly associated with a clinical advantage (NCB: 0.11, 95% CI: 0.09-0.14; p < 0.001). CONCLUSIONS Restarting OAC therapy after a major bleeding event in AF was associated with a positive clinical benefit when compared to non-restarting OAC, with a significant reduction in any thromboembolism and all-cause mortality.
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Affiliation(s)
- Marco Proietti
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom; IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Department of Neuroscience, Milan, Italy
| | | | - Imma Romanazzi
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom
| | - Alessio Farcomeni
- Department of Public Health and Infectious Disease, Sapienza-University of Rome, Rome, Italy
| | - Laila Staerk
- Cardiovascular Research Centre, Herlev and Gentofte University Hospital, Hellerup, Denmark
| | - Peter Brønnum Nielsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark.
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Abstract
Non-variceal upper gastrointestinal bleeding continues to be an important cause of morbidity and mortality. The most common causes include peptic ulcer disease, Mallory-Weiss syndrome, erosive gastritis, duodenitis, esophagitis, malignancy, angiodysplasias and Dieulafoy's lesion. Initial assessment and early aggressive resuscitation significantly improves outcomes. Upper gastrointestinal endoscopy continues to be the gold standard for diagnosis and treatment. We present a comprehensive review of literature for the evaluation and management of non-variceal upper gastrointestinal bleeding.
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Affiliation(s)
- Ronald Samuel
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Mohammad Bilal
- Division of Gastroenterology & Hepatology, University of Texas Medical Branch, 7400 Jones Drive, Apt 724, Galveston, TX 77551.
| | - Obada Tayyem
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Praveen Guturu
- Division of Gastroenterology & Hepatology, University of Texas Medical Branch, 7400 Jones Drive, Apt 724, Galveston, TX 77551
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Paik WH, Lee SH, Ahn DW, Jeong JB, Kang JW, Son JH, Ryu JK, Kim YT. Optimal time of resuming anticoagulant after endoscopic sphincterotomy in patients at risk for thromboembolism: a retrospective cohort study. Surg Endosc 2018; 32:3902-3908. [PMID: 29511881 DOI: 10.1007/s00464-018-6129-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 02/23/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND One major adverse event of endoscopic sphincterotomy (EST) is bleeding, which could be more common and severe in patients receiving anticoagulant therapy. However, the cessation of anticoagulants for long periods could lead to thromboembolic events. We aimed to evaluate the optimal timing of resumption of anticoagulants after EST in patients at risk for thromboembolism. MATERIALS AND METHODS From January 2010 through October 2017, a retrospective cohort at risk for thromboembolism who had taken warfarin and bridging therapy with heparin around EST from three tertiary hospitals in South Korea was investigated. The primary outcome was to compare the incidence of post-EST delayed bleeding according to the resumption time of anticoagulant. The secondary outcome was to investigate any thromboembolic adverse events related to interruption of the anticoagulant. RESULTS A total of 96 patients (46 males and 50 females; median age 75 years [range, 24-91 years]) were enrolled. Overall, the patient numbers of very early (< 24 h), early (24-48 h), and late resumption (> 48 h) of anticoagulant after EST were 56, 23, and 17, respectively. The baseline characteristics were similar between groups except resumption time of anticoagulant. There was no significant difference in the rate of post-EST delayed bleeding (5% in very early group vs. 9% in early group vs. 0 in late group, p = 0.47). The rate of thromboembolic adverse events was significantly higher in the late resumption of anticoagulant group (0 vs. 0 vs. 24%, p < 0.001). CONCLUSION There was no significant difference in the incidence of post-EST delayed bleeding according to the resuming time of anticoagulant. Since long cessation of anticoagulant could increase the risk of thrombotic adverse events, the early resumption of anticoagulant seems to be preferred.
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Affiliation(s)
- Woo Hyun Paik
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea.,Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Sang Hyub Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea.
| | - Dong Won Ahn
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Ji Bong Jeong
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Jin Woo Kang
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Jun Hyuk Son
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Ji Kon Ryu
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Yong-Tae Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
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Katritsis GD, Katritsis DG. Management of Complications in Anticoagulated Patients with Atrial Fibrillation. Arrhythm Electrophysiol Rev 2017; 6:167-178. [PMID: 29326831 PMCID: PMC5739886 DOI: 10.15420/aer.2017.23.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 07/27/2017] [Indexed: 12/23/2022] Open
Abstract
Oral anticoagulation is mandatory for patients at high risk of thromboembolism, but the risk of bleeding should also be taken into account. Direct oral anticoagulants are now recommended for non-valvular AF as a potential alternative to warfarin. In this article we discuss methods to assess the anticoagulant effect of these agents, specific and general antidotes, and management of complications such as embolic and haemorrhagic stroke, and significant bleeding.
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Tomaselli GF, Mahaffey KW, Cuker A, Dobesh PP, Doherty JU, Eikelboom JW, Florido R, Hucker W, Mehran R, Messé SR, Pollack CV, Rodriguez F, Sarode R, Siegal D, Wiggins BS. 2017 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants. J Am Coll Cardiol 2017; 70:3042-3067. [DOI: 10.1016/j.jacc.2017.09.1085] [Citation(s) in RCA: 187] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Nagata N, Sakurai T, Shimbo T, Moriyasu S, Okubo H, Watanabe K, Yokoi C, Yanase M, Akiyama J, Uemura N. Acute Severe Gastrointestinal Tract Bleeding Is Associated With an Increased Risk of Thromboembolism and Death. Clin Gastroenterol Hepatol 2017. [PMID: 28634133 DOI: 10.1016/j.cgh.2017.06.028] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We performed a retrospective cohort study of patients with and without gastrointestinal bleeding (GIB) to determine whether GIB increases the risks of thromboembolism and death. METHODS We collected data from 522 patients with acute severe GIB and 1044 patients without GIB (control subjects, matched for age, sex, year of diagnosis, history of thromboembolism, and use of antithrombotic drugs) who underwent endoscopy at the National Center for Global Health and Medicine in Japan from January 2009 through December 2014. Hazard ratios of GIB for thromboembolism and mortality risk were estimated, adjusting for confounders. We also compared standardized mortality ratios between the GIB cohort and the age- and sex-matched general population in Japan. RESULTS During a mean follow up of 23.7 months, thromboembolism was identified in 11.5% of patients with GIB and 2.4% of control subjects (hazard ratio, 5.3; 95% confidence interval, 3.3-8.5; P < .001). Multivariate analysis revealed GIB as a risk factor for all-thromboembolic events, cerebrovascular events, and cardiovascular events. During a mean follow-up of 24.6 months, 15.9% of patients with GIB and 8.6% of control subjects died (hazard ratio, 2.1; 95% confidence interval, 1.6-2.9; P < .001). Multivariate analysis revealed GIB as a risk factor for all-cause mortality. Compared with the general population, patients with GIB were at increased risk of death (standardized mortality ratio, 12.0). CONCLUSIONS In a retrospective analysis of patients undergoing endoscopy in Japan, we identified acute GIB was a significant risk factor for late thromboembolism and death, compared with patients without GIB. GIB also increased risk of death compared with the general population.
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Affiliation(s)
- Naoyoshi Nagata
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan.
| | - Toshiyuki Sakurai
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | | | - Shiori Moriyasu
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hidetaka Okubo
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kazuhiro Watanabe
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Chizu Yokoi
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Mikio Yanase
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Junichi Akiyama
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Naomi Uemura
- Department of Gastroenterology and Hepatology, Kohnodai Hospital, National Center for Global Health and Medicine, Chiba, Japan
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Siau K, Hannah JL, Hodson J, Widlak M, Bhala N, Iqbal TH. Stopping antithrombotic therapy after acute upper gastrointestinal bleeding is associated with reduced survival. Postgrad Med J 2017; 94:137-142. [PMID: 29101296 DOI: 10.1136/postgradmedj-2017-135276] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 09/20/2017] [Accepted: 10/13/2017] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Antithrombotic drugs are often stopped following acute upper gastrointestinal bleeding (AUGIB) and frequently not restarted. The practice of antithrombotic discontinuation on discharge and its impact on outcomes are unclear. OBJECTIVE To assess whether restarting antithrombotic therapy, prior to hospital discharge for AUGIB, affected clinical outcomes. DESIGN Retrospective cohort study. SETTING University hospital between May 2013 and November 2014, with median follow-up of 259 days. PATIENTS Patients who underwent gastroscopy for AUGIB while on antithrombotic therapy. INTERVENTIONS Continuation or cessation of antithrombotic(s) at discharge. MAIN OUTCOMES MEASURES Cause-specific mortality, thrombotic events, rebleeding and serious adverse events (any of the above). RESULTS Of 118 patients analysed, antithrombotic treatment was stopped in 58 (49.2%). Older age, aspirin monotherapy and peptic ulcer disease were significant predictors of antithrombotic discontinuation, whereas dual antiplatelet use predicted antithrombotic maintenance. The 1-year postdischarge mortality rate was 11.3%, with deaths mainly due to thrombotic causes. Stopping antithrombotic therapy at the time of discharge was associated with increased mortality (HR 3.32; 95% CI 1.07 to 10.31, P=0.027), thrombotic events (HR 5.77; 95% CI 1.26 to 26.35, P=0.010) and overall adverse events (HR 2.98; 95% CI 1.32 to 6.74, P=0.006), with effects persisting after multivariable adjustment for age and peptic ulcer disease. On subgroup analysis, the thromboprotective benefit remained significant with continuation of non-aspirin regimens (P=0.016). There were no significant differences in postdischarge bleeding rates between groups (HR 3.43, 0.36 to 33.04, P=0.255). CONCLUSION In this hospital-based study, discontinuation of antithrombotic therapy is associated with increased thrombotic events and reduced survival.
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Affiliation(s)
- Keith Siau
- Joint Advisory Group in Gastrointestinal Endoscopy, Royal College of Physicians, London.,Department of Gastroenterology, Dudley Group Hospitals NHS Foundation Trust, Dudley
| | - Jack L Hannah
- Department of Medicine, Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - James Hodson
- Department of Medical Statistics, Institute of Translational Medicine, Queen Elizabeth Hospital, Birmingham, England
| | - Monika Widlak
- Department of Gastroenterology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, England
| | - Neeraj Bhala
- Department of Gastroenterology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, England
| | - Tariq H Iqbal
- Department of Gastroenterology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, England
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Outcomes of patients hospitalized with peptic ulcer disease diagnosed in acute upper endoscopy. Eur J Gastroenterol Hepatol 2017; 29:1251-1257. [PMID: 28857894 DOI: 10.1097/meg.0000000000000951] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The incidence and complications of peptic ulcer disease (PUD) have declined, but mortality from bleeding ulcers has remained unchanged. The aims of the current study were to evaluate the significance of PUD among patients admitted for acute upper endoscopy and to evaluate the survival of PUD patients. PATIENTS AND METHODS In this prospective, observational cohort study, data on 1580 acute upper endoscopy cases during 2012-2014 were collected. A total of 649 patients were included with written informed consent. Data on patients' characteristics, living habits, comorbidities, drug use, endoscopy and short-term and long-term survival were collected. RESULTS Of all patients admitted for endoscopy, 147/649 (23%) had PUD with the main symptom of melena. Of these PUD patients, 35% had major stigmata of bleeding (Forrest Ia-IIb) in endoscopy. Patients with major stigmata had significantly more often renal insufficiency, lower level of blood pressure with tachycardia and lower level of haemoglobin, platelets and ratio of thromboplastin time. No differences in drug use, Charlson comorbidity class, BMI, smoking or alcohol use were found. Of the PUD patients, 31% were Helicobacter pylori positive. The 30-day mortality was 0.7% (95% confidence interval: 0.01-4.7), 1-year mortality was 12.9% (8.4-19.5) and the 2-year mortality was 19.4% (13.8-26.8), with no difference according to major or minor stigmata of bleeding. Comorbidity (Charlson>1) was associated with decreased survival (P=0.029) and obesity (BMI≥30) was associated with better survival (P=0.023). CONCLUSION PUD is still the most common cause for acute upper endoscopy with very low short-term mortality. Comorbidity, but not the stigmata of bleeding, was associated with decreased long-term survival.
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Dong J, Wei K, Deng J, Zhou X, Huang X, Deng M, Lü M. Effects of antithrombotic therapy on bleeding after endoscopic submucosal dissection. Gastrointest Endosc 2017; 86:807-816. [PMID: 28732709 DOI: 10.1016/j.gie.2017.07.017] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 07/13/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Bleeding is the most common adverse event after endoscopic submucosal dissection (ESD). Although several studies have reported on the use of antithrombotic agents and post-ESD bleeding, many issues remain controversial. We conducted a meta-analysis and systematic review to evaluate the effects of antithrombotic therapy on post-ESD bleeding. METHODS The published literature was searched on online databases, and all studies were included up to January 2017. Standard forms were used to extract data by 2 independent reviewers. The Newcastle-Ottawa Scale score was used to assess the quality of studies. The pooled odds ratio (OR) was computed for the effect of antithrombotic agents. Publication bias was assessed by funnel plots. Heterogeneity was assessed by the Cochran Q test and I2 statistic. RESULTS Sixteen retrospective articles were included. Regardless of discontinuation (OR, 1.66; 95% confidence interval [CI], 1.15-2.39; P = .007) or continuation (OR, 8.39; 95% CI, 4.64-15.17; P < .00001), antithrombotic therapy was significantly associated with post-ESD bleeding, particularly for delayed bleeding (OR, 2.66; 95% CI, 1.42-4.98; P = .002). The bleeding rate was higher in the discontinued multiple antithrombotics group (OR, 5.17; 95% CI, 3.13-8.54; P < .00001) than in the discontinued a single antithrombotic group (OR, 2.23; 95% CI, 1.29-3.85; P = .004) and single antiplatelet group (OR, 2.08; 95% CI, 0.93-4.63; P = .07). In the subgroup analysis, resuming antithrombotics within 1 week (OR, 2.46; 95% CI, 1.54-3.93; P = .0002) and using heparin replacement (OR, 4.20; 95% CI, 1.94-9.09; P= .0003) significantly increased post-ESD bleeding risk. Continued use of low-dose aspirin (OR, 1.22; 95% CI, 0.17-8.61; P = .84) did not significantly increase the bleeding risk. CONCLUSIONS Antithrombotic therapy is a risk factor for post-ESD bleeding, especially for delayed bleeding. Using multiple antithrombotic drugs, resuming antithrombotics within 1 week, and heparin replacement were significantly associated with post-ESD bleeding; but continuous low-dose aspirin was not. However, much larger prospective studies are required.
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Affiliation(s)
- Jiaqi Dong
- Department of Gastroenterology, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China; Department of Gastroenterology, People's Hospital of Deyang, Deyang, Sichuan, P.R. China
| | - Kunyan Wei
- Department of Gastroenterology, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Jiaqi Deng
- School of Foreign Languages, Southwest Medical University, Luzhou, Sichuan, China
| | - Xi Zhou
- Department of Gastroenterology, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Xiaomei Huang
- Department of Gastroenterology, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - MingMing Deng
- Department of Gastroenterology, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Muhan Lü
- Department of Gastroenterology, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
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Wallis CJD, Juvet T, Lee Y, Matta R, Herschorn S, Kodama R, Kulkarni GS, Satkunasivam R, Geerts W, McLeod A, Narod SA, Nam RK. Association Between Use of Antithrombotic Medication and Hematuria-Related Complications. JAMA 2017; 318:1260-1271. [PMID: 28973248 PMCID: PMC5818855 DOI: 10.1001/jama.2017.13890] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
IMPORTANCE Antithrombotic medications are among the most commonly prescribed medications. OBJECTIVE To characterize rates of hematuria-related complications among patients taking antithrombotic medications. DESIGN, SETTING, AND PARTICIPANTS Population-based, retrospective cohort study including all citizens in Ontario, Canada, aged 66 years and older between 2002 and 2014. The final follow-up date was December 31, 2014. EXPOSURES Receipt of an oral anticoagulant or antiplatelet medication. MAIN OUTCOMES AND MEASURES Hematuria-related complications, defined as emergency department visit, hospitalization, or a urologic procedure to investigate or manage gross hematuria. RESULTS Among 2 518 064 patients, 808 897 (mean [SD] age, 72.1 [6.8] years; 428 531 [53%] women) received at least 1 prescription for an antithrombotic agent over the study period. Over a median follow-up of 7.3 years, the rates of hematuria-related complications were 123.95 events per 1000 person-years among patients actively exposed to antithrombotic agents vs 80.17 events per 1000 person-years among patients not exposed to these drugs (difference, 43.8; 95% CI, 43.0-44.6; P < .001, and incidence rate ratio [IRR], 1.44; 95% CI, 1.42-1.46). The rates of complications among exposed vs unexposed patients (80.17 events/1000 person-years) were 105.78 for urologic procedures (difference, 33.5; 95% CI, 32.8-34.3; P < .001, and IRR, 1.37; 95% CI, 1.36-1.39), 11.12 for hospitalizations (difference, 5.7; 95% CI, 5.5-5.9; P < .001, and IRR, 2.03; 95% CI, 2.00-2.06), and 7.05 for emergency department visits (difference, 4.5; 95% CI, 4.3-4.7; P < .001, and IRR, 2.80; 95% CI, 2.74-2.86). Compared with patients who were unexposed to thrombotic agents, the rates of hematuria-related complications were 191.61 events per 1000 person-years (difference, 117.3; 95% CI, 112.8-121.8) for those exposed to both an anticoagulant and antiplatelet agent (IRR, 10.48; 95% CI, 8.16-13.45), 140.92 (difference, 57.7; 95% CI, 56.9-58.4) for those exposed to anticoagulants (IRR, 1.55; 95% CI, 1.52-1.59), and 110.72 (difference, 26.5; 95% CI, 25.9-27.0) for those exposed to antiplatelet agents (IRR, 1.31; 95% CI, 1.29-1.33). Patients exposed to antithrombotic agents, compared with patients not exposed to these drugs, were more likely to be diagnosed as having bladder cancer within 6 months (0.70% vs 0.38%; odds ratio, 1.85; 95% CI, 1.79-1.92). CONCLUSIONS AND RELEVANCE Among older adults in Ontario, Canada, use of antithrombotic medications, compared with nonuse of these medications, was significantly associated with higher rates of hematuria-related complications (including emergency department visits, hospitalizations, and urologic procedures to manage gross hematuria).
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Affiliation(s)
- Christopher J. D. Wallis
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Tristan Juvet
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Yuna Lee
- Department of Medicine, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Rano Matta
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sender Herschorn
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ronald Kodama
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Girish S. Kulkarni
- Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Urology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Raj Satkunasivam
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - William Geerts
- Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Anne McLeod
- Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Steven A. Narod
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Robert K. Nam
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
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Abstract
Acute upper gastrointestinal haemorrhage due to peptic ulcer bleeding remains an important cause of emergency presentation and hospital admission. Despite advances in many aspects of management, peptic ulcer bleeding is still associated with significant morbidity, mortality, and healthcare costs. Comprehensive international guidelines have been published, but advances as well as controversies continue to evolve. Important recent advances include the evidence supporting a more restrictive transfusion strategy aiming for a target haemoglobin of 70–90 g/l. Comparative studies have confirmed that the Glasgow–Blatchford score remains the most useful score for predicting the need for intervention as well as for identifying the lowest-risk patients suitable for outpatient management. New scores, including the AIMS65 and Progetto Nazionale Emorragia Digestiva score, may be more accurate in predicting mortality. Pre-endoscopy erythromycin appears to improve outcomes and is probably underused. High-dose oral proton pump inhibition (PPI) for 11 days after PPI infusion is advantageous in those with a Rockall score of 6 or more. Oral is as effective as parenteral iron at restoring haemoglobin levels after a peptic ulcer bleed and both are superior to placebo in this respect. Within endoscopic techniques, haemostatic powders and over-the-scope clips can be used when other methods have failed. A disposable Doppler probe appears to provide more accurate determination of both rebleeding risk and the success of endoscopic therapy than purely visual guidance. Non-
Helicobacter pylori, non-aspirin/non-steroidal anti-inflammatory drug ulcers contribute an increasing percentage of bleeding peptic ulcers and are associated with a poor prognosis and high rebleeding rate. The optimal management of these ulcers remains to be determined.
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Affiliation(s)
- Ian Beales
- Department of Gastroenterology, Norfolk and Norwich University Hospital, Norwich, UK
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64
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Nagata N, Sakurai T, Moriyasu S, Shimbo T, Okubo H, Watanabe K, Yokoi C, Yanase M, Akiyama J, Uemura N. Impact of INR monitoring, reversal agent use, heparin bridging, and anticoagulant interruption on rebleeding and thromboembolism in acute gastrointestinal bleeding. PLoS One 2017; 12:e0183423. [PMID: 28863196 PMCID: PMC5580916 DOI: 10.1371/journal.pone.0183423] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Accepted: 08/03/2017] [Indexed: 12/18/2022] Open
Abstract
Background Anticoagulant management of acute gastrointestinal bleeding (GIB) during the pre-endoscopic period has not been fully addressed in American, European, or Asian guidelines. This study sought to evaluate the risks of rebleeding and thromboembolism in anticoagulated patients with acute GIB. Methods Baseline, endoscopy, and outcome data were reviewed for 314 patients with acute GIB: 157 anticoagulant users and 157 age-, sex-, and important risk-matched non-users. Data were also compared between direct oral anticoagulants (DOACs) and warfarin users. Results Between anticoagulant users and non-users, of whom 70% underwent early endoscopy, no endoscopy-related adverse events or significant differences were found in the rate of endoscopic therapy need, transfusion need, rebleeding, or thromboembolism. Rebleeding was associated with shock, comorbidities, low platelet count and albumin level, and low-dose aspirin use but not HAS-BLED score, any endoscopic results, heparin bridge, or international normalized ratio (INR) ≥ 2.5. Risks for thromboembolism were INR ≥ 2.5, difference in onset and pre-endoscopic INR, reversal agent use, and anticoagulant interruption but not CHA2DS2-VASc score, any endoscopic results, or heparin bridge. In patients without reversal agent use, heparin bridge, or anticoagulant interruption, there was only one rebleeding event and no thromboembolic events. Warfarin users had a significantly higher transfusion need than DOACs users. Conclusion Endoscopy appears to be safe for anticoagulant users with acute GIB compared with non-users. Patient background factors were associated with rebleeding, whereas anticoagulant management factors (e.g. INR correction, reversal agent use, and drug interruption) were associated with thromboembolism. Early intervention without reversal agent use, heparin bridge, or anticoagulant interruption may be warranted for acute GIB.
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Affiliation(s)
- Naoyoshi Nagata
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
- * E-mail:
| | - Toshiyuki Sakurai
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
| | - Shiori Moriyasu
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
| | - Takuro Shimbo
- Ohta Nishinouchi Hospital, Koriyama, Fukushima, Japan
| | - Hidetaka Okubo
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
| | - Kazuhiro Watanabe
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
| | - Chizu Yokoi
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
| | - Mikio Yanase
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
| | - Junichi Akiyama
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
| | - Naomi Uemura
- Department of Gastroenterology and Hepatology, Kohnodai Hospital, National Center for Global Health and Medicine, Ichikawa, Chiba, Japan
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Lempereur M, Aminian A, Freixa X, Gafoor S, Shakir S, Omran H, Berti S, Santoro G, Kefer J, Landmesser U, Nielsen-Kudsk JE, Cruz-Gonzalez I, Kanagaratnam P, Nietlispach F, Ibrahim R, Sievert H, Schillinger W, Park JW, Gloekler S, Tzikas A. Left Atrial Appendage Occlusion in Patients With Atrial Fibrillation and Previous Major Gastrointestinal Bleeding (from the Amplatzer Cardiac Plug Multicenter Registry). Am J Cardiol 2017; 120:414-420. [PMID: 28595859 DOI: 10.1016/j.amjcard.2017.04.046] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 04/25/2017] [Accepted: 04/25/2017] [Indexed: 12/19/2022]
Abstract
History of major gastrointestinal (GI) bleeding may represent a frequent clinical indication for left atrial appendage occlusion (LAAO) in patients with non-valvular atrial fibrillation (AF). This study aims to investigate the procedural safety and long-term outcome of patients with previous major GI bleeding (MGIB) who underwent LAAO. Data from the Amplatzer Cardiac Plug multicenter registry on 1,047 patients were analyzed. Patients with previous MGIB as indication for LAAO were compared with patients without previous MGIB. A total of 151 patients (14.4%) with previous MGIB were identified. Periprocedural major bleeding events were more frequent in patients with previous MGIB (4.0% vs 0.8%, p = 0.001). With an average follow-up of 1.3 years, the observed annual rate of stroke/transient ischemic attack and major bleeding for patients with previous MGIB were 2.1% (61.4% relative reduction according to the Congestive Heart failure, Hypertension, Age ≥75 (doubled), Diabetes, Stroke (doubled), Vascular disease, Age 65-74, and Sex (female) [CHA2DS2-VASc] score) and 4.6% (20.1% relative reduction according to the expected rate based on the Hypertension, Abnormal renal/liver function (1 point each), Stroke, Bleeding history or predisposition, Labile INR, Elderly (>65 years), Drugs/alcohol concomitantly (1 point each) [HAS-BLED] score), respectively. In conclusion, in patients with non-valvular atrial fibrillation and previous MGIB, LAAO was associated with a low annual rate of stroke/transient ischemic attack. Periprocedural major bleeding events were more frequent in this specific population although the annual major bleeding rate showed a 20.1% relative risk reduction according to the HAS-BLED score.
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66
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Kido K, Scalese MJ. Management of Oral Anticoagulation Therapy After Gastrointestinal Bleeding: Whether to, When to, and How to Restart an Anticoagulation Therapy. Ann Pharmacother 2017. [PMID: 28639882 DOI: 10.1177/1060028017717019] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To evaluate current clinical evidence for management of oral anticoagulation therapy after gastrointestinal bleeding (GIB) with an emphasis on whether to, when to, and how to resume an anticoagulation therapy. DATA SOURCES Relevant articles from MEDLINE, Cochrane Library, and EMBASE databases were identified from 1946 through May 20, 2017, using the keywords: gastrointestinal hemorrhage or gastrointestinal bleeding and antithrombotic therapy or anticoagulation therapy or warfarin or dabigatran or rivaroxaban or apixaban or edoxaban. STUDY SELECTION AND DATA EXTRACTION All English-language studies assessing management of oral anticoagulation therapy after GIB were evaluated. DATA SYNTHESIS A total of 9 studies were identified. Four retrospective cohort studies showed that resuming anticoagulation therapy was associated with significantly lower rate of thromboembolism (TE) in the general population. Meta-analyses and prospective cohort studies also supported this finding. Two retrospective cohort studies indicated an increase in GIB when anticoagulation reinitiation occurred in less than 7 days without a decrease in TE. Resuming therapy between 7 and 15 days did not demonstrate a significant increase in GIB or TE. A large retrospective study showed that apixaban was associated with the significantly lowest risk of GIB compared with both rivaroxaban and dabigatran. CONCLUSION Anticoagulation therapy resumption is recommended, with resumption being considered between 7 and 14 days following GIB regardless of the therapy chosen. Data for warfarin management after GIB should be applied with caution to direct oral anticoagulants (DOACs) because of the quicker onset and experimental nature of reversal agents. Apixaban may be a preferred option when restarting a DOAC therapy.
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Affiliation(s)
- Kazuhiko Kido
- 1 South Dakota State University, Sioux Falls, SD, USA
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67
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Abstract
OPINION STATEMENT Management of patients on anticoagulant or antiplatelet therapy undergoing endoscopy presents a balance of risks between haemorrhage due to the procedure, and thrombosis due to discontinuation of antithrombotic therapy. Haemorrhage is usually controllable endoscopically, but thrombosis could, on occasion, result in myocardial infarction or stroke, with permanent disability or death. For elective procedures, there is adequate time to plan best management of antithrombotic therapy. International guidelines have been published, but recommendations are based on limited evidence and consultation with appropriate medical specialists, and the patient is important. Patients on dual antiplatelet therapy for coronary stents are at particularly high risk of thrombosis if therapy is interrupted. Direct oral anticoagulants have been a great advance in the management of anticoagulation but can present an increased risk of spontaneous gastrointestinal haemorrhage, as well as a difficult management situation in haemorrhage following endoscopic therapy. For elective endoscopic procedures, there may be a suitable alternative investigation, and some patients can have therapy deferred if high-risk antithrombotic therapy is temporary. Gastrointestinal haemorrhage on antithrombotic therapy can present a life-threatening situation from potential thrombosis as well as haemorrhage. Management is particularly challenging on direct oral anticoagulants (DOACs), but a reversal agent is available for dabigatran, and others are in development. The safest time to restart antithrombotic therapy after therapeutic procedures or haemorrhage has been little studied, and the relevant risk factors are discussed together with advice on management. Although guidelines have been produced, there remains much uncertainty in the management of antithrombotic therapy for endoscopy, particularly for newer agents, and further research is required.
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68
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Smit MD, Van Gelder IC. Resumption of anticoagulation after major bleeding decreases the risk of stroke in patients with atrial fibrillation. ACTA ACUST UNITED AC 2017; 22:107-108. [PMID: 28512109 DOI: 10.1136/ebmed-2017-110694] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2017] [Indexed: 12/14/2022]
Affiliation(s)
- Marcelle D Smit
- Department of Cardiology, Thoraxcenter, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Isabelle C Van Gelder
- Department of Cardiology, Thoraxcenter, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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69
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Lanas-Gimeno A, Lanas A. Risk of gastrointestinal bleeding during anticoagulant treatment. Expert Opin Drug Saf 2017; 16:673-685. [PMID: 28467190 DOI: 10.1080/14740338.2017.1325870] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Gastrointestinal bleeding (GIB) is a major problem in patients on oral anticoagulation therapy. This issue has become even more pressing since the introduction of direct oral anticoagulants (DOACs) in 2009. Areas covered: Here we review current evidence related to GIB associated with oral anticoagulants, focusing on randomized controlled trials, meta-analyses, and post-marketing observational studies. Dabigatran 150 mg twice daily and rivaroxaban 20 mg once daily increase the risk of GIB compared to warfarin. The risk increase with edoxaban is dose-dependent, while apixaban shows apparently, no increased risk. We summarize what is known about GIB risk factors for individual anticoagulants, the location of GIB in patients taking these compounds, and prevention strategies that lower the risk of GIB. Expert opinion: Recently there has been an important shift in the clinical presentation of GIB. Specifically, upper GIB has decreased with the decreased incidence of peptic ulcers due to the broad use of proton pump inhibitors and the decreased prevalence of H. pylori infections. In contrast, the incidence of lower GIB has increased, due in part to colonic diverticular bleeding and angiodysplasia in the elderly. In this population, the addition of oral anticoagulation therapy, especially DOACs, seems to increase the risk of lower GIB.
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Affiliation(s)
- Aitor Lanas-Gimeno
- a Servicio de Aparato Digestivo , Hospital Universitario La Princesa , Madrid , Spain
| | - Angel Lanas
- b Servicio de Digestivo , University Clinic Hospital Lozano Blesa. IIS Aragón , Zaragoza , Spain.,c University of Zaragoza - Medicine , Zaragoza , Spain.,d CIBERehd , Madrid , Spain
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Sengupta N, Tapper EB. Derivation and Internal Validation of a Clinical Prediction Tool for 30-Day Mortality in Lower Gastrointestinal Bleeding. Am J Med 2017; 130:601.e1-601.e8. [PMID: 28065767 DOI: 10.1016/j.amjmed.2016.12.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 12/09/2016] [Accepted: 12/15/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND There are limited data to predict which patients with lower gastrointestinal bleeding are at risk for adverse outcomes. We aimed to develop a clinical tool based on admission variables to predict 30-day mortality in lower gastrointestinal bleeding. METHODS We used a validated machine learning algorithm to identify adult patients hospitalized with lower gastrointestinal bleeding at an academic medical center between 2008 and 2015. The cohort was split randomly into derivation and validation cohorts. In the derivation cohort, we used multiple logistic regression on all candidate admission variables to create a prediction model for 30-day mortality, using area under the receiving operator characteristic curve and misclassification rate to estimate prediction accuracy. Regression coefficients were used to derive an integer score, and mortality risk associated with point totals was assessed. RESULTS In the derivation cohort (n = 4044), 8 variables were most associated with 30-day mortality: age, dementia, metastatic cancer, chronic kidney disease, chronic pulmonary disease, anticoagulant use, admission hematocrit, and albumin. The model yielded a misclassification rate of 0.06 and area under the curve of 0.81. The integer score ranged from -10 to 26 in the derivation cohort, with a misclassification rate of 0.11 and area under the curve of 0.74. In the validation cohort (n = 2060), the score had an area under the curve of 0.72 with a misclassification rate of 0.12. After dividing the score into 4 quartiles of risk, 30-day mortality in the derivation and validation sets was 3.6% and 4.4% in quartile 1, 4.9% and 7.3% in quartile 2, 9.9% and 9.1% in quartile 3, and 24% and 26% in quartile 4, respectively. CONCLUSIONS A clinical tool can be used to predict 30-day mortality in patients hospitalized with lower gastrointestinal bleeding.
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Affiliation(s)
- Neil Sengupta
- Section of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Chicago Medical Center, Ill.
| | - Elliot B Tapper
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor
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71
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Milling TJ, Frontera J. Exploring indications for the Use of direct oral anticoagulants and the associated risks of major bleeding. THE AMERICAN JOURNAL OF MANAGED CARE 2017; 23:S67-S80. [PMID: 28581331 PMCID: PMC5568002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Thrombosis is a leading cause of morbidity and mortality in the United States. Arterial and venous thromboses are implicated in the pathogenesis of major disorders, including myocardial infarction, ischemic stroke, and venous thromboembolism. Over the past decade, direct oral anticoagulants (DOACs) (eg, direct thrombin inhibitor and factor Xa [FXa] inhibitors) have been adopted as alternatives to warfarin due to their clinical advantages and efficacy for the treatment of thrombosis. As with all anticoagulants, treatment with DOACs is associated with a risk of major bleeding, including life-threatening gastrointestinal bleeds and intracranial hemorrhages (ICHs). In turn, the burden of bleeding associated with DOAC treatment is itself associated with substantial healthcare costs that are amplified by an increased risk of thromboembolic events and mortality following major bleeding events, especially in patients with ICHs. Given the rapid adoption of the DOACs and projected usage in the large patient population affected by thromboembolic conditions, clinicians are increasingly likely to encounter patients with major bleeding events due to DOAC therapy. Unlike warfarin, effective strategies to manage these bleeds are limited. There is an unmet need for reversal agents for use in the management of patients who receive FXa inhibitors and experience life-threatening bleeding or need emergency surgery. Andexanet alfa and ciraparantag are being evaluated as potential antidotes for both direct and indirect FXa inhibitors.
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72
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Scott MJ, Veitch A, Thachil J. Reintroduction of anti-thrombotic therapy after a gastrointestinal haemorrhage: if and when? Br J Haematol 2017; 177:185-197. [PMID: 28272736 DOI: 10.1111/bjh.14599] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 12/20/2016] [Indexed: 12/11/2022]
Abstract
Gastrointestinal haemorrhage is a common clinical scenario and, in those using antithrombotic agents, the risk is significantly increased. Management of these patients, in terms of initial resuscitation is well established and numerous guidelines exist in this area. However, few studies have addressed the subsequent dilemma of if and when antithrombotic agents should be reintroduced. Consequently, practice is variable and not necessarily evidenced-based. Overall, for patients that are either anticoagulated or using antiplatelet drugs for secondary prophylaxis, there is a clear benefit to restarting these agents. However, there is limited data to guide when this should occur. For individuals at low risk of re-bleeding, current guidelines suggest single agent aspirin can be continued without interruption, assuming haemostatic control has been confirmed endoscopically. For those at higher bleeding risk, aspirin should be withheld, but reintroduced early (within 3 days of index endoscopy). However, randomised evidence is lacking, as are studies including more modern agents or combined anticoagulant/ antiplatelet regimens. As such, guidance statements are limited and management suggestions must be extrapolated from clinical trials, retrospective studies and data relating specifically to warfarin and aspirin. The intention of this review is to summarise what evidence is available and, where this is lacking, suggest pragmatic management options based on a risk-benefit assessment of thromboembolism and recurrent bleeding.
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Affiliation(s)
- Martin J Scott
- Department of Haematology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Andrew Veitch
- Department of Gastroenterology, New Cross Hospital, Wolverhampton, UK
| | - Jecko Thachil
- Department of Haematology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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73
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Lange CM, Fichtlscherer S, Miesbach W, Zeuzem S, Albert J. The Periprocedural Management of Anticoagulation and Platelet Aggregation Inhibitors in Endoscopic Interventions. DEUTSCHES ARZTEBLATT INTERNATIONAL 2017; 113:129-35. [PMID: 26976713 DOI: 10.3238/arztebl.2016.0129] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 10/05/2015] [Accepted: 10/05/2015] [Indexed: 01/05/2023]
Abstract
BACKGROUND In Germany, more than half a million persons, most of them elderly, are under long-term treatment with anticoagulants. The approval of new oral anticoagulants and platelet aggregation inhibitors, as well as new data on periprocedural bridging with heparins, have introduced marked complexity to the management of treatment with anticoagulants and platelet aggregation inhibitors for endoscopic interventions in visceral surgery. METHODS This review is based on pertinent publications retrieved by a selective literature search in PubMed, as well as on the relevant guidelines. RESULTS Robust data are available on the management of vitamin K antagonists (VKA) and platelet aggregation inhibitors for endoscopic procedures; on the other hand, the data on the periprocedural management of non-VKA oral anticoagulants (NOAC) are still inadequate. Endoscopic procedures that carry a low risk of bleeding can be performed under treatment with anticoagulants or platelet aggregation inhibitors. Before any procedure with a high risk of bleeding (≥ 1.5%) oral anticoagulants of any type and P2Y12 inhibitors should generally be discontinued. Patients in whom VKA are temporarily discontinued for this reason need bridging treatment with heparin only if they are at high risk of thromboembolic events (≥ 10% per year). For patients who are anticoagulated with NOAC, timely discontinuation of the drug depending on renal function is of key importance, and bridging is usually unnecessary. CONCLUSION Adequate scientific evidence supports the current recommendations and treatment algorithms for the periprocedural management of oral anticoagulants and platelet aggregation inhibitors in endoscopic procedures. Larger-scale studies are still needed to provide a sound basis for the corresponding recommendations about NOAC.
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Affiliation(s)
- Christian M Lange
- Gastroenterology and Hepatology, Department of Medicine 1, Frankfurt University Hospital, Frankfurt am Main, Cardiology, Department of Medicine 3, Frankfurt University Hospital, Frankfurt am Main, Hemostaseology, Department of Medicine 2, Frankfurt University Hospital, Frankfurt am Main
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Majeed A, Wallvik N, Eriksson J, Höijer J, Bottai M, Holmström M, Schulman S. Optimal timing of vitamin K antagonist resumption after upper gastrointestinal bleeding. A risk modelling analysis. Thromb Haemost 2016; 117:491-499. [PMID: 28004062 DOI: 10.1160/th16-07-0498] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Accepted: 11/23/2016] [Indexed: 11/05/2022]
Abstract
The optimal timing of vitamin K antagonists (VKAs) resumption after an upper gastrointestinal (GI) bleeding, in patients with continued indication for oral anticoagulation, is uncertain. We included consecutive cases of VKA-associated upper GI bleeding from three hospitals retrospectively. Data on the bleeding location, timing of VKA resumption, recurrent GI bleeding and thromboembolic events were collected. A model was constructed to evaluate the 'total risk', based on the sum of the cumulative rates of recurrent GI bleeding and thromboembolic events, depending on the timing of VKA resumption. A total of 121 (58 %) of 207 patients with VKA-associated upper GI bleeding were restarted on anticoagulation after a median (interquartile range) of one (0.2-3.4) week after the index bleeding. Restarting VKAs was associated with a reduced risk of thromboembolism (HR 0.19; 95 % CI, 0.07-0.55) and death (HR 0.61; 95 % CI, 0.39-0.94), but with an increased risk of recurrent GI bleeding (HR 2.5; 95 % CI, 1.4-4.5). The composite risk obtained from the combined statistical model of recurrent GI bleeding, and thromboembolism decreased if VKAs were resumed after three weeks and reached a nadir at six weeks after the index GI bleeding. On this background we will discuss how the disutility of the outcomes may influence the decision regarding timing of resumption. In conclusion, the optimal timing of VKA resumption after VKA-associated upper GI bleeding appears to be between 3-6 weeks after the index bleeding event but has to take into account the degree of thromboembolic risk, patient values and preferences.
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Affiliation(s)
- Ammar Majeed
- Ammar Majeed, MD, Coagulation Unit, Hematology Center, Karolinska University Hospital, 171 76 Stockholm, Sweden, Tel.: +46 8 51773368, E-mail:
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75
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Witt DM. What to do after the bleed: resuming anticoagulation after major bleeding. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:620-624. [PMID: 27913537 PMCID: PMC6142471 DOI: 10.1182/asheducation-2016.1.620] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Resuming anticoagulation therapy after a potentially life-threatening bleeding complication evokes high anxiety levels among clinicians and patients trying to decide whether resuming oral anticoagulation to prevent devastating and potentially fatal thromboembolic events or discontinuing anticoagulation in hopes of reducing the risk of recurrent bleeding is best. The available evidence favors resumption of anticoagulation therapy for gastrointestinal tract bleeding and intracranial hemorrhage survivors, and it is reasonable to begin postbleeding decision making with resuming anticoagulation therapy as the default plan. After considering factors related to the index bleeding event, the underlying thromboembolic risk, and comorbid conditions, a decision to accept or modify the default plan can be made in collaboration with other care team members, the patient, and their caregivers. Although additional information is needed regarding the optimal timing of anticoagulation resumption, available evidence indicates that waiting ∼14 days may best balance the risk of recurrent bleeding, thromboembolism, and mortality after gastrointestinal tract bleeding. When to resume anticoagulation after intracranial hemorrhage is less clear, but most studies indicate that resumption within the first month of discharge is associated with better outcomes.
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Affiliation(s)
- Daniel M Witt
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT
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76
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Hernandez I, Zhang Y, Brooks MM, Chin PKL, Saba S. Anticoagulation Use and Clinical Outcomes After Major Bleeding on Dabigatran or Warfarin in Atrial Fibrillation. Stroke 2016; 48:159-166. [PMID: 27909200 DOI: 10.1161/strokeaha.116.015150] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 10/05/2016] [Accepted: 10/18/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Little is known about the clinical outcomes associated with posthemorrhage anticoagulation resumption for atrial fibrillation. This study had 2 objectives: first, to evaluate anticoagulation use after a first major bleed on warfarin or dabigatran and, second, to compare effectiveness and safety outcomes between patients discontinuing anticoagulation after a major bleed and patients restarting warfarin or dabigatran. METHODS Using 2010 to 2012 Medicare Part D data, we identified atrial fibrillation patients who experienced a major bleeding event while using warfarin (n=1135) or dabigatran (n=404) and categorized them by their posthemorrhage use of anticoagulation. We followed them until an ischemic stroke, recurrent hemorrhage, or death through December 31, 2012. We constructed logistic regression models to evaluate factors affecting anticoagulation resumption and Cox proportional hazard models to compare the combined risk of ischemic stroke and all-cause mortality and the risk of recurrent bleeding between treatment groups. RESULTS Resumption of anticoagulation with warfarin (hazard ratio [HR] 0.76; 95% confidence interval [CI] 0.59-0.97) or dabigatran (HR 0.66; 95% CI 0.44-0.99) was associated with lower combined risk of ischemic stroke and all-cause mortality than anticoagulation discontinuation. The incidence of recurrent major bleeding was higher for patients prescribed warfarin after the event than for those prescribed dabigatran (HR 2.31; 95% CI 1.19-4.76) or whose anticoagulation ceased (HR 1.56; 95% CI 1.10-2.22), but did not differ between patients restarting dabigatran and those discontinuing anticoagulation (HR 0.65; 95% CI 0.32-1.33). CONCLUSIONS Dabigatran was associated with a superior benefit/risk ratio than warfarin and anticoagulation discontinuation in the treatment of atrial fibrillation patients who have survived a major bleed.
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Affiliation(s)
- Inmaculada Hernandez
- From the Department of Pharmacy and Therapeutics, School of Pharmacy (I.H.), Department of Health Policy and Management, Graduate School of Public Health (Y.Z.), and Department of Epidemiology, Graduate School of Public Health (M.M.B.), University of Pittsburgh, PA; Department of Medicine, University of Otago, Christchurch, New Zealand (P.K.L.C.); and Heart and Valvular Institute, University of Pittsburgh Medical Centre, PA (S.S.)
| | - Yuting Zhang
- From the Department of Pharmacy and Therapeutics, School of Pharmacy (I.H.), Department of Health Policy and Management, Graduate School of Public Health (Y.Z.), and Department of Epidemiology, Graduate School of Public Health (M.M.B.), University of Pittsburgh, PA; Department of Medicine, University of Otago, Christchurch, New Zealand (P.K.L.C.); and Heart and Valvular Institute, University of Pittsburgh Medical Centre, PA (S.S.).
| | - Maria M Brooks
- From the Department of Pharmacy and Therapeutics, School of Pharmacy (I.H.), Department of Health Policy and Management, Graduate School of Public Health (Y.Z.), and Department of Epidemiology, Graduate School of Public Health (M.M.B.), University of Pittsburgh, PA; Department of Medicine, University of Otago, Christchurch, New Zealand (P.K.L.C.); and Heart and Valvular Institute, University of Pittsburgh Medical Centre, PA (S.S.)
| | - Paul K L Chin
- From the Department of Pharmacy and Therapeutics, School of Pharmacy (I.H.), Department of Health Policy and Management, Graduate School of Public Health (Y.Z.), and Department of Epidemiology, Graduate School of Public Health (M.M.B.), University of Pittsburgh, PA; Department of Medicine, University of Otago, Christchurch, New Zealand (P.K.L.C.); and Heart and Valvular Institute, University of Pittsburgh Medical Centre, PA (S.S.)
| | - Samir Saba
- From the Department of Pharmacy and Therapeutics, School of Pharmacy (I.H.), Department of Health Policy and Management, Graduate School of Public Health (Y.Z.), and Department of Epidemiology, Graduate School of Public Health (M.M.B.), University of Pittsburgh, PA; Department of Medicine, University of Otago, Christchurch, New Zealand (P.K.L.C.); and Heart and Valvular Institute, University of Pittsburgh Medical Centre, PA (S.S.)
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77
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Abstract
Direct oral anticoagulants (DOACs) are a relatively recent addition to the oral anticoagulant armamentarium, and provide an alternative to the use of vitamin K antagonists such as warfarin. Regardless of the type of agent used, bleeding is the major complication of anticoagulant therapy. The decision to restart oral anticoagulation following a major hemorrhage in a previously anticoagulated patient is supported largely by retrospective studies rather than randomized clinical trials (mostly with vitamin K antagonists), and remains an issue of individualized clinical assessment: the patient's risk of thromboembolism must be balanced with the risk of recurrent major bleeding. This review provides guidance for clinicians regarding if and when a patient should be re-initiated on DOAC therapy following a major hemorrhage, based on the existing evidence.
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Affiliation(s)
- Truman J Milling
- Departments of Neurology and Surgery and Perioperative Care, Seton Dell Medical School Stroke Institute, Austin, TX.
| | - Alex C Spyropoulos
- Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Hofstra North Shore-LIJ School of Medicine, North Shore-LIJ Health System, Manhasset, NY
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78
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Abstract
Direct oral anticoagulants (DOACs) are a relatively recent addition to the oral anticoagulant armamentarium, and provide an alternative to the use of vitamin K antagonists such as warfarin. Regardless of the type of agent used, bleeding is the major complication of anticoagulant therapy. The decision to restart oral anticoagulation following a major hemorrhage in a previously anticoagulated patient is supported largely by retrospective studies rather than randomized clinical trials (mostly with vitamin K antagonists), and remains an issue of individualized clinical assessment: the patient’s risk of thromboembolism must be balanced with the risk of recurrent major bleeding. This review provides guidance for clinicians regarding if and when a patient should be re-initiated on DOAC therapy following a major hemorrhage, based on the existing evidence.
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Affiliation(s)
- Truman J Milling
- Departments of Neurology and Surgery and Perioperative Care, Seton Dell Medical School Stroke Institute, Austin, TX.
| | - Alex C Spyropoulos
- Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Hofstra North Shore-LIJ School of Medicine, North Shore-LIJ Health System, Manhasset, NY
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79
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Lau YC, Proietti M, Guiducci E, Blann AD, Lip GY. Atrial Fibrillation and Thromboembolism in Patients With Chronic Kidney Disease. J Am Coll Cardiol 2016; 68:1452-1464. [DOI: 10.1016/j.jacc.2016.06.057] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 06/14/2016] [Indexed: 02/06/2023]
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80
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Diagnostic and Therapeutic Yield of Endoscopy in Patients with Elevated INR and Gastrointestinal Bleeding. Am J Med 2016; 129:628-34. [PMID: 26714209 DOI: 10.1016/j.amjmed.2015.11.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 11/05/2015] [Accepted: 11/18/2015] [Indexed: 01/20/2023]
Abstract
BACKGROUND Gastrointestinal bleeding is a well-known risk of systemic anticoagulation. However, bleeding in the setting of supratherapeutic anticoagulation may have a milder natural history than unprovoked bleeding. It is a common clinical gestalt that endoscopy is common, but bleeding source identification or intervention is uncommon, yet few data exist to inform this clinical impression. Consequently, we sought to examine our institutional experience with gastrointestinal bleeding in the setting of supratherapeutic international normalized ratio (INR) with the aim of identifying predictors of endoscopically identifiable lesions, interventions, and outcomes. METHODS A retrospective review was conducted at a tertiary referral academic medical center to identify patients presenting with gastrointestinal bleeding in the setting of warfarin and a supratherapeutic INR (>3.5) who underwent an endoscopic procedure. Relevant clinical covariates, endoscopic findings, need for intervention, and outcomes were collected by review of the medical record. Logistic regression adjusting for potential confounders identified predictors of endoscopically significant lesions as well as intervention and outcomes. RESULTS A total of 134 patients with INR 3.5 or greater (mean 5.5, range 3.5-17.1) presented with symptoms of gastrointestinal bleeding, most commonly as melena or symptomatic anemia. Antiplatelet agents were used by 54% of patients, and 60% of patients were on concomitant acid suppression on admission. Procedures included esophagogastroduodenoscopy (upper endoscopy; EGD) (n = 128), colonoscopy (n = 73), and video capsule endoscopy (n = 32). Active bleeding at first EGD or colonoscopy was found in only 19 patients (18%), with endoscopic intervention in only 26 patients (25%). At a critical threshold of INR 7.5 at presentation, the likelihood of finding an endoscopically significant lesion fell to <20%. On multivariate logistic regression, concomitant antiplatelet therapy (odds ratio [OR] 2.59; 95% confidence interval [CI], 1.13-5.94), timing of EGD within 12 hours of presentation (OR 3.71; 95% CI, 1.05-13.08), and INR level (OR 0.79; 95% CI, 0.64-0.98) were the only significant independent predictors of identifying a source of bleeding. A risk score incorporating these covariates performed modestly in identifying risk of significant finding on EGD (area under the curve 0.68). We found no association between identification of a significant lesion at EGD and future readmission for gastrointestinal bleeding. CONCLUSION This study demonstrates that the relationship between INR elevation and identification of a bleeding source or endoscopic intervention at EGD are indeed antiparallel. Concomitant antiplatelet therapy increases the likelihood of bleeding source identification and intervention, as does EGD within 12 hours of presentation. However, regardless of source identification or endoscopic intervention, important clinical outcomes were unchanged, suggesting that decisions about endoscopy should be made on a case-by-case basis, particularly in patients with INR > 7.5. Future prospective studies on appropriate indications and timing of endoscopy in such patients are warranted.
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81
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Radaelli F, Dentali F, Paggi S, Repici A. Reply to "When to resume anticoagulation after acute gastrointestinal bleeding?". Dig Liver Dis 2016; 48:690-1. [PMID: 27038704 DOI: 10.1016/j.dld.2016.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Accepted: 03/12/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Franco Radaelli
- Department of Gastroenterology, Valduce Hospital, Como, Italy.
| | - Francesco Dentali
- Department of Clinical Medicine, University of Insubria, Varese, Italy
| | - Silvia Paggi
- Department of Gastroenterology, Valduce Hospital, Como, Italy
| | - Alessandro Repici
- Department of Gastroenterology and Hepatology, Humanitas Research Hospital, Humanitas University, Milan, Italy
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82
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Voukalis C, Lip GY, Shantsila E. Emerging Tools for Stroke Prevention in Atrial Fibrillation. EBioMedicine 2016; 4:26-39. [PMID: 26981569 PMCID: PMC4776061 DOI: 10.1016/j.ebiom.2016.01.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 01/07/2016] [Accepted: 01/14/2016] [Indexed: 02/02/2023] Open
Abstract
Ischaemic strokes resulting from atrial fibrillation (AF) constitute a devastating condition for patients and their carers with huge burden on health care systems. Prophylactic treatment against systemic embolization and ischaemic strokes is the cornerstone for the management of AF. Effective stroke prevention requires the use of the vitamin K antagonists or non-vitamin K oral anticoagulants (NOACs). This article summarises the latest developments in the field of stroke prevention in AF and aims to assist physicians with the choice of oral anticoagulant for patients with non-valvular AF with different risk factor profile.
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Key Words
- Atrial fibrillation
- CKD, chronic kidney disease
- CrCl, creatinine clearance
- DM, diabetes mellitus
- ESRF, end stage renal failure
- HF, heart failure
- HTN, hypertension
- ICH, intracranial haemorrhage
- INR, international normalised ratio
- LV, left ventricle
- NCB, net clinical benefit
- NICE, National institute for Health and Care Excellence
- NVAF, non-valvular atrial fibrillation
- Net clinical benefit
- Non-vitamin K oral anticoagulants
- Oral anticoagulation
- PCI, percutaneous coronary intervention
- RSM, risk stratification model
- Risk stratification
- SE, systemic embolism
- Stroke prevention
- TE, thromboembolic episode
- TIA, transient ischaemic attack
- TTR, time in therapeutic range
- eGFR, estimated glomerular filtration rate
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Affiliation(s)
| | | | - Eduard Shantsila
- University of Birmingham, Institute of Cardiovascular Sciences, City Hospital, Birmingham B18 7QH, UK
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83
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Chan PH, Li WH, Hai JJ, Chan KH, Tse HF, Cheung BMY, Chan EW, Wong IC, Leung WK, Hung IFN, Lip GY, Siu CW. Gastrointestinal haemorrhage in atrial fibrillation patients: impact of quality of anticoagulation control. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2015; 1:265-72. [DOI: 10.1093/ehjcvp/pvv032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 08/06/2015] [Indexed: 11/13/2022]
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Cerini F, Gonzalez JM, Torres F, Puente Á, Casas M, Vinaixa C, Berenguer M, Ardevol A, Augustin S, Llop E, Senosiaín M, Villanueva C, de la Peña J, Bañares R, Genescá J, Sopeña J, Albillos A, Bosch J, Hernández-Gea V, Garcia-Pagán JC. Impact of anticoagulation on upper-gastrointestinal bleeding in cirrhosis. A retrospective multicenter study. Hepatology 2015; 62:575-83. [PMID: 25773591 DOI: 10.1002/hep.27783] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Accepted: 03/11/2015] [Indexed: 12/11/2022]
Abstract
UNLABELLED Recent studies have shown that liver cirrhosis (LC) behaves as an acquired hypercoagulable state with increased thrombotic risk. This is why anticoagulation therapy (AT) is now frequently used in these patients. Variceal bleeding is a severe complication of LC. It is unknown whether AT may impact the outcome of bleeding in these patients. Fifty-two patients on AT with upper gastrointestinal bleeding (UGIB) were evaluated. Portal vein thrombosis (PVT) and different cardiovascular disorders (CVDs) were the indication for AT in 14 and 38 patients, respectively. Overall, 104 patients with LC and UGIB not under AT matched for severity of LC, age, sex, source of bleeding, and Sequential Organ Failure Assessment (SOFA) score served as controls. UGIB was attributed to portal hypertension (PH) in 99 (63%) patients and peptic/vascular lesions in 57 (37%). Twenty-six (17%) patients experienced 5-day failure; SOFA, source of UGIB, and PVT, but not AT, were independent predictors of 5-day failure. In addition, independent predictors of 6-week mortality, which was observed in 26 (11%) patients, were SOFA, Charlson Comorbidity index, and use of AT for a CVD. There were no differences between patients with/without AT in needs for rescue therapies, intensive care unit admission, transfusions, and hospital stay. CONCLUSIONS Factors that impact the outcome of UGIB in patients under AT are degree of multiorgan failure and comorbidity, but not AT itself.
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Affiliation(s)
- Federica Cerini
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic-IDIBAPS, University of Barcelona, Spain.,CIBERehd (Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas), Barcelona, Spain
| | - Javier Martínez Gonzalez
- Department of Gastroenterology, Hospital Universitario Ramón y Cajal, IRYCIS, University of Alcalá, Madrid, Spain.,CIBERehd (Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas), Barcelona, Spain
| | - Ferran Torres
- Biostatistics and Data Management Core Facility, IDIBAPS, Hospital Clinic Barcelona, Barcelona, Spain.,Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ángela Puente
- Hepatology Unit, Gastroenterolgy Department, Marques de Valdecilla University Hospital, Marques de Valdecilla Investigation Institute (IDIVAL), Santander, Spain
| | - Meritxell Casas
- Liver Unit, Department of Gastroenterology, Corporación Sanitaria Parc Taulí. Sabadell, Barcelona, Spain
| | - Carmen Vinaixa
- Liver Transplantation and Hepatology Unit, Hospital Universitari i Politècnic La Fe de Valencia, Valencia, Spain.,CIBERehd (Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas), Barcelona, Spain
| | - Marina Berenguer
- Liver Transplantation and Hepatology Unit, Hospital Universitari i Politècnic La Fe de Valencia, Valencia, Spain.,CIBERehd (Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas), Barcelona, Spain
| | - Alba Ardevol
- Department of Gastroenterology, Hospital Sant Pau, Barcelona, Spain.,CIBERehd (Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas), Barcelona, Spain
| | - Salvador Augustin
- Liver Unit-Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain.,CIBERehd (Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas), Barcelona, Spain
| | - Elba Llop
- Department of Gastroenterology, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Maria Senosiaín
- Department of Gastroenterology, Hospital General Universitario Gregorio Marañón, (IISGM), Facultad de Medicina, Universidad Complutense, Madrid, Spain.,CIBERehd (Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas), Barcelona, Spain
| | - Càndid Villanueva
- Department of Gastroenterology, Hospital Sant Pau, Barcelona, Spain.,CIBERehd (Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas), Barcelona, Spain
| | - Joaquin de la Peña
- Hepatology Unit, Gastroenterolgy Department, Marques de Valdecilla University Hospital, Marques de Valdecilla Investigation Institute (IDIVAL), Santander, Spain
| | - Rafael Bañares
- Department of Gastroenterology, Hospital General Universitario Gregorio Marañón, (IISGM), Facultad de Medicina, Universidad Complutense, Madrid, Spain.,CIBERehd (Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas), Barcelona, Spain
| | - Joan Genescá
- Liver Unit-Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain.,Department of Gastroenterology, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Júlia Sopeña
- Liver Unit, Department of Gastroenterology, Corporación Sanitaria Parc Taulí. Sabadell, Barcelona, Spain
| | - Agustín Albillos
- Department of Gastroenterology, Hospital Universitario Ramón y Cajal, IRYCIS, University of Alcalá, Madrid, Spain.,CIBERehd (Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas), Barcelona, Spain
| | - Jaume Bosch
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic-IDIBAPS, University of Barcelona, Spain.,CIBERehd (Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas), Barcelona, Spain
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic-IDIBAPS, University of Barcelona, Spain.,CIBERehd (Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas), Barcelona, Spain
| | - Juan Carlos Garcia-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic-IDIBAPS, University of Barcelona, Spain.,CIBERehd (Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas), Barcelona, Spain
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85
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Sengupta N, Tapper EB, Patwardhan VR, Ketwaroo GA, Thaker AM, Leffler DA, Feuerstein JD. Risk Factors for Adverse Outcomes in Patients Hospitalized With Lower Gastrointestinal Bleeding. Mayo Clin Proc 2015; 90:1021-9. [PMID: 26141075 PMCID: PMC4770256 DOI: 10.1016/j.mayocp.2015.04.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 04/10/2015] [Accepted: 04/22/2015] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To determine which risk factors and subtypes of lower gastrointestinal bleeding (LGIB) are associated with adverse outcomes after hospital discharge (30-day readmissions, recurrent LGIB, and death). PATIENTS AND METHODS We conducted a prospective observational study of consecutive patients admitted with LGIB to Beth Israel Deaconess Medical Center from April 1, 2013, through March 30, 2014. Patients were contacted 30 days after discharge to determine hospital readmissions, recurrent LGIB, and death. Multivariable Cox proportional hazards regression models were used to describe associations of variables with 30-day readmissions or recurrent LGIB. Logistic regression was used to determine association with mortality. RESULTS There were 277 patients hospitalized with LGIB. Of the 271 patients surviving to discharge, 21% (n=57) were readmitted within 30 days, 21 of whom were admitted for recurrent LGIB. The following factors were associated with 30-day readmissions: developing in-hospital LGIB (hazard ratio [HR], 2.26; 95% CI, 1.08-4.28), anticoagulation (HR, 1.82; 95% CI, 1.05-3.10), and active malignancy (HR, 2.33; 95% CI, 1.11-4.42). Patients discharged while taking anticoagulants had higher rates of recurrent bleeding (HR, 2.93; 95% CI, 1.15-6.95). Patients with higher Charlson Comorbidity Index scores (odds ratio [OR], 1.57; 95% CI, 1.25-2.08), active malignancy (OR, 6.57; 95% CI, 1.28-28.7), and in-hospital LGIB (OR, 11.5; 95% CI, 2.56-52.0) had increased 30-day mortality risk. CONCLUSION In-hospital LGIB, anticoagulation, and active malignancy are risk factors for 30-day readmissions in patients hospitalized with LGIB. In-hospital LGIB, Charlson Comorbidity Index scores, and active malignancy are risk factors for 30-day mortality.
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Affiliation(s)
- Neil Sengupta
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA.
| | - Elliot B Tapper
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Vilas R Patwardhan
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Adarsh M Thaker
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Daniel A Leffler
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Joseph D Feuerstein
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA
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