The Impact of Traditional Anticoagulants, Novel Anticoagulants, and Antiplatelets on Epistaxis

The impact of different anticoagulants and antiplatelets regimens on acute epistaxis outcomes

BACKGROUND

The impact of anticoagulants (AC) and antiplatelets (AP) on the management of acute epistaxis remains unclear. This study investigated the association between AC/AP therapy and treatment outcomes in patients with acute epistaxis.

METHODOLOGY

A retrospective analysis of patients presented to the otolaryngology emergency room with acute epistaxis (2014-2022). Patients were categorized based on their regular medications: AP, dual AP therapy (DAPT), new oral anticoagulants (NOAC), vitamin K antagonists (VKA), or no regular AC/AP use (control group). Outcome measures included rates of minor interventions (chemical or electrical cautery, nasal tamponade), major interventions (endoscopic ligation, embolization), recurrent emergency department visits, admission rates, and duration.

RESULTS

786 patients were included with an average follow-up period of 52.56 ± 20.4 months. Compared to the control group, patients on AP, DAPT, or VKA had significantly higher rates of minor interventions (63.1% vs. 74.4%, 79.6%, and 77.3%, respectively, p < 0.05). DAPT users exhibited a higher rate of major interventions than the control (5.6% vs. 1.3%, p = 0.053). NOAC users showed no significant difference in minor interventions compared to control and required no major interventions. Both NOAC and VKA users had significantly higher rates of recurrent epistaxis events and prolonged hospitalization compared to the control (p < 0.01 and p < 0.05, respectively).

CONCLUSIONS

NOAC demonstrated more favorable outcomes than VKA in patients with acute epistaxis, and DAPT use was associated with an increased need for major interventions. These findings suggest a more conservative approach in NOAC users than other AC/AP agents.

Intractable epistaxis requiring surgical exploration or arterial embolization; Associated comorbidities and locations of the bleeder

OBJECTIVE

This study aimed to determine which comorbidities were associated with intractable epistaxis requiring electrocauterization or embolization, and to identify the location where intractable epistaxis frequently occurred.

METHODS

The patients were divided into two groups: patients with epistaxis successfully controlled in outpatient department (OPD) and those with intractable epistaxis in OPD which was controlled by surgical exploration or arterial embolization (OP/EM). Evaluations of the bleeding locations, related vessels, and patient's comorbidities were conducted.

RESULTS

A total of 41 patients from the OP/EM group and 725 patients from the OPD group were enrolled. The following comorbidities showed elevated risks of the intractable epistaxis (p< 0.05) in multivariate analysis; hypertension (OR 1.089, 95% CI 1.049 - 1.132), dyslipidemia (1.132, 1.041 - 1.232), liver cirrhosis (1.272, 1.152 - 1.406), chronic obstructive pulmonary disease (1.234, 1.078 - 1.412) and asthma (1.205, 1.053 - 1.379). Inferior and middle turbinate were equally the most common location of the intractable bleeding.

CONCLUSION

In patients with epistaxis requiring hemostatic treatments, comorbidities such as hypertension, dyslipidemia, liver diseases, COPD, and asthma were associated with intractable epistaxis. The main bleeding sites of intractable epistaxis were the middle and inferior turbinate.

Posterior epistaxis management: review of the literature and proposed guidelines of the hellenic rhinological-facial plastic surgery society

PURPOSE

Posterior epistaxis is a common emergency in ENT practice varying in severity and treatment. Many management guidelines have been proposed, all of which are a product of retrospective analyses due to the nature of this pathology, as large-scale double-blind studies are impossible-even unethical-to conduct. The purpose of this review is to perform a thorough analysis and comparison of every treatment plan available and establish guidelines for the best possible outcome in accordance to every parameter studied. Given the extensive heterogeneity of information and the multitude of studies on this topic, along with the comparison of various treatment options, we opted for a literature review as our research approach.

METHODS

A review of the literature was performed using PubMed Database and search terms included "posterior epistaxis", "treatment", "management", "guidelines", "algorithm" "nasal packing", "posterior packing", "surgery", "SPA ligation", "embolization", "risk factors" or a combination of the above.

RESULTS

Initial patients' assessment invariably results in most cases in posterior packing. There seems to be a superiority in recent literature of early surgery over nasal packing as a definitive treatment. Embolization is usually used after surgery failure, except for specific occasions.

CONCLUSION

Despite the vast heterogeneity of information, there seems to be a need for re-evaluation of the well-established treatment plans according to more recent studies.

Risk factors and management outcomes in epistaxis: a tertiary centre experience

BACKGROUND

Risk factors and outcomes associated with severe epistaxis are not well understood. This study explores the associations between epistaxis severity, comorbidities, use of antiplatelets or anticoagulants and management outcomes.

METHODS

This is a retrospective cross-sectional study of all epistaxis cases presenting to the emergency department at a tertiary academic hospital from January 2016 to December 2019. Epistaxis severity was defined as mild (no intervention), moderate (required cautery and/or packing) and severe (clinical instability with reversal products, surgical or radiological intervention). Univariable and multivariable regression analyses were undertaken, with risk factors and management outcomes analysed according to severity.

RESULTS

A total of 543 patients with epistaxis (54.2% male, mean age 74.4 ± 15.7 years) were included in this study, with 14.7% (80) having severe epistaxis. Of these presentations 216 (39.8%) were on antiplatelets, while 207 (38.1%) were on anticoagulants. In univariate analyses, clopidogrel use, hereditary haemorrhagic telangiectasia (HHT), haematological malignancy, bleeding disorders and chronic liver disease (CLD) were associated with moderate to severe epistaxis (P < 0.05), while the use of rivaroxaban was inversely associated severity (P = 0.002). Only HHT, haematological malignancy and CLD remained significant in multivariate models. Cautery as first-line management was infrequently utilized while anticoagulation was frequently withheld. A longer length of stay (1.1 days vs. 4.3 days; P < 0.001) and higher 2-week readmission rates (2.2% vs. 12.5%; P < 0.001) were noted with severe epistaxis compared with mild presentations.

CONCLUSION

Epistaxis severity is associated with certain clinical conditions and poor outcomes. Despite recommended guidelines, variations in first-line management were evident.

Incidence and Predictors of Clinically Significant Bleedings after Transcatheter Left Atrial Appendage Closure

BACKGROUND

Transcatheter left atrial appendage closure (LAAC) is performed in patients unsuitable for long-term anticoagulation, predominantly due to prior bleeding events. The study aimed to investigate the incidence and predictors of clinically significant bleeding (CSB) post-LAAC.

METHODS

Consecutive patients after LAAC with an Amplatzer or WATCHMAN device were analyzed (05.2014-11.2019). Bleeding was classified as CSB when associated with at least one of the following: death, ≥2 g/dL hemoglobin drop, ≥2 blood units transfusion, critical anatomic site, or hospitalization/invasive procedure.

RESULTS

Among 195 patients (age 74 (68-80), 43.1% females, HAS-BLED score 2.0 (2.0-3.0)), during median follow-up of 370 (IQR, 358-392) days, there were 15 nonprocedural CSBs in 14 (7.2%) patients. Of those, 9 (60.0%) occurred during postprocedural dual antiplatelet therapy (DAPT) (median 46 (IQR: 16-60) days post-LAAC) vs. 6 (40%) after DAPT discontinuation (median 124 (81-210) days post-LAAC), translating into annualized CSB rates of 14.0% (per patient-year on DAPT) vs. 4.6% (per patient-year without DAPT). In 92.9% (13/14) of patients, the post-LAAC nonprocedural CSB was a recurrence from the same site as bleeding pre-LAAC. In the multivariable model, admission systolic blood pressure (SBP) > 127 mmHg (HR = 10.73, 1.37-84.26, p = 0.024), epistaxis history (HR = 5.84, 1.32-25.89, p = 0.020), permanent atrial fibrillation (AF) (HR = 4.55, 1.20-17.20, p = 0.025), and prior gastrointestinal bleeding (HR = 3.35, 1.01-11.08, p = 0.048) predicted post-LAAC CSB.

CONCLUSIONS

Nonprocedural CSBs after LAAC, with a similar origin as the pre-LAAC bleedings, were observed predominantly during postprocedural DAPT and predicted by elevated admission SBP, prior epistaxis, permanent AF, and gastrointestinal bleeding history. Whether a more reserved post-LAAC antiplatelet regimen and stringent blood pressure control may improve LAAC outcomes remains to be studied.

Risk Factors and Management for Epistaxis in a Hospitalized Adult Sample

INTRODUCTION

Epistaxis is a common otolaryngologic problem that affects most of the general population. Common risk factors for epistaxis include nasal irritants, nasal/facial oxygen use, certain systemic conditions (e.g., hypertension and coagulopathies) and medication use (e.g., anticoagulants and intranasal medications). This study examined risk factors for and management of epistaxis in patients admitted for other medical conditions who developed an episode of epistaxis during their hospital admission.

METHODS

Patients were included in the study if they were older than 18, admitted for medical illnesses other than epistaxis and developed an episode of epistaxis during their admission during calendar year 2020 at the authors' institution's hospitals. Electronic health record data regarding sociodemographic characteristics, common risk factors (e.g. oxygen use, anticoagulant use, history of hypertension) and treatment for epistaxis (e.g. holding anticoagulation therapy, administration of oxymetazoline, nasal cautery, nasal packing) were extracted from each chart. Patients were split into otolaryngologic treatment versus no treatment groups and risk factors were compared between sample subgroups.

RESULTS

A total of 143 sample patients were included, with most common reason for admission being cardiovascular related, 48 (33.6%). Most patients, 104 (72.7%), did not have a previous diagnosis of epistaxis, were positive for anticoagulant use, 106 (74.1%) and were positive for hypertension, 95 (66.4%). Oxygen use showed a significantly decreased risk for intervention (OR 0.45, 95% CI: 0.23-0.894; p = 0.028). Most patients required changes in medical management (e.g., holding anticoagulation or starting nasal saline sprays/emollients).

CONCLUSION

These results demonstrate the common risk factors for epistaxis in patients admitted for other clinical diseases. Identifying at-risk patients for epistaxis at hospital admission can help to initiate measures to prevent epistaxis episodes. Future studies are needed to study epistaxis risk factors and identify effective preventative measures for epistaxis among hospital populations.

Direct oral anticoagulants versus vitamin K antagonists in epistaxis patients: A systematic review and meta-analysis

OBJECTIVE

Epistaxis is the most common otolaryngological emergency and up to one third of patients in treated on an inpatient basis take oral anticoagulants (OAC). Direct oral anticoagulants (DOAC), an OAC subgroup, have been on the market since 2010 and are being increasingly prescribed due to the cardiological and haematological guidelines that favour them over vitamin K antagonists (VKA), the older of the OAC subgroups. The present study aims to investigate which subgroup of epistaxis patients taking OACs has a more favourable outcome.

DESIGN/SETTING

A systematic review and meta-analysis were performed according to the PRISMA 2020 statement using the PubMed and Cochrane Library databases. Continuous data were analysed and standardised mean difference (SMD) was calculated according to Hedges' g. Dichotomous data were analysed, and the Mantel-Haenszel method was applied to establish the odds ratio (OR). Heterogeneity was assessed according to the I²  statistics.

MAIN OUTCOME/RESULTS

A total of eight reports covering 1390 patients were included in the final synthesis. The pooled analysis demonstrated significantly shorter hospital stays in the DOAC group (SMD = -0.22, 95% CI-0.42 to -0.02, p = .03) and a significantly higher rate of posterior bleeding in the VKA group (OR = .39, 95% CI 0.23 to 0.68, p = .001). No statistically significant differences with regard to recurrence rates, admission rates, the need for transfusion or surgical intervention (p = .57, .12, .57 and .38 respectively) were found.

CONCLUSION

According to this meta-analysis, epistaxis patients taking DOACs have a more favourable outcome than patients taking VKAs.