1
|
Singer AJ, Abraham NS, Ganti L, Peacock WF, Dark J, Ishaq H, Negrete A, Mount B, Neuenschwander J. Evaluation and treatment of gastrointestinal bleeding in patients taking anticoagulants presenting to the emergency department. Int J Emerg Med 2024; 17:70. [PMID: 38822267 PMCID: PMC11141076 DOI: 10.1186/s12245-024-00649-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 05/21/2024] [Indexed: 06/02/2024] Open
Abstract
This manuscript is a consensus document of an expert panel on the Evaluation and Treatment of Gastrointestinal Bleeding in Patients Taking Anticoagulants Presenting to the Emergency Department, sponsored by the American College of Emergency Physicians.
Collapse
Affiliation(s)
| | | | - Latha Ganti
- Orlando College of Osteopathic Medicine, Winter Garden, FL, USA.
- Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | | | - Janaé Dark
- HCA Houston Healthcare, Clear Lake, TX, USA
| | | | - Ana Negrete
- Methodist University Hospital, Memphis, TN, USA
| | - Brandon Mount
- University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | | |
Collapse
|
2
|
Bozic D, Alicic D, Martinovic D, Zaja I, Bilandzic-Ivisic J, Sodan R, Kresic B, Bratanic A, Puljiz Z, Ardalic Z, Bozic J. Plasma Drug Values of DOACs in Patients Presenting with Gastrointestinal Bleeding: A Prospective Observational Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1466. [PMID: 37629757 PMCID: PMC10456420 DOI: 10.3390/medicina59081466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/13/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023]
Abstract
Background and Objectives: Anticoagulants are a well-known risk factor for gastrointestinal bleeding (GIB). In recent years, direct oral anticoagulants (DOACs) have taken a leading role in the treatment and prevention of thromboembolic incidents. The aim of this study was to investigate the prevalence of DOAC-treated patients with GIB whose plasma drug concentrations exceeded the cut-off values reported in the literature and to evaluate their clinical characteristics. Materials and Methods: Patients who were admitted to the Intensive Care Unit in the period 2/2020-3/2022 due to GIB were prospectively included in the study and classified into three groups according to the prescribed type of DOAC (apixaban, rivaroxaban, and dabigatran). For all participants, it was determined if the measured plasma drug levels exceeded the maximum serum concentration (Cmax) or trough serum concentration (Ctrough) obtained from the available data. A comparison of clinical parameters between the patients with and without excess drug values was performed. Results: There were 90 patients (54.4% men) included in the study, of whom 27 were treated with dabigatran, 24 with apixaban, and 39 with rivaroxaban. According to Cmax, there were 34 (37.8%), and according to Ctrough, there were 28 (31.1%) patients with excess plasma drug values. A statistically significant difference regarding excess plasma drug values was demonstrated between DOACs according to both Cmax (p = 0.048) and Ctrough (p < 0.001), with the highest rate in the group treated with dabigatran (55.6% for Cmax and 59.3% for Ctrough). Multivariate logistic regression showed that age (OR 1.177, p = 0.049) is a significant positive and glomerular filtration rate (OR 0.909, p = 0.016) is a negative predictive factor for excess plasma drug values. A total of six (6.7%) patients had fatal outcomes. Conclusions: Plasma drug concentrations exceed cut-off values reported in the literature in more than one-third of patients with GIB taking DOAC, with the highest rate in the dabigatran group. Clinicians should be more judicious when prescribing dabigatran to the elderly and patients with renal failure. In these patients, dose adjustment, plasma drug monitoring, or substitution with other, more appropriate DOACs should be considered.
Collapse
Affiliation(s)
- Dorotea Bozic
- Department of Gastroenterology, Clinic for Internal Medicine, University Hospital of Split, Spinciceva 1, 21000 Split, Croatia
| | - Damir Alicic
- Department of Gastroenterology, Clinic for Internal Medicine, University Hospital of Split, Spinciceva 1, 21000 Split, Croatia
| | - Dinko Martinovic
- Department of Maxillofacial Surgery, University Hospital of Split, Spinciceva 1, 21000 Split, Croatia
| | - Ivan Zaja
- Department of Gastroenterology, Clinic for Internal Medicine, University Hospital of Split, Spinciceva 1, 21000 Split, Croatia
| | - Josipa Bilandzic-Ivisic
- Department of Gastroenterology, General Hospital of Sibenik-Knin County, Stjepana Radica 83, 22000 Sibenik, Croatia
| | - Rosana Sodan
- Department of Gastroenterology, Clinic for Internal Medicine, University Hospital of Split, Spinciceva 1, 21000 Split, Croatia
| | - Branka Kresic
- Department of Medical Laboratory Diagnostics, University Hospital of Split, Spinciceva 1, 21000 Split, Croatia
| | - Andre Bratanic
- Department of Gastroenterology, Clinic for Internal Medicine, University Hospital of Split, Spinciceva 1, 21000 Split, Croatia
- Department of Internal medicine, University of Split School of Medicine, Soltanska 2, 21000 Split, Croatia
| | - Zeljko Puljiz
- Department of Gastroenterology, Clinic for Internal Medicine, University Hospital of Split, Spinciceva 1, 21000 Split, Croatia
- Department of Internal medicine, University of Split School of Medicine, Soltanska 2, 21000 Split, Croatia
| | - Zarko Ardalic
- Department of Gastroenterology, Clinic for Internal Medicine, University Hospital of Split, Spinciceva 1, 21000 Split, Croatia
| | - Josko Bozic
- Department of Pathophysiology, University of Split School of Medicine, Soltanska 2, 21000 Split, Croatia;
| |
Collapse
|
3
|
Vorobyeva NM, Tkacheva ON. Value of Safety of Anticoagulant Therapy in Elderly Patient with Atrial Fibrillation and High Risk of Bleeding. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2023. [DOI: 10.20996/1819-6446-2023-01-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
Abstract
The review article discusses the safety issue of anticoagulant therapy in elderly patients with atrial fibrillation and high risk of bleeding. An evidence base is presented demonstrating the high safety of rivaroxaban in patients over 80 years of age, with a high risk of bleeding and cardiovascular complications, the presence of comorbid pathology, geriatric syndromes and chronic kidney disease (including in combination with anemia). The problem of low adherence to treatment in elderly patients and the possibility of solving it were separately considered.
Collapse
|
4
|
Pálinkás D, Teutsch B, Gagyi EB, Engh MA, Kalló P, Veres DS, Földvári-Nagy L, Hosszúfalusi N, Hegyi P, Erőss B. No Association between Gastrointestinal Rebleeding and DOAC Therapy Resumption: A Systematic Review and Meta-Analysis. Biomedicines 2023; 11:biomedicines11020554. [PMID: 36831090 PMCID: PMC9953612 DOI: 10.3390/biomedicines11020554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 01/27/2023] [Accepted: 02/07/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND There are recommendations for anticoagulation resumption after gastrointestinal bleeding (GIB), although data addressing this topic by direct oral anticoagulants (DOACs)-treated patients is lacking. We aim to determine the safety and efficacy of restarting DOACs after GIB. METHODS Studies that reported rebleeding, thromboembolic events, and mortality after restarting or withholding DOACs were selected. The systematic research was conducted in five databases (MEDLINE, EMBASE, CENTRAL, Web of Science, and Scopus). The random effect model was implemented to calculate the pooled odds ratio (OR). The ROBINS-I tool was used for risk of bias assessment, and the certainty of the evidence was evaluated with the GRADE approach. RESULTS Four retrospective cohort studies (1722 patients) were included in the meta-analysis. We did not find a significant increase in the risk of rebleeding in patients restarting DOACs after index GIB (OR = 1.12; 95% CI: 0.74-1.68). The outcomes of thromboembolic events and mortality data were not suitable for meta-analytic calculations. Single studies did not show statistically significant differences. Data quality assessment showed a serious overall risk of bias and very low quality of evidence (GRADE D). CONCLUSION DOAC resumption after a GIB episode may not elevate the risk of rebleeding. However, the need for high-quality randomized clinical trials is crucial.
Collapse
Affiliation(s)
- Dániel Pálinkás
- Centre for Translational Medicine, Semmelweis University, H-1085 Budapest, Hungary
- Department of Gastroenterology, Military Hospital—State Health Centre, H-1134 Budapest, Hungary
| | - Brigitta Teutsch
- Centre for Translational Medicine, Semmelweis University, H-1085 Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, H-7622 Pécs, Hungary
| | - Endre Botond Gagyi
- Centre for Translational Medicine, Semmelweis University, H-1085 Budapest, Hungary
- Selye János Doctoral College for Advanced Studies, Semmelweis University, H-1085 Budapest, Hungary
| | - Marie Anne Engh
- Centre for Translational Medicine, Semmelweis University, H-1085 Budapest, Hungary
| | - Patrícia Kalló
- Institute for Translational Medicine, Medical School, University of Pécs, H-7622 Pécs, Hungary
| | - Dániel S. Veres
- Centre for Translational Medicine, Semmelweis University, H-1085 Budapest, Hungary
- Department of Biophysics and Radiation Biology, Semmelweis University, H-1094 Budapest, Hungary
| | - László Földvári-Nagy
- Department of Morphology and Physiology, Faculty of Health Science, Semmelweis University, H-1088 Budapest, Hungary
| | - Nóra Hosszúfalusi
- Department of Internal Medicine and Haematology, Semmelweis University, H-1088 Budapest, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, H-1085 Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, H-7622 Pécs, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, H-1085 Budapest, Hungary
| | - Bálint Erőss
- Centre for Translational Medicine, Semmelweis University, H-1085 Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, H-7622 Pécs, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, H-1085 Budapest, Hungary
- Correspondence: ; Tel.: +(36)-30-8874028
| |
Collapse
|
5
|
Ito N, Funasaka K, Fujiyoshi T, Furukawa K, Kakushima N, Furune S, Ishikawa E, Mizutani Y, Sawada T, Maeda K, Ishikawa T, Yamamura T, Ohno E, Nakamura M, Kawashima H, Miyahara R, Hirooka Y, Haruta JI, Fujishiro M. Modified N score is helpful for identifying patients who need endoscopic intervention among those with black stools without hematemesis. Dig Endosc 2022; 34:1157-1165. [PMID: 35396885 DOI: 10.1111/den.14323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 04/02/2022] [Accepted: 04/07/2022] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Although black stools are one of the signs of upper gastrointestinal bleeding, not all patients without hematemesis need endoscopic intervention. There is no apparent indicator to select who needs treatment thus far. The aim of this study was to establish a novel score that predicts the need for endoscopic intervention in patients with black stools without hematemesis. METHODS We retrospectively enrolled 721 consecutive patients with black stools without hematemesis who underwent emergency endoscopy from two facilities. In the development stage (from January 2016 to December 2018), risk factors that predict the need for endoscopic intervention were determined from the data of 422 patients by multivariate logistic regression analysis, and a novel scoring system, named the modified Nagoya University score (modified N score), was developed. In the validation stage (from January 2019 to September 2020), we evaluated the diagnostic value of the modified N score for 299 patients. RESULTS Multivariate logistic regression analysis revealed four predictive factors for endoscopic intervention: syncope, the blood urea nitrogen (BUN) level, and the BUN/creatinine ratio as positive indicators and anticoagulant drug use as a negative indicator. In the validation stage, the area under the curve of the modified N score was 0.731, and the modified N score showed a sensitivity of 82.0% and a specificity of 58.8%. CONCLUSIONS Our modified N score, which consists of only four factors, can identify patients who need endoscopic intervention among those with black stools without hematemesis.
Collapse
Affiliation(s)
- Nobuhito Ito
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kohei Funasaka
- Department of Gastroenterology and Hepatology, Fujita Health University School of Medicine, Aichi, Japan
| | - Toshihisa Fujiyoshi
- Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Aichi, Japan
| | - Kazuhiro Furukawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Naomi Kakushima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Satoshi Furune
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Eri Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yasuyuki Mizutani
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Tsunaki Sawada
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Keiko Maeda
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Takuya Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Takeshi Yamamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Masanao Nakamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Hiroki Kawashima
- Department of Endoscopy, Nagoya University Hospital, Aichi, Japan
| | - Ryoji Miyahara
- Department of Gastroenterology and Hepatology, Fujita Health University School of Medicine, Aichi, Japan
| | - Yoshiki Hirooka
- Department of Gastroenterology and Hepatology, Fujita Health University School of Medicine, Aichi, Japan
| | - Jun-Ichi Haruta
- Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Aichi, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| |
Collapse
|
6
|
Protective Role of Antithrombotics in Acute Upper Gastrointestinal Bleeding: Horizon Is Still Far. J Clin Gastroenterol 2022; 56:641-642. [PMID: 35357338 DOI: 10.1097/mcg.0000000000001697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
|
7
|
Starup-Linde J, Langdahl B, Vestergaard P, Harsløf T. Incident peptic ulcers and concomitant treatment of direct oral anticoagulants and oral bisphosphonates-a real-world cohort study. Osteoporos Int 2022; 33:1323-1334. [PMID: 35080633 DOI: 10.1007/s00198-022-06315-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 01/19/2022] [Indexed: 11/27/2022]
Abstract
UNLABELLED Oral bisphosphonates and direct oral anticoagulants are related to upper gastrointestinal ulcers. The present study investigated whether concomitant use of these drugs increase the risk of upper gastrointestinal ulcers and report no increased risk of upper gastrointestinal ulcers compared to the use of either drug alone, when individuals with previous upper gastrointestinal ulcers are excluded. INTRODUCTION This study examines whether concomitant use of oral bisphosphonates (oBP) and direct oral anticoagulants (DOAC) increases the risk of peptic ulcers more than any drug alone. METHODS A population-based cohort study was performed. We sampled a cohort of oBP and DOAC users from a sample of 2,622,742 individuals, consisting of diabetes patients and age- and gender-matched controls, obtained from the Danish National Patient Register. The exposures were concomitant use of oBP and DOAC and single use of DOAC and single use of oBP. The primary endpoint was the first incident peptic ulcer. Information on exposure and outcome were collected from national registries. The period of observation was from 01.01.2008 until 31.12.2018. Unadjusted and adjusted Cox regressions were performed. RESULTS 8077 individuals received concomitant treatment with DOAC and oBP; 96,451 individuals used DOAC and no oBP; and 118,675 used oBP and no DOAC. The mean duration of follow-up was 1.9 years for concomitant users, 2.5 years for DOAC users, and 4.5 years for oBP users. A total of 4742 individuals with incident peptic ulcers were collected. We observed an increased risk of incident ulcer in users of DOAC and oBP compared to single DOAC treatment in the adjusted analysis (HR = 1.23, 95% CI: 1.03; 1.48). However, the effects were abolished when excluding individuals with a previous ulcer. We observed an increased risk of incident ulcer in users of DOAC and oBP compared to users of oBP in the adjusted model (HR = 1.34, 95% CI: 1.11; 1.63). CONCLUSION Based on our results, concomitant use of oBP and DOAC is associated with a slight increase in the risk of peptic ulcers compared to either drug alone. The prescribing physician should weigh the slight increased risk of ulcer in concomitant users of oBP and DOAC with beneficial reductions in stroke and fractures.
Collapse
Affiliation(s)
- J Starup-Linde
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus, Denmark.
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark.
| | - B Langdahl
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - P Vestergaard
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Jutland, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - T Harsløf
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus, Denmark
| |
Collapse
|
8
|
Pang Y, Ma M, Xia J, Wang D, YanChen, Ye J, Jia Z, Wu S, Yang J, Hou L. A randomized non-inferiority study of low-dose and standard-dose ticagrelor after intervention for acute coronary syndrome: study protocol for the TIGER STUDY. Trials 2022; 23:203. [PMID: 35248132 PMCID: PMC8898426 DOI: 10.1186/s13063-022-06124-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/20/2022] [Indexed: 12/02/2022] Open
Abstract
Background Current guidelines recommend that patients with acute coronary syndrome (ACS) who have successfully undergone percutaneous coronary intervention (PCI) should continue to use dual antiplatelet therapy (DAPT) for 12 months. The long-term use of standard-dose dual antiplatelet therapy will increase the risk of bleeding. An optimized antiplatelet strategy that can prevent ischemic events and reduce the risk of bleeding remains to be explored. Methods The study is a prospective, multicenter, randomized, open-label, controlled study involving 2090 patients from six clinical centers in China. Through the interactive web response system (IWRS), ACS patients undergoing successful PCI will be randomly divided into the low-dose ticagrelor group or the normal-dose ticagrelor group, after taking 100 mg aspirin and 90 mg ticagrelor bid for 1 week. The primary endpoint is a composite of cardiovascular death, non-fatal myocardial infarction, stent thrombosis, repeat revascularization, and stroke. The secondary endpoints are bleeding events of grade 2 or higher according to Bleeding Academic Research Consortium [BARC] criteria, cardiovascular death, acute myocardium infarction, and coronary revascularization at 1 year. Discussion Recent studies have confirmed that 90 mg ticagrelor alone can safely and effectively reduce bleeding without increasing ischemic events of patients with ACS after PCI. Compared with standard-dose DAPT, whether low-dose ticagrelor combined with aspirin can ensure the anti-ischemic effect while reducing the bleeding risk remains unclear in Chinese patients. The TIGER study will be the first large-scale, multicenter study to compare the efficacy and safety of low-dose and standard-dose ticagrelor combined with aspirin in ACS patients 1 week after successful PCI. Trial registration Clinicaltrials.gov NCT04255602. Registered on 5 February 2020.
Collapse
|
9
|
Polidocanol foam sclerotherapy in the treatment of hemorrhoidal disease in patients with bleeding disorders: a multicenter, prospective, cohort study. Tech Coloproctol 2022; 26:615-625. [PMID: 35217937 PMCID: PMC8879173 DOI: 10.1007/s10151-022-02600-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 02/13/2022] [Indexed: 02/06/2023]
Abstract
Background The management of hemorrhoidal disease (HD) in patients with bleeding disorders (BD) is challenging. Polidocanol foam sclerotherapy (PFS) is associated with a low rate of bleeding complications. The aim of this study was to compare the efficacy and safety of PFS in the treatment of HD in patients with and without BD. Methods This prospective, multicenter, cohort study enrolled patients with (group B) and without (group A) BD, with symptomatic internal HD grades I–III over an 18-month period. All patients were treated with PFS. Patients with congenital BD did not undergo prior replacement therapy and those with acquired BD due to antithrombotic drugs, did not discontinue therapy. Efficacy outcomes included therapeutic success and HD recurrence during a 1-year follow-up period. To evaluate safety the complications related to PFS were recorded. Results We included 228 patients (group A: 155, group B: 73; male/female: 114/114; mean age: 59.4 ± 15.9 years). The baseline hemorrhoidal disease bleeding grade (p < 0.001) and Sodergren hemorrhoidal symptom severity score (p = 0.019) were higher for group B. The overall therapeutic success rate was 93.4% with an average number of sessions of 1.51 ± 0.74, significantly higher for group B (1.68 ± 0.86 vs 1.43 ± 0.65, p = 0.013). Complications occurred in 11.4% of the patients, with bleeding reported in 4.8%. The majority of complications were mild (96.2%). No significant differences between the two groups were observed for therapeutic success, recurrence, or complication rate. Conclusions Patients with BD may have more symptomatic HD at baseline. Even so, PSF showed similar effectiveness and safety in patients with BD compared to patients without BD. Supplementary Information The online version contains supplementary material available at 10.1007/s10151-022-02600-5.
Collapse
|
10
|
Capodanno D, Bhatt DL, Gibson CM, James S, Kimura T, Mehran R, Rao SV, Steg PG, Urban P, Valgimigli M, Windecker S, Angiolillo DJ. Bleeding avoidance strategies in percutaneous coronary intervention. Nat Rev Cardiol 2022; 19:117-132. [PMID: 34426673 DOI: 10.1038/s41569-021-00598-1] [Citation(s) in RCA: 66] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/05/2021] [Indexed: 02/08/2023]
Abstract
For many years, bleeding has been perceived as an unavoidable consequence of strategies aimed at reducing thrombotic complications in patients undergoing percutaneous coronary intervention (PCI). However, the paradigm has now shifted towards bleeding being recognized as a prognostically unfavourable event to the same extent as having a new or recurrent ischaemic or thrombotic complication. As such, in parallel with progress in device and drug development for PCI, there is clinical interest in developing strategies that maximize not only the efficacy but also the safety (for example, by minimizing bleeding) of any antithrombotic treatment or procedural aspect before, during or after PCI. In this Review, we discuss contemporary data and aspects of bleeding avoidance strategies in PCI, including risk stratification, timing of revascularization, pretreatment with antiplatelet agents, selection of vascular access, choice of coronary stents and antithrombotic treatment regimens.
Collapse
Affiliation(s)
- Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Deepak L Bhatt
- Department of Medicine, Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA, USA
| | - C Michael Gibson
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Stefan James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University Hospital, Uppsala, Sweden
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Roxana Mehran
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sunil V Rao
- The Duke Clinical Research Institute, Durham, NC, USA
| | | | | | - Marco Valgimigli
- Cardiocentro Ticino Institute and Università della Svizzera italiana (USI), Lugano, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | | |
Collapse
|
11
|
Alcalá-González L, Jiménez C, Cortina V, Jiménez A, Cerdá M, Johansson E, Olivera P, Santamaría A, Alonso-Cotoner C. Severity of gastrointestinal bleeding is similar between patients receiving direct oral anticoagulants or vitamin K antagonists. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2022; 114:599-604. [PMID: 35086339 DOI: 10.17235/reed.2022.8388/2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) is a common adverse event related to anticoagulation therapy. However, evidence comparing the severity, aetiology, and outcomes of GIB in patients taking direct oral anticoagulants (DOAC) vs. vitamin K antagonists (VKA) is scarce. AIMS To evaluate the severity, aetiology and outcomes of GIB in patients under DOACs compared to VKA. METHODS Patients under oral anticoagulant therapy admitted to the emergency department with acute GIB were prospectively recruited from July 2016 to January 2018 at a tertiary referral hospital. Demographic and clinical outcomes were obtained from medical records. Severity of the GIB event was classified as mild, major or severe according to clinical presentation and type of support needed. Aetiology and location of bleeding, number of packed red blood cells transfused (PRBC) and length of hospital stay were recorded until discharge or in-hospital death. RESULTS A total of 208 patients with acute GIB under oral anticoagulant treatment were recruited: 119 patients on VKA, and 89 patients on DOAC with similar characteristics. Thirty-one patients had severe GIB; 134 major and 43 mild, with no differences in severity, number of PRBC and length of hospital stay between groups. Peptic disease was the most frequent aetiology of GIB in patients on VKA (20.2 % vs. 13.6%, p=0.20). Diverticular bleeding was the most frequent in patients on DOAC (14.3% vs. 24.8%, p= 0.056). CONCLUSIONS Severity and clinical outcomes of GIB are similar between patients on DOAC and patients on VKA, regardless of aetiology of GIB.
Collapse
Affiliation(s)
| | - César Jiménez
- Gastroenterology, Hospital Universitari Vall d'Hebron
| | | | - Alba Jiménez
- Gastroenterology, Hospital Universitari Vall d'Hebron
| | - María Cerdá
- Hematology, Hospital Universitari Vall d'Hebron
| | | | | | | | | |
Collapse
|
12
|
Evaluating the impact of frailty on periprocedural adverse events and mortality among patients with GI bleeding. Gastrointest Endosc 2021; 94:517-525.e11. [PMID: 33753111 DOI: 10.1016/j.gie.2021.03.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 03/14/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Frailty is a known predictor of mortality and adverse events in the inpatient setting; however, it has not been studied as a modality to assess risk among patients undergoing endoscopy for GI bleeding (GIB). We aimed to determine the association between frailty status and risk of adverse events in hospitalized patients with GIB who underwent endoscopy. METHODS We performed a cohort study using the 2016 and 2017 National Inpatient Sample database, using International Classification of Diseases diagnostic codes to identify adult patients with GIB who underwent endoscopic procedures within 2 days of admission and the Hospital Frailty Risk Score to classify patients as frail or nonfrail. Univariable and multivariable logistic regression models were constructed to assess the predictors of periprocedural adverse events, and marginal standardization analysis was performed to assess for possible interaction between age and frailty. RESULTS A total of 757,920 patients met inclusion criteria, of which 44.4% (336,895) were identified as frail and 55.6% (421,025) as nonfrail; 49.2% of frail patients had composite periprocedural adverse events compared with 25.5% of nonfrail patients (P < .001). Frail patients notably had more cardiovascular (32.1% vs 17.1%, P < .001), pulmonary (18.5% vs 4.3%, P < .001), GI (10.1% vs 6.1%, P < .001), and infectious (9.9% vs .7%, P < .001) adverse events compared with nonfrail patients. Frail patients also had higher all-cause inpatient mortality rates (4.8% vs .5%, P < .001). On multivariable analysis, positive frailty status was associated with a 2.13 times increased likelihood of having composite periprocedural adverse events. CONCLUSIONS In hospitalized patients undergoing endoscopy for GIB, frailty status is associated with increased periprocedural adverse events including all-cause mortality. The use of frailty assessments can thus further guide clinical decision-making when considering endoscopy and risk of adverse events in adult patients with GI hemorrhage.
Collapse
|
13
|
Choe AR, Moon CM, Tae CH, Chun J, Bang KB, Lee YJ, Lee HS, Jung Y, Park SC, Koo HS. Characteristics, Location, and Clinical Outcomes of Gastrointestinal Bleeding in Patients Taking New Oral Anticoagulants Compared to Vitamin K Antagonists. J Clin Med 2021; 10:jcm10122693. [PMID: 34207296 PMCID: PMC8234640 DOI: 10.3390/jcm10122693] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/05/2021] [Accepted: 06/10/2021] [Indexed: 02/07/2023] Open
Abstract
New oral anticoagulants (NOACs) are commonly used in clinical practice as alternatives to vitamin K antagonists (VKA). However, the etiology, clinical course, and risk of gastrointestinal (GI) bleeding remain unclear. We aimed to evaluate the clinical characteristics and location of acute GI bleeding associated with NOACs and its severity and outcomes compared to VKA. This retrospective multicenter study included 381 subjects on anticoagulants who underwent appropriate diagnostic examination due to GI bleeding. Regarding the characteristics of acute GI bleeding, the proportion of vascular lesions was significantly lower in the NOACs group than that in the VKA group. Small bowel bleeding occurred less commonly in the NOACs group, but the difference did not reach statistical significance. Regarding severity and clinical outcomes, patients on NOACs received significantly smaller volumes of transfused blood products and had shorter ICU stays than those on VKA. Moreover, the need for surgery and the risk of rebleeding in the NOACs group were significantly lower than those in the VKA group. Patients on NOACs have better clinical outcomes in terms of severity of acute GI bleeding or rebleeding than patients on VKA. Patients on NOACs demonstrate different characteristics and location of acute GI bleeding than those on VKA.
Collapse
Affiliation(s)
- A Reum Choe
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul 07985, Korea; (A.R.C.); (C.H.T.)
| | - Chang Mo Moon
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul 07985, Korea; (A.R.C.); (C.H.T.)
- Inflammation-Cancer Microenvironment Research Center, College of Medicine, Ewha Womans University, Seoul 07804, Korea
- Correspondence: ; Tel.: +82-2-2650-2945
| | - Chung Hyun Tae
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul 07985, Korea; (A.R.C.); (C.H.T.)
| | - Jaeyoung Chun
- Department of Internal Medicine, Seoul National University College of Medicine, Liver Research Institute, Seoul 03080, Korea;
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea
| | - Ki Bae Bang
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan 31116, Korea;
| | - Yoo Jin Lee
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu 42601, Korea;
| | - Hyun Seok Lee
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu 41404, Korea;
| | - Yunho Jung
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan 31151, Korea;
| | - Sung Chul Park
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon 24289, Korea;
| | - Hoon Sup Koo
- Department of Internal Medicine, Konyang University College of Medicine, Daejeon 35365, Korea;
| |
Collapse
|
14
|
Wei ZQ. Digestive system injury induced by drugs for secondary prevention of ischemic stroke. Shijie Huaren Xiaohua Zazhi 2021; 29:81-86. [DOI: 10.11569/wcjd.v29.i2.81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The recurrence of ischemic stroke can be reduced by active secondary prevention, including antithrombotic, lipid-lowering, antihypertensive, and hypoglycemic treatment. However, long-term use of drugs for secondary prevention can cause damage to the digestive system, reduce patient compliance, increase the recurrence of stroke, and even lead to ulcer bleeding and life-threatening events. It is necessary to early identify populations at a high risk for digestive system injury, understand the adverse reactions of various drugs, and standardize the treatment, which can improve the effect of secondary prevention of ischemic stroke.
Collapse
Affiliation(s)
- Zhi-Qiang Wei
- Department of Internal Medicine-Neurology, The Second Hospital of Tianjin Medical University, Tianjin 300211, China
| |
Collapse
|
15
|
Lv M, Zheng X, Wu T, Chen W, Jiang S, Zhang H, Xu F, Zhang J. A New Score for Predicting Acute Gastrointestinal Bleeding in Patients Administered Oral Antiplatelet Drugs. Front Pharmacol 2021; 11:571605. [PMID: 33519436 PMCID: PMC7841335 DOI: 10.3389/fphar.2020.571605] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 12/02/2020] [Indexed: 12/21/2022] Open
Abstract
Antiplatelet drugs may increase the risk of gastrointestinal bleeding. Currently, there is no specific score for predicting the risk of gastrointestinal bleeding caused by oral antiplatelet drugs. In this study, the gastrointestinal bleeding risk score was established and compared with the CRUSADE score in order to reduce the occurrence of clinical gastrointestinal bleeding events. Our study included 4052 patients who received oral antiplatelet drugs. Data were obtained from the patient medical records inpatient system. Cases of acute gastrointestinal bleeding and mortality were recorded. The bleeding score was established by logistic regression, area under the receiver operating characteristic curve, and the Hosmer–Lemeshow test. Finally, 171 patients had acute gastrointestinal bleeding. The mortality rates of patients in the bleeding and nonbleeding groups were 24.6 and 4.7%, respectively. A multivariate analysis revealed that an age of >65 years, anemia, recent major bleeding, a history of gastrointestinal bleeding, combined oral anticoagulants, and dual antiplatelet therapy are risk factors, and combined proton pump inhibitors are protective factors for acute gastrointestinal bleeding. We used these risk factors to establish a score for predicting acute gastrointestinal bleeding, named (ABC)2D score. The area under the curve for (ABC)2D score was 0.857 (p < 0.001), higher than the CRUSADE score of 0.693 (p < 0.001). The Hosmer–Lemeshow p value was 0.324. We developed the (ABC)2D score based on seven risk factors (i.e., age, anemia, recent major bleeding, a history of gastrointestinal bleeding, no-proton pump inhibitors use, combined oral anticoagulants, and dual antiplatelet therapy). (ABC)2D score was superior to the CRUSADE score. This new risk-scoring model may help to identify patients at a significant risk of gastrointestinal bleeding.
Collapse
Affiliation(s)
- Meina Lv
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China.,College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Xiaochun Zheng
- College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Tingting Wu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China.,College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Wenjun Chen
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China.,College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Shaojun Jiang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China.,College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Hongqin Zhang
- Department of Pharmacy, Fuzhou Second Hospital Affiliated to Xiamen University, Fuzhou, China
| | - Fangda Xu
- Department of Information, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China.,College of Pharmacy, Fujian Medical University, Fuzhou, China
| |
Collapse
|
16
|
Jurin I, Lucijanić M, Šakić Z, Hulak Karlak V, Atić A, Magličić A, Starčević B, Hadžibegović I. Patterns of anticoagulation therapy in atrial fibrillation: results from a large real-life single-center registry. Croat Med J 2021. [PMID: 33150762 PMCID: PMC7684544 DOI: 10.3325/cmj.2020.61.440] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Aim To investigate the differences in the characteristics and clinical outcomes of recently diagnosed patients with atrial fibrillation (AF) receiving different types of anticoagulants in a real-life setting. Methods We retrospectively analyzed the charts of 1000 consecutive patients with non-valvular AF diagnosed and referred for hospitalization at our institution from 2013 to 2018. Results Over the observed period, the frequency of direct oral anticoagulation (DOAC) therapy use significantly increased (P = 0.002). Patients receiving warfarin had more unfavorable thromboembolic and bleeding risk factors than patients receiving DOAC. Predetermined stroke and major bleeding risks were similarly distributed among the dabigatran, rivaroxaban, and apixaban groups. Patients receiving warfarin had shorter time-to-major bleeding (TTB), time to thrombosis (TTT), and overall survival (OS) than patients receiving DOACs. After adjustment for factors unbalanced at baseline, the warfarin group showed significantly shorter OS (hazard ratio 2.27, 95% confidence interval 1.44-3.57, P < 0.001], while TTB and TTT did not significantly differ between the groups. Only 37% of patients on warfarin had optimal dosing control, and they did not differ significantly in TTB, TTT, and OS from patients on DOACs. Conclusion Warfarin and DOACs are administered to different target populations, possibly due to socio-economic reasons. Patients receiving warfarin rarely obtain optimal dosing control, and experience significantly shorter survival compared with patients receiving DOACs.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Irzal Hadžibegović
- Irzal Hadžibegović, Department for Cardiovascular Diseases, University Hospital Dubrava, Avenija Gojka Šuška 6, 10000 Zagreb, Croatia,
| |
Collapse
|
17
|
Sun X, Ze B, Zhang LJ, BaiMa YZ, Zuo W, Zhao B, GeSang LB. Hemorrhage Risk Profiles among Different Antithrombotic Regimens: Evidence from a Real-World Analysis of Postmarketing Surveillance Data. Cardiovasc Drugs Ther 2020; 36:103-112. [PMID: 33226545 DOI: 10.1007/s10557-020-07110-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although the use of direct oral anticoagulants (DOACs) has been reported in patients with atrial fibrillation (AF), there is currently no consensus on the occurrence or characteristics of the hemorrhage risk in different antithrombotic regimens. METHODS Disproportionality and Bayesian analyses were performed in mining data of suspected hemorrhagic events after antithrombotic drug use from the FDA Adverse Event Reporting System (FAERS) from January 2004 to September 2019. The time to onset and fatality rate of hemorrhage following different antithrombotic regimens were also compared. RESULTS A total of 84,998 reports of hemorrhage-related adverse events with the use of antithrombotic drugs were identified. The patients included were mostly from the Americas (80.87%) and Europe (13.22%), with most data submitted by nonhealthcare professionals. Among the seven antithrombotic drug monotherapies, betrixaban had the highest association with hemorrhage based on the highest reporting odds ratio (ROR, 829.95; 95% CI = 113.61-6063.15), proportional reporting ratio (PRR, 24.68, χ2 = 804.24), and multi-item gamma Poisson shrinker (MGPS, 24.68, 95% one-sided CI = 4.67). The combination therapies of clopidogrel plus new oral anticoagulants had higher RORs, PRRs, and empirical Bayesian geometric means (EBGMs) than the antithrombotic drug monotherapies. Hemorrhage associated with rivaroxaban plus clopidogrel appeared to have an earlier onset (171 days vs 219 days, 95% two-sided CI =68.68-27.34, p < 0.0001) and a lower fatality rate (15.30% vs 17.74%, p<0.05) than that associated with rivaroxaban monotherapy. CONCLUSION This study provides a relevant overview of the hemorrhagic complications/fatalities associated with different antithrombotic regimens in their real-world use. Among the combination therapies, clopidogrel plus DOACs were found to have stronger associations with hemorrhage than traditional dual antithrombotic therapies. Rivaroxaban showed a stronger association with hemorrhage than other antithrombotic drug monotherapies, and apixaban monotherapy appeared to have weaker associations with hemorrhage than others.
Collapse
Affiliation(s)
- Xue Sun
- People's Hospital of the Tibet Autonomous Region, Lhasa, 850000, China
| | - Bi Ze
- People's Hospital of the Tibet Autonomous Region, Lhasa, 850000, China
| | - Ling-Jun Zhang
- Internal Medicine Branch of Cadiovascular Diseases/Plateau Medicine, People's Hospital of Tibet Autonomous Region, Lhasa, 850000, China
| | - Yang-Zhong BaiMa
- People's Hospital of the Tibet Autonomous Region, Lhasa, 850000, China
| | - Wei Zuo
- Department of Pharmacy, Peking Union Medical College Hospital, No.1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Bin Zhao
- People's Hospital of the Tibet Autonomous Region, Lhasa, 850000, China. .,Department of Pharmacy, Peking Union Medical College Hospital, No.1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
| | - Luo-Bo GeSang
- Internal Medicine Branch of Cadiovascular Diseases/Plateau Medicine, People's Hospital of Tibet Autonomous Region, Lhasa, 850000, China
| |
Collapse
|
18
|
Bouget J, Viglino D, Yvetot Q, Oger E. Major gastrointestinal bleeding and antithrombotics: Characteristics and management. World J Gastroenterol 2020; 26:5463-5473. [PMID: 33024397 PMCID: PMC7520611 DOI: 10.3748/wjg.v26.i36.5463] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/30/2020] [Accepted: 08/29/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND There are few reports on major gastrointestinal (GI) bleeding among patients receiving an antithrombotic.
AIM To describe clinical characteristics, bleeding locations, management and in-hospital mortality related to these events.
METHODS Over a three-year period, we prospectively identified 1080 consecutive adult patients admitted in two tertiary care hospitals between January 1, 2013 and December 31, 2015 for major GI bleeding while receiving an antithrombotic. The bleeding events were medically validated. Clinical characteristics, causative lesions, management and fatalities were described. The distribution of antithrombotics prescribed was compared across the bleeding lesions identified.
RESULTS Of 576 patients had symptoms of upper GI bleeding and 504 symptoms of lower GI bleeding. No cause was identified for 383 (35.5%) patients. Gastro-duodenal ulcer was the first causative lesion in the upper tract (209 out of 408) and colonic diverticulum the first causative lesion in the lower tract (120 out of 289). There was a larger proportion of direct oral anticoagulant use among patients with lower GI than among those with upper GI lesion locations (P = 0.03). There was an independent association between gastro-duodenal ulcer and antithrombotic use (P = 0.03), taking account of confounders and proton pump inhibitor co-prescription. Pair wise comparisons pointed to a difference between vitamin K antagonist, direct oral anticoagulants, and antiplatelet agents in monotherapy vs dual antiplatelet agents.
CONCLUSION We showed a higher rate of bleeding lesion identification and suggested a different pattern of antithrombotic exposure between upper and lower GI lesion locations and between gastro-duodenal ulcer and other identified upper GI causes of bleeding. Management was similar across antithrombotics and in-hospital mortality was low (5.95%).
Collapse
Affiliation(s)
- Jacques Bouget
- EA 7449 REPERES, Pharmacoepidemiology and Health Services Research, Univ Rennes, Rennes 35000, France
| | - Damien Viglino
- Emergency Department and Mobile Intensive Care Unit-HP2 Laboratory INSERM U1042, University Grenoble Alps, La Tronche 38700, France
| | | | - Emmanuel Oger
- EA 7449 REPERES, Université de Rennes 1, Rennes 35000, France
| |
Collapse
|
19
|
Bouget J, Balusson F, Viglino D, Roy PM, Lacut K, Pavageau L, Oger E. Major bleeding risk and mortality associated with antiplatelet drugs in real-world clinical practice. A prospective cohort study. PLoS One 2020; 15:e0237022. [PMID: 32764775 PMCID: PMC7413418 DOI: 10.1371/journal.pone.0237022] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 07/18/2020] [Indexed: 12/20/2022] Open
Abstract
Background Major bleedings other than gastrointestinal (GI) and intracranial (ICH) and mortality rates associated with antiplatelet drugs in real-world clinical practice are unknown. The objective was to estimate major bleeding risk and mortality among new users of antiplatelet drugs in real-world clinical practice. Methods and findings A population-based prospective cohort using the French national health data system (SNIIRAM), identified 69,911 adults living within five well-defined geographical areas, who were new users of antiplatelet drugs in 2013–2015 and who had not received any antithrombotics in 2012. Among them, 63,600 started a monotherapy and 6,311 a dual regimen. Clinical data for all adults referred for bleeding was collected from all emergency departments within these areas, and medically validated. Databases were linked using common key variables. The main outcome measure was time to major bleeding (GI, ICH and other bleedings). Secondary outcomes were death, and event-free survival (EFS). Hazard ratios (HR) were derived from adjusted Cox proportional hazard models. We used Inverse Propensity of Treatment Weighting as a stratified sensitivity analysis according to the antiplatelet monotherapy indication: primary prevention without cardiovascular (CV) risk factors, with CV risk factors, and secondary prevention. We observed 250 (0.36%) major haemorrhages, 81 ICH, 106 GI and 63 other types of bleeding. Incidences were twice as high in dual therapy as in monotherapy. Compared to low-dose aspirin (≤ 100 mg daily), high-dose (> 100 up to 325 mg daily) was associated with an increased risk of ICH (HR = 1.80, 95%CI 1.10 to 2.95). EFS was improved by high-dose compared to low-dose aspirin (1.41, 1.04 to 1.90 and 1.32, 1.03 to 1.68) and clopidogrel (1.30, 0.73 to 2.3 and 1.7, 1.24 to 2.34) respectively in primary prevention with and without CV risk factors. Conclusion The incidence of major bleeding and mortality was low. In monotherapy, low-dose aspirin was the safest therapeutic option whatever the indication. Trial registration NCT02886533.
Collapse
Affiliation(s)
- Jacques Bouget
- EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Univ Rennes, CHU Rennes, Rennes, France
| | - Frédéric Balusson
- EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Univ Rennes, CHU Rennes, Rennes, France
| | - Damien Viglino
- Emergency Department, Grenoble-Alpes University Hospital, Grenoble, France
| | - Pierre-Marie Roy
- Emergency Department, Centre Hospitalier Universitaire, Institut MITOVASC, Université d'Angers, Angers, France.,F-CRIN INNOVTE, France
| | - Karine Lacut
- CIC 1412, Université de Bretagne Loire, Université de Brest, INSERM CIC 1412, CHRU de Brest, Brest, France
| | - Laure Pavageau
- Emergency Department, University Hospital, Nantes, France
| | - Emmanuel Oger
- EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Univ Rennes, CHU Rennes, Rennes, France
| |
Collapse
|
20
|
Zhou J, Yang RP, Song W, Xu HM, Wang YH. Antiplatelet Activity of Tussilagone via Inhibition of the GPVI Downstream Signaling Pathway in Platelets. Front Med (Lausanne) 2020; 7:380. [PMID: 32850895 PMCID: PMC7403204 DOI: 10.3389/fmed.2020.00380] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 06/19/2020] [Indexed: 12/22/2022] Open
Abstract
Tussilagone is a sesquiterpenoid extracted from Tussilago farfara and is used as an oriental medicine for asthma and bronchitis. Although previous studies have shown that tussilagone has an inhibitory effect on platelet aggregation, no studies have been performed to investigate its precise effect on platelets, and the underlying mechanism remains unclear. In the present study, we showed that tussilagone inhibited platelet aggregation induced by collagen, thrombin and ADP, as well as platelet release induced by collagen and thrombin, in mice. Tussilagone decreased P-selectin expression and αIIbβ3 activation (JON/A binding) in activated platelets, which indicated that tussilagone inhibited platelet activation. Moreover, tussilagone suppressed platelet spreading on fibrinogen and clot retraction. The levels of phosphorylated Syk, PLCγ2, Akt, GSK3β, and MAPK (ERK1/2 and P38) and molecules associated with GPVI downstream signaling were downregulated in the presence of tussilagone. In addition, tussilagone prolonged the occlusion time in a mouse model of FeCl3-induced carotid artery thrombosis and had no effect on mouse tail bleeding time. These results indicate that tussilagone inhibits platelet function in vitro and in vivo and that the underlying mechanism involves the Syk/PLCγ2-PKC/MAPK and PI3K-Akt-GSK3β signaling pathways downstream of GPVI. This research suggests that tussilagone is a potential candidate antiplatelet drug for the prevention of thrombosis.
Collapse
Affiliation(s)
- Jing Zhou
- Department of Pharmacy, Zhumadian Central Hospital, Zhumadian, China
| | - Ru-Ping Yang
- Department of Pharmacy, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | - Wei Song
- Department of Pharmacy, Renmin Hospital, Wuhan University, Wuhan, China
| | - Hui-Min Xu
- Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yong-Hui Wang
- Department of Pharmacy, Zhumadian Central Hospital, Zhumadian, China
| |
Collapse
|
21
|
Cafuir L, Cheng E, Kempton C. Outcomes of direct oral anticoagulant- and warfarin-associated hemorrhage: A single center retrospective cohort study. Thromb Res 2020; 189:128-131. [DOI: 10.1016/j.thromres.2019.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 08/13/2019] [Accepted: 09/02/2019] [Indexed: 10/26/2022]
|
22
|
Management of direct factor Xa inhibitor-related major bleeding with prothrombin complex concentrate: a meta-analysis. Blood Adv 2020; 3:158-167. [PMID: 30658963 DOI: 10.1182/bloodadvances.2018024133] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 11/03/2018] [Indexed: 01/12/2023] Open
Abstract
A targeted antidote for reversal of direct factor Xa (FXa) inhibitors is now available for clinical use in the United States, but it is costly and has limited availability. In a systematic review, we evaluated the safety and effectiveness of 4-factor prothrombin complex concentrate (4F-PCC) as an alternative for managing direct FXa inhibitor-related major bleeding. A systematic literature search was conducted using Medline, Embase, and the Cochrane Register of Controlled Trials up to September 2018. No comparative studies were found. Ten case series with 340 patients who received PCC for direct FXa inhibitor-related major bleeding were included. The pooled proportion of patients with effective management of major bleeding was 0.69 (95% confidence interval [CI], 0.61-0.76) in 2 studies using the International Society on Thrombosis and Haemostasis (ISTH) criteria and 0.77 (95% CI, 0.63-0.92) in 8 studies that did not use the ISTH criteria; all-cause mortality was 0.16 (95% CI, 0.07-0.26), and thromboembolism rate was 0.04 (95% CI, 0.01-0.08). On the basis of evidence with very low certainty from single-arm case series, it is difficult to determine whether 4F-PCC in addition to cessation of direct oral FXa inhibitor is more effective than cessation of direct oral FXa inhibitor alone in patients with direct FXa inhibitor-related major bleeding.
Collapse
|
23
|
Butt JH, Li A, Xian Y, Peterson ED, Garcia D, Torp-Pedersen C, Køber L, Fosbøl EL. Direct oral anticoagulant- versus vitamin K antagonist-related gastrointestinal bleeding: Insights from a nationwide cohort. Am Heart J 2019; 216:117-124. [PMID: 31425898 DOI: 10.1016/j.ahj.2019.07.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/19/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND The purpose of the study was to examine the association between the type of preceding oral anticoagulant use (warfarin or direct oral anticoagulants [DOACs]) and in-hospital mortality among patients admitted with gastrointestinal bleeding. METHODS In this observational cohort study, all patients admitted with a first-time gastrointestinal bleeding from January 2011 to March 2017 while receiving any oral anticoagulant therapy prior to admission were identified using data from Danish nationwide registries. The risk of in-hospital mortality according to type of oral anticoagulation therapy was examined by multivariable logistic regression models. RESULTS Among 5,774 patients admitted with gastrointestinal bleeding (median age, 78 years [25th-75th percentile, 71-85 years]; 56.8% men), 2,038 (35.3%) were receiving DOACs and 3,736 (64.7%) were receiving warfarin prior to admission. The unadjusted in-hospital mortality rates were 7.5% for DOAC (7.2% for dabigatran, 6.4% for rivaroxaban, and 10.1% for apixaban) and 6.5% for warfarin. After adjustment for baseline demographic and clinical characteristics, there was no statistically significant difference in in-hospital mortality between prior use of any DOAC and warfarin (unadjusted odds ratio [OR] 1.18 [95% CI 0.95-1.45], adjusted OR 0.97 [95% CI 0.77-1.24]). Similar results were found for each individual DOAC as compared with warfarin (dabigatran: unadjusted OR 1.12 [95% CI 0.84-1.49], adjusted OR 0.96 [95% CI 0.71-1.30]); rivaroxaban: unadjusted OR 0.98 [95% CI 0.71-1.37], adjusted OR 0.84 [95% CI 0.59-1.21]; and apixaban: unadjusted OR 1.62 [95% CI 0.84-1.49], adjusted OR 1.22 [95% CI 0.83-1.79]). CONCLUSIONS Among patients admitted with gastrointestinal bleeding, there was no statistically significant difference in in-hospital mortality between prior use of DOAC and warfarin.
Collapse
Affiliation(s)
- Jawad H Butt
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Ang Li
- Division of Hematology, University of Washington School of Medicine, Seattle, WA
| | - Ying Xian
- Duke Clinical Research Institute, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC
| | | | - David Garcia
- Division of Hematology, University of Washington School of Medicine, Seattle, WA
| | | | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Emil L Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| |
Collapse
|
24
|
Guelker JE, Ilousis D, Kröger K, Santosa F, Kowall B, Stang A. Increasing use of anticoagulants in Germany and its impact on hospitalization for gastrointestinal bleeding. Thromb Res 2019; 181:135-140. [PMID: 31415939 DOI: 10.1016/j.thromres.2019.07.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 07/08/2019] [Accepted: 07/12/2019] [Indexed: 01/18/2023]
Abstract
OBJECTIVES The aim of the study was to compare nationwide time trends of oral anticoagulant prescriptions with the time trend of gastrointestinal bleeding (GIB) in Germany from 2005 through 2016. PATIENTS AND METHODS The annual number of hospital admissions for GIB associated with gastric ulcers, duodenal ulcers, hematemesis, melena, hematochezia, and unspecified gastrointestinal bleeding (USGIH) was taken from the nationwide hospital referral file by the Federal Bureau of Statistics. The hospitalization rates were age-standardized using the German Standard Population 2011. The defined daily doses (DDD) of prescribed anticoagulants in outpatients for the same calendar period were taken from reports of the drug information system of the statutory health insurance. Based on DDD, drug treatment rates were calculated per 100,000 people. RESULTS From 2005 to 2016, the annual anticoagulant prescription rates per 100,000 persons increased by 135.8% (from 901.4 to 2125.9). By 2011, direct oral anticoagulants (DOAC) accounted for <0.1% of all anticoagulants, but 49.9% in 2016. Over the same period, age-standardized hospital admissions for GIBs per 100,000 person-years decreased by 14% (from 128.89 to 110.87). Hospitalization rates for gastric ulcer and duodenal ulcer decreased steadily, and those for hematoma, melena and hematochezia continued to increase. Only the USGIH decreased from 2005 to 2011 (annual change of -3.35 (95% CI -5.44; -1.25) per 100,000 person-years) and subsequently increased (0.61, 95% CI -0,42; 1.65). Of all GIB cases, 5.8% received at least 6 red blood cell concentrates in 2005 and 4.6% in 2016. The two-phase time trend for USGIH was no longer present in this subgroup. CONCLUSION Our nationwide comparison of outpatient OAC treatment rates and hospitalization rates for GIBs showed that GIB hospitalization rates declined despite increasing OAC treatment rates from 2005 to 2016. With increasing impact of DOACs after 2011, this decline was not affected.
Collapse
Affiliation(s)
| | | | - Knut Kröger
- Clinic of Vascular Medicine, HELIOS Klinik Krefeld, Germany.
| | - Frans Santosa
- Medical Faculty Universitas Pembangunan Nasional Veteran Jakarta, Indonesia
| | - Bernd Kowall
- Institute for Medical Informatics, Biometry and Epidemiology, Germany
| | - Andreas Stang
- Institute for Medical Informatics, Biometry and Epidemiology, Germany; Department of Epidemiology, Boston University School of Public Health, 715 Albany St, Boston, MA 02118, USA
| |
Collapse
|
25
|
Sheikh Rezaei S, Mittlböck M, Reichardt B, Wolzt M. SSRI co-medication with NOAC or VKA does not increase hospitalisation for bleeding: A retrospective nationwide cohort study in Austria 2010-2015. Int J Geriatr Psychiatry 2019; 34:1194-1199. [PMID: 30968457 PMCID: PMC6767374 DOI: 10.1002/gps.5117] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 04/05/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Non-vitamin K oral anticoagulants (NOACs) or vitamin K antagonists (VKAs) are used for the prophylaxis and treatment of thromboembolic events. A potential drug-drug interaction and increased bleeding events have been reported with co-medication of selective serotonin receptor inhibitors (SSRIs) and VKA. The aim of this study was to investigate the bleeding risk of a coprescription of NOAC or VKA with SSRI. METHODS Patients with prescription of NOAC or VKA and an antidepressant drug therapy (ADTx) were selected from the drug reimbursement database of 13 Austrian health insurance funds. For this cohort, hospital discharge diagnoses for gastrointestinal bleeding, cerebral haemorrhage, and bleeding anaemia between 2010 and 2015 were analysed. RESULTS Data were available from 50 196 female and 31 308 male patients. Among these, 892 patients had 987 hospitalisations with bleeding events. The most frequent bleeding cases were gastrointestinal bleedings with 588 events (59.6%), followed by cerebral haemorrhage with 344 (34.8%), and bleeding anaemia with 55 events (5.6%), respectively. The risk of bleeding events was similar between SSRI and other ADTx, when combined with oral anticoagulants (p = 0.51). Concomitant treatment of patients with SSRI or other ADTx and NOAC was associated with an increased bleeding risk compared with cotreatment with VKA (1.21, 95% CI: 1.05-1.40; p = 0.0097). CONCLUSION Co-medication of SSRI with VKA or NOAC has little if any impact on hospital discharge diagnoses for bleeding events compared with cotreatment of those anticoagulants with other antidepressant medications.
Collapse
Affiliation(s)
| | - Martina Mittlböck
- Center for Medical Statistics, Informatics and Intelligent SystemsMedical University of ViennaViennaAustria
| | | | - Michael Wolzt
- Department of Clinical PharmacologyMedical University of ViennaViennaAustria
| |
Collapse
|
26
|
Deutsch D, Romegoux P, Boustière C, Sabaté JM, Benamouzig R, Albaladejo P. Clinical and endoscopic features of severe acute gastrointestinal bleeding in elderly patients treated with direct oral anticoagulants: a multicentre study. Therap Adv Gastroenterol 2019; 12:1756284819851677. [PMID: 31244894 PMCID: PMC6580723 DOI: 10.1177/1756284819851677] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 04/29/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The aim of the study was to describe the clinical and endoscopic characteristics and management of severe acute gastrointestinal (GI) bleeding in patients treated with direct oral anticoagulants (DOACs). METHODS Patients hospitalized for severe GI bleeding under DOAC therapy were identified in 36 centres between June 2013 and March 2016. Clinical outcomes including re-bleeding, major cerebral and cardiovascular events or all-cause mortality were assessed initially and 30 days after admission. RESULTS A total of 59 patients with anonymized detailed endoscopy reports for severe GI bleeding were considered. Mean age was 79.3 ± 10.0 years and 61.3% of patients were men. Patients had histories of hypertension (65.6%), heart failure (29.5%), coronary artery disease (27.9%), stroke (19.7%) and peripheral vascular disease (36.1%). Life-threatening bleeding was observed in 42.6%. Mean number of packed red blood cells transfused was 3.4 (range 1-31). Aetiology of bleeding (identified in 66.2% of cases) was peptic gastroduodenal ulcers (22%), diverticula (11.9%), angiodysplasia (8.5%), colorectal neoplasia (5.1%) and anorectal causes (5.1%). Endoscopic haemostasis was performed in 37.7% of patients. A low haemoglobin level was predictive of life-threatening bleeding and death in multivariate analysis. All-cause mortality rate at day 30 was 11.8%. CONCLUSIONS In this cohort of elderly patients with multiple comorbidities treated with DOACs, the main cause of severe acute GI bleeding was peptic gastroduodenal ulcer and mortality was high.
Collapse
Affiliation(s)
| | - Pauline Romegoux
- Department of Anaesthesiology and Critical Care,
Grenoble-Alpes University Hospital, Grenoble, France
| | | | - Jean-Marc Sabaté
- Department of Gastroenterology, AP-HP Avicenne
Hospital, Paris-13 University, Bobigny, France
| | - Robert Benamouzig
- Department of Gastroenterology, AP-HP Avicenne
Hospital, Paris-13 University, Bobigny, France
| | - Pierre Albaladejo
- Department of Anaesthesiology and Critical Care,
Grenoble-Alpes University Hospital, Grenoble, France
| |
Collapse
|
27
|
Van der Wall SJ, Lopes RD, Aisenberg J, Reilly P, van Ryn J, Glund S, Elsaesser A, Klok FA, Pollack CV, Huisman MV. Idarucizumab for Dabigatran Reversal in the Management of Patients With Gastrointestinal Bleeding. Circulation 2019; 139:748-756. [DOI: 10.1161/circulationaha.118.036710] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Sake J. Van der Wall
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands (S.J.V.d.W., F.A.K., M.V.H.)
| | - Renato D. Lopes
- Division Cardiology, Duke University Medical Center, Durham, NC (R.D.L.)
| | - James Aisenberg
- Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY (J.A.)
| | - Paul Reilly
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (P.R.)
| | - Joanne van Ryn
- Boehringer Ingelheim International GmbH, Ingelheim and Biberach, Germany (J.v.R., S.G., A.E.)
| | - Stephan Glund
- Boehringer Ingelheim International GmbH, Ingelheim and Biberach, Germany (J.v.R., S.G., A.E.)
| | - Amelie Elsaesser
- Boehringer Ingelheim International GmbH, Ingelheim and Biberach, Germany (J.v.R., S.G., A.E.)
| | - Frederikus A. Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands (S.J.V.d.W., F.A.K., M.V.H.)
| | - Charles V. Pollack
- Emergency Medicine, Thomas Jefferson University and Sidney Kimmel Medical College, Philadelphia, PA (C.V.P.)
| | - Menno V. Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands (S.J.V.d.W., F.A.K., M.V.H.)
| |
Collapse
|
28
|
Lucijanic M, Ziga S, Grgurevic I. Comment to: "Management and outcome of gastrointestinal bleeding in patients taking oral anticoagulants or antiplatelet drugs". J Gastroenterol 2017. [PMID: 28623413 DOI: 10.1007/s00535-017-1361-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Marko Lucijanic
- Haematology Department, University Hospital Dubrava, Av. Gojka Suska 6, 10000, Zagreb, Croatia.
| | - Sead Ziga
- Emergency Department, University Hospital Dubrava, Zagreb, Croatia
| | - Ivica Grgurevic
- Gastroenterology Department, University Hospital Dubrava, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| |
Collapse
|