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Park N, Turcato G, Zaboli A, Santini M, Cipriano A. The state of the art of the management of anticoagulated patients with mild traumatic brain injury in the Emergency Department. EMERGENCY CARE JOURNAL 2022. [DOI: 10.4081/ecj.2022.10640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The effects of Oral Anticoagulation Therapy (OAT) in older patients who suffered a mild Traumatic Brain Injury (mTBI) are widely debated but still strong guidelines are lacking and clinical approaches and management are sometimes heterogeneous. Different predictors of adverse outcomes were identified in the literature but their use in the decision-making process is unclear. Moreover, there is no consensus on the appropriate length of stay in the Observation Unit nor on the continuation of OAT, even if the diagnosis of life-threatening delayed post-traumatic Intracranial Hemorrhage is rare. The recurrence of a control CT scan is often needless. This review aims to summarize recent scientific literature focusing on patients with mTBI taking OAT and to identify crucial questions on the topic to suggest a best clinical practice.
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EASL Clinical Practice Guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis. J Hepatol 2022; 76:1151-1184. [PMID: 35300861 DOI: 10.1016/j.jhep.2021.09.003] [Citation(s) in RCA: 109] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 09/13/2021] [Indexed: 12/11/2022]
Abstract
The prevention and management of bleeding and thrombosis in patients with cirrhosis poses several difficult clinical questions. These Clinical Practice Guidelines have been developed to provide practical guidance on debated topics, including current views on haemostasis in liver disease, controversy regarding the need to correct thrombocytopenia and abnormalities in the coagulation system in patients undergoing invasive procedures, and the need for thromboprophylaxis in hospitalised patients with haemostatic abnormalities. Multiple recommendations in this document are based on interventions that the panel feels are not useful, even though widely applied in clinical practice.
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Sbrana F, Ripoli A, Dal Pino B. Patients with diabetes mellitus and atrial fibrillation treated with non-vitamin K antagonist oral anticoagulants. Acta Cardiol 2021; 77:565. [PMID: 34379034 DOI: 10.1080/00015385.2021.1962623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
| | - Andrea Ripoli
- Fondazione Toscana “Gabrielel Monasterio”, Pisa, Italy
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4
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Cipriano A, Park N, Pecori A, Bionda A, Bardini M, Frassi F, Lami V, Leoli F, Manca ML, Del Prato S, Santini M, Ghiadoni L. Predictors of post-traumatic complication of mild brain injury in anticoagulated patients: DOACs are safer than VKAs. Intern Emerg Med 2021; 16:1061-1070. [PMID: 33386604 DOI: 10.1007/s11739-020-02576-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 11/17/2020] [Indexed: 01/23/2023]
Abstract
Although mild traumatic brain injury (MTBI) in people on oral anticoagulant treatment (OAT) is a frequent challenge for Emergency Department (ED), strong guidelines recommendations are lacking. In the attempt to assess the safety profile of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs), we have recruited 473 patients with a MTBI on OAT (43.6% males; age 81.8 ± 8.7 years), admitted to the Pisa's University Hospital ED (Jan 2016-Oct 2018). All patients underwent a head CT scan with those with no sign of acute bleedings remaining under clinical observation for the ensuing 24 h. Fifty patients (10.6%, 95% CI: 8.1-13.7%) had immediate intracranial hemorrhage (ICH), with a prevalence of patient-important outcomes due to immediate ICH of 1.1% (95% CI 0.4-2.4%); 3 patients died (0.6%, 95% CI 0.2-1.8) and 2 required neurosurgical intervention. Immediate ICHs were more frequent in VKA-treated than in DOAC-treated patients (15.9 vs. 6.4%. RR 2.5. 95%CI 1.4-4.4. p < 0.05). Multivariate analysis identified that post-traumatic amnesia, evidence of trauma above clavicles, high blood glucose, high blood pressure (BP) at arrival, and low prothrombin activity were predictors of immediate ICH. The prevalence of delayed ICH was 1.0% (95%CI 0.4-2.5%) without differences between DOACs and VKAs. Despite ICH being a frequent complication of MTBI in patients on OAT, immediate and delayed patient-important outcomes are rare. DOACs have a better safety profile than VKAs. Simple clinical parameters such as blood pressure at arrival or blood glucose might provide useful predictors of immediate ICH.Trial registration number: 11924_CIPRIANO. Local ethics committee approval number 33096.
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Affiliation(s)
- Alessandro Cipriano
- U.O. Medicina D'Urgenza E Pronto Soccorso, Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria of Pisa, Pisa, Italy.
| | - Naria Park
- U.O. Medicina D'Urgenza E Pronto Soccorso, Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria of Pisa, Pisa, Italy
| | - Alessio Pecori
- U.O. Medicina D'Urgenza E Pronto Soccorso, Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria of Pisa, Pisa, Italy
| | - Alessandra Bionda
- U.O. Medicina D'Urgenza E Pronto Soccorso, Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria of Pisa, Pisa, Italy
| | - Michele Bardini
- U.O. Medicina D'Urgenza E Pronto Soccorso, Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria of Pisa, Pisa, Italy
| | - Francesca Frassi
- U.O. Medicina D'Urgenza E Pronto Soccorso, Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria of Pisa, Pisa, Italy
| | - Valentina Lami
- U.O. Medicina D'Urgenza E Pronto Soccorso, Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria of Pisa, Pisa, Italy
| | - Francesco Leoli
- U.O. Medicina D'Urgenza E Pronto Soccorso, Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria of Pisa, Pisa, Italy
| | - Maria Laura Manca
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Stefano Del Prato
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Massimo Santini
- U.O. Medicina D'Urgenza E Pronto Soccorso, Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria of Pisa, Pisa, Italy
| | - Lorenzo Ghiadoni
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Challenges in Patient Blood Management for Cardiac Surgery: A Narrative Review. J Clin Med 2021; 10:jcm10112454. [PMID: 34205971 PMCID: PMC8198483 DOI: 10.3390/jcm10112454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 11/16/2022] Open
Abstract
About 15 years ago, Patient Blood Management (PBM) emerged as a new paradigm in perioperative medicine and rapidly found support of all major medical societies and government bodies. Blood products are precious, scarce and expensive and their use is frequently associated with adverse short- and long-term outcomes. Recommendations and guidelines on the topic are published in an increasing rate. The concept aims at using an evidence-based approach to rationalize transfusion practices by optimizing the patient's red blood cell mass in the pre-, intra- and postoperative periods. However, elegant as a concept, the implementation of a PBM program on an institutional level or even in a single surgical discipline like cardiac surgery, can be easier said than done. Many barriers, such as dogmatic ideas, logistics and lack of support from the medical and administrative departments need to be overcome and each center must find solutions to their specific problems. In this paper we present a narrative overview of the challenges and updated recommendations for the implementation of a PBM program in cardiac surgery.
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Fantoni C, Bertù L, Galliazzo S, Pola R, Pomero F, Porfidia A, Porreca E, Valeriani E, Ageno W. Follow-up management of patients receiving direct oral anticoagulants. Intern Emerg Med 2021; 16:571-580. [PMID: 32661795 DOI: 10.1007/s11739-020-02433-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 07/02/2020] [Indexed: 12/01/2022]
Abstract
Over the last years, direct oral anticoagulants (DOACs) have radically changed and simplified the therapeutic approach and management of patients on anticoagulant therapy. For these patients, international guidelines recommend to set up a regular follow-up (every 1-6 months) to re-enforce education, to ensure adequate adherence and persistence to treatment. In real-life setting, the application of the suggested follow-up regimens and incidence rates of thrombotic and bleeding complications related to the intensity of follow-up strategies has not been described. We conducted a multicentre, retrospective study at 4 Italian Thrombosis Centres to describe follow-up strategies of patients on DOACs treatment and to assess the incidence of bleeding and thrombotic complications. We enrolled 534 patients, with median follow-up 24 months: 52.1% had < 3 visits/year (group 1), while 47.9% required ≥ 3 visits/year (group 2). Mean age and gender were similar between the 2 groups, while severe anaemia (4.4% and 1.2%, p 0.03) and creatinine clearance < 50 mL/min were more common in group 2 (26.8% and 17.8%, p 0.02). The incidence of thromboembolic events was 3.9% in group 2 and 1.1% in group 1 (p 0.03). Major bleeding rates were non-significantly higher in group 2, whereas non-major bleeding rates occurred significantly more frequently in group 2 (26.6% and 18.7%, respectively, p 0.03). A tailored follow-up program is of critical importance to correctly manage patients on DOACs. A less intense follow-up management is feasible and safe for a substantial proportion of patients, provided they are carefully identified at specialized centres.
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Affiliation(s)
- Chiara Fantoni
- Department of Medicine, Maggiore Hospital, Bologna, Italy.
| | - Lorenza Bertù
- Department of Clinical Medicine, University of Insubria, Varese, Italy
| | - Silvia Galliazzo
- Internal Medicine Department, San Valentino Hospital, Montebelluna, Treviso, Italy
| | - Roberto Pola
- A. Gemelli University Hospital IRCCS, Rome, Italy
| | - Fulvio Pomero
- Internal Medicine Department, S. Lazzaro Hospital, Alba, Italy
| | | | - Ettore Porreca
- Department of Medical, Oral and Biotechnological Sciences "G. D'Annunzio" University, Chieti, Italy
| | - Emanuele Valeriani
- Department of Medical, Oral and Biotechnological Sciences "G. D'Annunzio" University, Chieti, Italy
| | - Walter Ageno
- Department of Clinical Medicine, University of Insubria, Varese, Italy
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Violi F, Loffredo L, Pastori D. Anticoagulation in patients with advanced liver disease: an open issue. Intern Emerg Med 2021; 16:61-71. [PMID: 33073317 DOI: 10.1007/s11739-020-02526-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 09/30/2020] [Indexed: 12/14/2022]
Abstract
Liver disease has been long considered as a risk factor for bleeding for the presence of prolongation of global tests of clotting activation and low platelet count. For this reason, the use of anticoagulants in patients with liver disease and an indication to anticoagulation, such as atrial fibrillation of venous thrombosis, has been poorly considered. Furthermore, recent studies underscored the fact that patients with chronic liver disease may experience thrombosis in portal as well as systemic circulation and treatment with anticoagulants should be considered. The introduction of direct oral anticoagulants has increased therapeutic options for thromboprophylaxis; however, evidence on their safety and efficacy in specific populations, such as patients with liver disease, is still scarce and needs further investigation. Thus, atrial fibrillation patients with coexistent liver disease have been excluded from clinical trials with direct oral anticoagulants. Here, we provide an overview on mechanisms of thrombosis in patients with advanced chronic liver disease and a summary of evidence on the use of oral anticoagulants in patients with liver disease and portal vein thrombosis or atrial fibrillation.
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Affiliation(s)
- Francesco Violi
- Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, I Clinica Medica, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
- Mediterranea Cardiocentro, via Orazio 2, 80122, Naples, Italy.
| | - Lorenzo Loffredo
- Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, I Clinica Medica, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Daniele Pastori
- Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, I Clinica Medica, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
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Barcellona D, Marongiu F. Thrombosis centres and AVKs monitoring in COVID-19 pandemic. Intern Emerg Med 2020; 15:1365-1368. [PMID: 32686059 PMCID: PMC7369471 DOI: 10.1007/s11739-020-02439-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 07/08/2020] [Indexed: 12/21/2022]
Abstract
Vitamin K-Antagonists (VKAs) are the treatment of choice in patients with indications other than atrial fibrillation and venous thromboembolism. Moreover, some patients still assume VKAs refusing to change their therapy when direct oral anticoagulants (DOACs) are properly indicated. The COVID-19 pandemic has completely changed our lives, nullifying inter-personal relationships to avoid contagion, making difficult the VKAs monitoring. We describe the re-organization of our thrombosis centre (TC) as an example on how to face the emergency due to the COVID-19 pandemic. In the first phase, to avoid overcrowding at the TC, we planned to increase the interval time between INRs checks and to encourage blood sampling at home, especially for elderly patients. Moreover, precise scheduled blood sampling was also organized while telephone and email counselling were guaranteed by two doctors of the TC. In the second phase, to reduce the number of patients who daily attended our TC a switch from VKAs to DOACs was carried out, if no contraindications were identified. In the third phase, to protect patients, healthcare staff and hospital from COVID-19 widespread, telemedicine was strengthened. We tried to extend self-testing at home by means of portable coagulometers to as more patients as possible. To avoid patients staying or coming back to the TC an ad hoc web platform for sending the therapeutic dose adjustment and the next scheduled appointment was developed. The TC re-organization allowed us to monitor anticoagulated patients respecting personal isolation and security measures to avoid possible COVID-19 contagion.
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Affiliation(s)
- Doris Barcellona
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy.
- SHRO, Temple University, Philadelphia, PA, USA.
| | - Francesco Marongiu
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
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Poli D, Tosetto A, Palareti G, Barcellona D, Ciampa A, Grandone E, Manotti C, Moia M, Squizzato A, Toschi V, Testa S. Managing anticoagulation in the COVID-19 era between lockdown and reopening phases. Intern Emerg Med 2020; 15:783-786. [PMID: 32514682 PMCID: PMC7278243 DOI: 10.1007/s11739-020-02391-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 05/29/2020] [Indexed: 01/20/2023]
Abstract
Patients on anticoagulant treatment are constantly increasing, with an estimated prevalence in Italy of 2% of the total population. The recent spreadout of the COVID-19 pandemic requires a re-organization of Anticoagulation Clinics to prevent person-to-person viral diffusion and continue to offer the highest possible quality of assistance to patients. In this paper, based on the Italian Federation of Anticoagulation Clinics statements, we offer some advice aimed at improving patient care during COVID-19 pandemic, with particular regard to the lockdown and reopening periods. We give practical guidance regarding the following points: (1) re-thinking the AC organization, (2) managing patients on anticoagulants when they become infected by the virus, (3) managing anticoagulation surveillance in non-infected patients during the lockdown period, and (4) organizing the activities during the reopening phases.
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Affiliation(s)
- Daniela Poli
- Dipartimento Cardiotoracovascolare, Centro Trombosi, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Alberto Tosetto
- UOS Centro Malattie Emorragiche e Trombotiche - Divisione di Ematologia, Ospedale S. Bortolo, Vicenza, Italy
| | | | - Doris Barcellona
- Dipartimento di Scienze Mediche e Sanità Pubblica, Università di Cagliari, Cagliari, Italy
| | | | - Elvira Grandone
- Thrombosis and Haemostasis Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
- Ob/Gyn Department of The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Cesare Manotti
- Centro Emostasi, Medicina Interna ad indirizzo angiologico e coagulativo, Dipartimento di Medicina Interna e Specialistica, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | | | - Alessandro Squizzato
- Department of Medicine and Surgery, Research Centre on Thromboembolic Diseases and Antithrombotic Therapies, University of Insubria, Varese and Como, Italy
| | - Vincenzo Toschi
- Department of Hematology and Blood Transfusion, ASST Santi Paolo e Carlo, Milan, Italy
| | - Sophie Testa
- Centro Emostasi e Trombosi, Ospedale di Cremona, Cremona, Italy
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Poli D, Tosetto A, Palareti G, Barcellona D, Ciampa A, Grandone E, Manotti C, Moia M, Squizzato A, Toschi V, Testa S. Managing anticoagulation in the COVID-19 era between lockdown and reopening phases. Intern Emerg Med 2020. [PMID: 32514682 DOI: 10.1007/s11739-020-02391-34] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
Patients on anticoagulant treatment are constantly increasing, with an estimated prevalence in Italy of 2% of the total population. The recent spreadout of the COVID-19 pandemic requires a re-organization of Anticoagulation Clinics to prevent person-to-person viral diffusion and continue to offer the highest possible quality of assistance to patients. In this paper, based on the Italian Federation of Anticoagulation Clinics statements, we offer some advice aimed at improving patient care during COVID-19 pandemic, with particular regard to the lockdown and reopening periods. We give practical guidance regarding the following points: (1) re-thinking the AC organization, (2) managing patients on anticoagulants when they become infected by the virus, (3) managing anticoagulation surveillance in non-infected patients during the lockdown period, and (4) organizing the activities during the reopening phases.
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Affiliation(s)
- Daniela Poli
- Dipartimento Cardiotoracovascolare, Centro Trombosi, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Alberto Tosetto
- UOS Centro Malattie Emorragiche e Trombotiche - Divisione di Ematologia, Ospedale S. Bortolo, Vicenza, Italy
| | | | - Doris Barcellona
- Dipartimento di Scienze Mediche e Sanità Pubblica, Università di Cagliari, Cagliari, Italy
| | | | - Elvira Grandone
- Thrombosis and Haemostasis Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
- Ob/Gyn Department of The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Cesare Manotti
- Centro Emostasi, Medicina Interna ad indirizzo angiologico e coagulativo, Dipartimento di Medicina Interna e Specialistica, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | | | - Alessandro Squizzato
- Department of Medicine and Surgery, Research Centre on Thromboembolic Diseases and Antithrombotic Therapies, University of Insubria, Varese and Como, Italy
| | - Vincenzo Toschi
- Department of Hematology and Blood Transfusion, ASST Santi Paolo e Carlo, Milan, Italy
| | - Sophie Testa
- Centro Emostasi e Trombosi, Ospedale di Cremona, Cremona, Italy
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Testa S, Paoletti O, Giorgi-Pierfranceschi M, Pan A. Switch from oral anticoagulants to parenteral heparin in SARS-CoV-2 hospitalized patients. Intern Emerg Med 2020; 15:751-753. [PMID: 32297089 PMCID: PMC7157827 DOI: 10.1007/s11739-020-02331-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 03/30/2020] [Indexed: 10/26/2022]
Abstract
The development of COVID-19 syndrome in anticoagulated patients, and especially their admission to intensive-care units with acute severe respiratory syndrome (SARS-CoV-2), expose them to specific problems related to their therapy, in addition to those associated with the acute viral infection. Patients on VKA hospitalized with SARS-CoV-2 show high instability of PT INR due to the variability of vitamin K metabolism, diet, fasting, co-medications, liver impairment, and heart failure. Patients on DOAC are exposed to under/over treatment caused by significant pharmacological interferences. In consideration of the pharmacological characteristics of oral anticoagulant drugs, the multiple pharmacological interactions due to the treatment of acute disease and the possible necessity of mechanical ventilation with hospitalization in intensive-care units, we suggest replacing oral anticoagulant therapies (VKA and DOAC) with parenteral heparin to avoid the risk of over/under treatment.
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Affiliation(s)
- Sophie Testa
- Haemostasis and Thrombosis Center, Cremona Hospital, Viale Concordia 1, 26100, Cremona, Italy.
| | - Oriana Paoletti
- Haemostasis and Thrombosis Center, Cremona Hospital, Viale Concordia 1, 26100, Cremona, Italy
| | | | - Angelo Pan
- Division of Infectious Disease, Cremona Hospital, Viale Concordia 1, 26100 Cremona, Italy
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Palareti G, Cosmi B. The direct oral anticoagulants may also be effective against the risk of post-thrombotic syndrome. Intern Emerg Med 2020; 15:365-367. [PMID: 31872344 DOI: 10.1007/s11739-019-02251-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 12/02/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Gualtiero Palareti
- "Arianna Anticoagulazione" Foundation, via Paolo Fabbri 1/3, 40138, Bologna, Italy.
| | - Benilde Cosmi
- Dept Angiology and Blood Coagulation, S. Orsola-Malpighi University Hospital, via Albertoni 15, 40138, Bologna, Italy
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Magon A, Arrigoni C, Moia M, Mancini M, Dellafiore F, Manara DF, Caruso R. Determinants of health-related quality of life: a cross-sectional investigation in physician-managed anticoagulated patients using vitamin K antagonists. Health Qual Life Outcomes 2020; 18:73. [PMID: 32178684 PMCID: PMC7077005 DOI: 10.1186/s12955-020-01326-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 03/11/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Literature has paid little attention in describing the specific contribution of each modifiable and non-modifiable characteristics on health-related quality of life (HRQoL) in physician-managed anticoagulated patients using vitamin K antagonists (VKAs). To describe how patients' treatment-specific knowledge, health literacy, treatment beliefs, clinical, and socio-demographic characteristics influence HRQoL in Italian physician-managed anticoagulated patients using VKAs. METHODS Cross-sectional multicentre study with a consecutive sampling strategy, enrolling 164 long-term anticoagulated patients. Clinical and socio-demographic characteristics were collected from electronic medical records. Valid and reliable questionnaires were used to collect patients' treatment-specific knowledge, health literacy, beliefs about VKAs, physical and health perceptions. RESULTS Obtaining and understanding health information (i.e., communicative health literacy) positively predicts both adequate mental (ORadjusted = 10.9; 95%CI = 1.99-19.10) and physical (ORadjusted = 11.54; 95%CI = 1.99-34.45) health perceptions. Conversely, the ability to perform proper health decision making (i.e., critical health literacy) was associated with lower rates of adequate mental health perception (ORadjusted = 0.13; 95%CI = 0.03-0.63). Further, age negatively predicted physical health perception (ORadjusted = 0.87; 95%CI = 0.81-0.93). CONCLUSIONS Health literacy plays an interesting role in predicting HRQoL. The relationship between critical health literacy and mental health perception could be influenced by some psychological variables, such as distress and frustration, which could be present in patients with higher levels of critical health literacy, as they could be more inclined for self-monitoring. For this reason, future research are needed to identify the most suitable patients' profile for each OAC-management model, by longitudinally describing the predictive performance of each modifiable and non-modifiable determinant of HRQoL.
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Affiliation(s)
- Arianna Magon
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier, 1 - 00133, Rome, Italy.
| | - Cristina Arrigoni
- Department of Public Health, Experimental and Forensic Medicine, Section of Hygiene, University of Pavia, Pavia, Italy
| | - Marco Moia
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
| | - Michela Mancini
- Nursing Office, ASST Melegnano e della Martesana, Melzo, Italy
| | - Federica Dellafiore
- Health Professions Research and Development Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Duilio F Manara
- School of Nursing, Vita-Salute San Raffaele University, Milan, Italy
| | - Rosario Caruso
- Health Professions Research and Development Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
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Pomero F, Dentali F, Mumoli N, Salomone P, Tangianu F, Desideri G, Mastroiacovo D. The continuous challenge of antithrombotic strategies in diabetes: focus on direct oral anticoagulants. Acta Diabetol 2019; 56:1247-1258. [PMID: 31552542 DOI: 10.1007/s00592-019-01426-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 09/17/2019] [Indexed: 12/16/2022]
Abstract
Direct oral anticoagulants (DOACs) include dabigatran, which inhibits thrombin, and apixaban, edoxaban, and rivaroxaban, which inhibit factor Xa. They have been extensively studied in large trials involving patients affected by the most common cardiovascular diseases. As the presence of diabetes leads to peculiar changes in primary and secondary hemostasis, in this review we highlight the current evidence regarding DOAC use in diabetic patients included in the majority of recently conducted studies. Overall, in trials involving patients with atrial fibrillation, data seem to confirm at least a similar efficacy and safety of DOACs compared to warfarin in patients with or without diabetes. Furthermore, in diabetic patients, treatment with DOACs is associated with a significant relative reduction in vascular death compared to warfarin. In trials enrolling patients undergoing percutaneous coronary intervention, results concerning bleeding events are consistent in patients with or without diabetes. With regards to the COMPASS study, in patients with diabetes (n = 10,241), addition of rivaroxaban 2.5 mg to aspirin resulted in a significantly lower incidence of major adverse cardiovascular events (HR 0.74, 95% CI 0.61-0.90; interaction p = 0.68) with higher rates of major bleeding expected (HR 1.70, 95% CI 1.25-2.31). The 3287 patients with peripheral artery disease and diabetes receiving rivaroxaban plus aspirin had a twofold higher absolute reduction in the composite endpoint (cardiovascular death, myocardial infarction, and stroke) than patients without diabetes. Finally, we report the involvement of cytochromes or P-glycoprotein on the metabolism of the most commonly prescribed glucose-lowering drugs. No clinically relevant interactions are expected during the concomitant use of DOACs and anti-diabetic agents.
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Affiliation(s)
- Fulvio Pomero
- Department of Internal Medicine, S. Lazzaro Hospital, Alba, CN, Italy.
| | - Francesco Dentali
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - Nicola Mumoli
- Department of Internal Medicine, Ospedale Fornaroli, Magenta, Italy
| | - Pietro Salomone
- Specialty Training in Internal Medicine, University of Turin, Turin, Italy
| | - Flavio Tangianu
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - Giovambattista Desideri
- Department of Life, Health and Environmental Science, San Salvatore Hospital, University of L'Aquila, Building Delta 6, L'Aquila, Italy
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15
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Violi F, Pastori D. Real-world efficacy and safety of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Intern Emerg Med 2019; 14:1199-1201. [PMID: 31250259 DOI: 10.1007/s11739-019-02135-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 06/21/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Francesco Violi
- Department of Internal Medicine and Medical Specialties, I Clinica Medica, Atherothrombosis Center, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Daniele Pastori
- Department of Internal Medicine and Medical Specialties, I Clinica Medica, Atherothrombosis Center, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
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16
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Godino C, Melillo F, Rubino F, Arrigoni L, Cappelletti A, Mazzone P, Mattiello P, Della Bella P, Colombo A, Salerno A, Cera M, Margonato A. Real-world 2-year outcome of atrial fibrillation treatment with dabigatran, apixaban, and rivaroxaban in patients with and without chronic kidney disease. Intern Emerg Med 2019; 14:1259-1270. [PMID: 31073827 DOI: 10.1007/s11739-019-02100-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 04/29/2019] [Indexed: 01/05/2023]
Abstract
Patients with non-valvular atrial fibrillation (NVAF) and chronic kidney disease (CKD) are at increased risk of stroke and bleeding. Although direct oral anticoagulant (DOAC) trials excluded patients with severe CKD, a growing portion of CKD patients have been starting DOACs and limited data from real-world outcome in this high-risk setting are available. The INSigHT registry included 632 consecutive NVAF patients that started apixaban (256 patients, 41%), dabigatran (245, 39%) and rivaroxaban (131, 20%) between 2012 and 2015. Based on creatinine clearance, two sub-cohorts were defined: (1) non-CKD group (CrCl 60-89 mL/min, 413 patients) and (2) CKD group (15-59 ml/min, 219). Compared to non-CKD patients, those with CKD, were at higher ischemic (CHA2DS2-VASc 4.5 vs 2.9, p < 0.001) and hemorrhagic risk (HAS-BLED 2.4 vs 1.8, p < 0.001). At 2-year follow-up, the overall ISTH-major bleeding and thromboembolic event rates were 5.2% and 2.3% and no significant difference between non-CKD and CKD patients for both efficacy and safety endpoints were observed. In non-CKD patients, the 2-year ISTH-major bleeding rates were higher in rivaroxaban group (HR 2.9, 95% CI 1.1-7.3; p = 0.047) while dabigatran showed non-significant excess in thromboembolic events (HR 4.3, 95% CI 0.9-20.8; p = 0.068). In CKD patients, a significantly higher rate of thromboembolic events was observed in rivaroxaban (HR 6.3, 95% CI 1.1-38.1; p = 0.044). This real-world, non-insurance database registry shows remarkable 2-year safety and efficacy profile of DOACs even in patients with moderate to severe CKD. Head to head differences between DOACs are exploratory, hypothesis generating and warrant further investigation in larger studies.
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Affiliation(s)
- Cosmo Godino
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
| | - Francesco Melillo
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Francesca Rubino
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Luca Arrigoni
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Alberto Cappelletti
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Patrizio Mazzone
- Arrhythmia and Electrophysiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Mattiello
- Information Systems Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Della Bella
- Arrhythmia and Electrophysiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Colombo
- Interventional Cardiovascular Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Anna Salerno
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Michela Cera
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Alberto Margonato
- Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
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Pomero F, Spadafora L, D'Agnano S, Dentali F, Fenoglio LM. Direct oral anticoagulants in factor VII deficiency patient. Intern Emerg Med 2019; 14:1353-1356. [PMID: 31529192 DOI: 10.1007/s11739-019-02186-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 08/26/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Fulvio Pomero
- U.O. Medicina Interna, Ospedale S. Lazzaro, Via P. Belli 26, 12051, Alba, Italy.
| | | | - Salvatore D'Agnano
- Specialty Training in Internal Medicine, University of Turin, Turin, Italy
| | - Francesco Dentali
- Department of Clinical Medicine, University of Insubria, Varese, Italy
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18
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Sbrana F, Dal Pino B, Papa A, Bigazzi F, Panchetti L, Sampietro T. Direct oral anticoagulants in lipoprotein apheresis: handle with care. Intern Emerg Med 2019; 14:1171-1173. [PMID: 31165345 DOI: 10.1007/s11739-019-02118-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 05/27/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Francesco Sbrana
- Lipoapheresis Unit and Reference Center for Inherited Dyslipidemias, Fondazione Toscana "Gabriele Monasterio", Via Moruzzi 1, 56124, Pisa, Italy.
| | - Beatrice Dal Pino
- Lipoapheresis Unit and Reference Center for Inherited Dyslipidemias, Fondazione Toscana "Gabriele Monasterio", Via Moruzzi 1, 56124, Pisa, Italy
| | - Angela Papa
- Department of Laboratory Medicine, Fondazione Toscana "Gabriele Monasterio", Pisa, Italy
| | - Federico Bigazzi
- Lipoapheresis Unit and Reference Center for Inherited Dyslipidemias, Fondazione Toscana "Gabriele Monasterio", Via Moruzzi 1, 56124, Pisa, Italy
| | - Luca Panchetti
- U.O. Elettrofisiologia interventistica, Fondazione Toscana "Gabriele Monasterio", Pisa, Italy
| | - Tiziana Sampietro
- Lipoapheresis Unit and Reference Center for Inherited Dyslipidemias, Fondazione Toscana "Gabriele Monasterio", Via Moruzzi 1, 56124, Pisa, Italy
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19
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Extended treatment of cancer-associated thrombosis. Thromb Res 2019; 181:1-9. [PMID: 31302473 DOI: 10.1016/j.thromres.2019.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 06/04/2019] [Accepted: 07/02/2019] [Indexed: 12/20/2022]
Abstract
Venous thromboembolism (VTE) is a growing concern in patients with cancer. Current guidelines recommend that cancer patients with VTE should receive anticoagulation for at least 3-6 months. However, the question as to whether anticoagulants should be continued after 3 to 6 months of treatment remains open. In presence of an active malignancy, physicians should weigh the benefits and burdens of ongoing anticoagulation taking into account the clinical status, patient expectations, and the risk of bleeding. As the length of time from the index event increases, the available evidence is not conclusive. The most critical unresolved issues include the decision to continue or discontinue anticoagulation and the selection of the most appropriate anticoagulant agent. On this background, our article provides an overview of the available studies focusing on extended (i.e., >6 months) anticoagulation treatment in cancer-associated thrombosis, with the ultimate goal of refining real-world clinical decision-making in this patient population.
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20
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Galliazzo S, Squizzato A. Optimal management of major bleeding on DOACs: not only reversal agents. Intern Emerg Med 2019; 14:207-208. [PMID: 30612343 DOI: 10.1007/s11739-018-02020-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 12/27/2018] [Indexed: 12/12/2022]
Affiliation(s)
- Silvia Galliazzo
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, Department of Medicine and Surgery, School of Medicine, University of Insubria, U.O. Medicina 1, ASST Settelaghi, Viale Borri 57, 21100, Varese, Italy
| | - Alessandro Squizzato
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, Department of Medicine and Surgery, School of Medicine, University of Insubria, U.O. Medicina 1, ASST Settelaghi, Viale Borri 57, 21100, Varese, Italy.
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21
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Prisco D, Tufano A, Cenci C, Pignatelli P, Santilli F, Di Minno G, Perticone F. Position paper of the Italian Society of Internal Medicine (SIMI) on prophylaxis and treatment of venous thromboembolism in patients with cancer. Intern Emerg Med 2019; 14:21-38. [PMID: 30276659 DOI: 10.1007/s11739-018-1956-1] [Citation(s) in RCA: 10] [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: 08/10/2018] [Accepted: 09/18/2018] [Indexed: 02/01/2023]
Abstract
Cancer patients are at high risk of developing thrombotic events, including venous thromboembolism (VTE) [deep venous thrombosis (DVT) and pulmonary embolism (PE)], and arterial thrombosis. DVT and PE represent the second leading cause of death in cancer patients; moreover, the development of thromboembolic events in cancer patients is linked to a greater need of hospitalization and frequency of side effects during treatment, in particular bleeding, and to an increased risk of recurrence during and following antithrombotic therapy. The thromboembolic risk may be different in different subgroups of cancer population, being highest in patients with metastatic disease, patients with pancreas, stomach, kidney or primary brain cancer, or during therapeutic interventions or surgery. This document focuses on several relevant topics including the epidemiology and pathogenesis of cancer-associated VTE, the current and future strategies of primary prevention and anticoagulant treatment, and the management of bleeding complications. The main literature data are discussed in detail, including, when available, evidence from randomized clinical trials and meta-analyses, international guidelines statements, the results of recently published trials comparing direct oral anticoagulants to low molecular weight heparin, and the design and aims of ongoing trials on prevention/treatment of cancer-associated VTE.
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Affiliation(s)
- Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Antonella Tufano
- Department of Clinical Medicine and Surgery, Regional Reference Centre for Coagulation Disorders, "Federico II" University Hospital, Via S. Pansini, 5, 80131, Naples, Italy.
| | - Caterina Cenci
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Pasquale Pignatelli
- Department of Internal Medicine and Medical Specialties, La Sapienza University of Rome, Rome, Italy
| | - Francesca Santilli
- Department of Medicine and Aging and Center of Aging Science and Translational Medicine (CESI-Met), "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Giovanni Di Minno
- Department of Clinical Medicine and Surgery, Regional Reference Centre for Coagulation Disorders, "Federico II" University Hospital, Via S. Pansini, 5, 80131, Naples, Italy
| | - Francesco Perticone
- Department of Medical and Surgical Sciences, "Magna-Græcia" University of Catanzaro, Catanzaro, Italy
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22
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Douketis JD, Radwi M. A clinical conundrum: to measure or not measure direct oral anticoagulants before a surgery or procedure? Intern Emerg Med 2018; 13:997-999. [PMID: 30143965 DOI: 10.1007/s11739-018-1930-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 08/10/2018] [Indexed: 01/04/2023]
Affiliation(s)
- James D Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton and McMaster University, Room F-544, 50 Charlton Ave East, Hamilton, ON, L8N 4A6, Canada.
| | - Mansoor Radwi
- Department of Hematology, Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia
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23
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Tripodi A, Marongiu F, Moia M, Palareti G, Pengo V, Poli D, Prisco D, Testa S, Zanazzi M. The vexed question of whether or not to measure levels of direct oral anticoagulants before surgery or invasive procedures. Intern Emerg Med 2018; 13:1029-1036. [PMID: 29700696 DOI: 10.1007/s11739-018-1854-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 04/08/2018] [Indexed: 12/12/2022]
Abstract
Direct oral anticoagulants (DOAC) possess high bioavailability, and their anticoagulant effect is more predictable than that of vitamin K antagonists, hence they do not require routine dose adjustment based on laboratory testing. However, there are circumstances when laboratory testing may be useful, including patients who need to undergo surgery or invasive procedures. Most guidelines state that patients on DOAC may safely undergo surgery/invasive procedures by stopping anticoagulation for a few days before intervention without testing if renal function is within normal limits. This review article discusses the pros and cons of measuring (or not measuring) DOAC levels before surgery/invasive procedures by a multidisciplinary team of experts with different background, including the thrombosis laboratory, clinical thrombosis, internal medicine, cardiology and nephrology. The conclusion is that measuring DOAC with dedicated tests before surgical or invasive procedures is important for patient safety. It provides the best and most direct evidence to rule in (or to rule out) clinically relevant concentrations of residual drugs. Regulatory agencies should urgently approve their use in clinical practice. Hospital administrators should make them available, and clinical laboratories should set up the relative methods and make them available to clinicians.
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Affiliation(s)
- Armando Tripodi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, IRCCS Cà Granda Maggiore Hospital Foundation, Via Pace 9, 20122, Milan, Italy.
| | - Francesco Marongiu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Marco Moia
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, IRCCS Cà Granda Maggiore Hospital Foundation, Via Pace 9, 20122, Milan, Italy
| | - Gualtiero Palareti
- Arianna Anticoagulation Foundation-START Register Section, Bologna, Italy
| | - Vittorio Pengo
- Cardiology Clinic, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Daniela Poli
- Thrombosis Centre, Careggi University Hospital, Florence, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Sophie Testa
- Department of Laboratory Medicine, Hemostasis and Thrombosis Centre, District Hospital, Cremona, Italy
| | - Maria Zanazzi
- Renal Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
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Riva N, Ageno W, Gatt A. Estimating renal function in patients with atrial fibrillation: which dose of direct oral anticoagulants? Intern Emerg Med 2018; 13:1001-1004. [PMID: 29797287 DOI: 10.1007/s11739-018-1883-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 05/18/2018] [Indexed: 01/09/2023]
Affiliation(s)
- Nicoletta Riva
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta.
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Alex Gatt
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
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25
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Volterrani M, Iellamo F, Alberto C, Pasquale A, Salvatore P, Massimo P, Marco M, Lucia U, Cesare P, Bruno R, Enrico P. NOAC in "real world" patients with atrial fibrillation in Italy: results from the ISPAF-2 (Indagine Sicoa Paziente Con Fibrillazione Atriale) survey study. Intern Emerg Med 2018; 13:1069-1075. [PMID: 29956065 DOI: 10.1007/s11739-018-1896-9] [Citation(s) in RCA: 12] [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: 01/10/2018] [Accepted: 06/15/2018] [Indexed: 01/08/2023]
Abstract
In the past few years, new oral anticoagulants (NOACs) targeting directly a single activated clotting factor, have been developed for the treatment of non-valvular atrial fibrillation (AF), which are currently recommended as first-line therapy in AF. The aim of this study is to provide an overall picture on the extent to which oral anticoagulation (OAC) with NOACs correspond to actually prescribed OAC therapy in an unselected, real world, population of consecutive patients with AF in Italy. Compliance with the therapy and quality of life were also assessed. A 50 cardiology unit network located in different geographic areas of Italy enrolled a total of 1742 consecutive outpatients with AF (54.6% males, 45.4% females, mean age 72.5 years). NOACs were prescribed in 56.1% patients and VKA in 43.9% (P < 0.0001). NOACs were significantly more prescribed than VKA in patients with high thrombo-embolic risk score (i.e., CHA2DS2-VASc > 2) (78.2 vs 67.3%, P < 0.0001), but also patients at low risk (i.e., CHA2DS2-VASc < 1 and HAS-BLED < 3) were still under OAC therapy with either NOACs (27%) or VKA (73%). Adherence to therapy (Morisky test) was greater in patients taking NOACs as was the quality of life. The ISPAF-2 study shows that in an Italian population of real-world patients with AF the prescription of OAC according to current guidelines and stroke-risk scoring system is rather high although it still needs to be improved. Contrary to recommendations, in a high proportion of low-risk patients, anticoagulation therapy, with either NOACs and VKA is still prescribed, and this exposes patients to unjustified risks.
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Affiliation(s)
- Maurizio Volterrani
- Istituto di Ricovero e Cura a Carttere Scientifico San Raffaele Pisana, Rome, Italy
| | - Ferdinando Iellamo
- Istituto di Ricovero e Cura a Carttere Scientifico San Raffaele Pisana, Rome, Italy.
- Dipartimento Scienze Cliniche e Medicina traslazionale, Università Tor Vergata, Rome, Italy.
- Cardiology Department, IRCCS San Raffaele Pisana, Rome, Italy.
| | | | | | | | | | | | | | | | | | - Pusineri Enrico
- Centro Cardio toracico Istituto Clinico San Ambrogio, Milan, Italy
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Testa S, Ageno W, Antonucci E, Morandini R, Beyer-Westendorf J, Paciaroni M, Righini M, Sivera P, Verhamme P, Pengo V, Poli D, Palareti G. Management of major bleeding and outcomes in patients treated with direct oral anticoagulants: results from the START-Event registry. Intern Emerg Med 2018; 13:1051-1058. [PMID: 29790125 DOI: 10.1007/s11739-018-1877-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 05/07/2018] [Indexed: 01/22/2023]
Abstract
The management of major bleeding in patients treated with direct oral anticoagulants (DOACs) is still not well established. START-Events, a branch of the START registry (Survey on anTicoagulated pAtients RegisTer) (NCT02219984), aims to describe the actual management of bleeding or recurrent thrombotic events in routine clinical practice. We here present the results of the management of bleeding patients. The START-Event registry is a prospective, observational, multicenter, international study. Baseline characteristics (demographic, clinical, risk factors) of patients, laboratory data at admission and during follow-up, site of bleeding, therapeutic strategies, and outcomes at the time of hospital discharge and after 6 months were recorded on a web-based case report form. Between January 2015 and December 2016, 117 patients with major bleeding events were enrolled. Non-valvular atrial fibrillation (NVAF) was the indication for treatment in 84% (62% males); 53 patients had intracranial bleeding (13 fatal), 42 had gastrointestinal bleeding (1 fatal), and 22 had bleeding in other sites. Therapeutic interventions for the management of bleeding were performed in 71% of patients. Therapeutic strategies with/without surgery or invasive procedures included: fluid replacement or red blood cells transfusion, prothrombin complex concentrates (3 or 4 factors), antifibrinolytic drugs, and the administration of idarucizumab. Creatinine, blood cell count, and PT/aPTT were the most frequent tests requested, while specific DOAC measurements were performed in 23% of patients. Mortality during hospitalization was 11.9%, at 6-month follow-up 15.5%. Our data confirm a high heterogeneity in the management of bleeding complications in patients treated with DOACs.
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Affiliation(s)
- Sophie Testa
- Haemostasis and Thrombosis Center, Ospedale di Cremona, Viale Concordia 1, 26100, Cremona, Italy.
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | | | - Rossella Morandini
- Haemostasis and Thrombosis Center, Ospedale di Cremona, Viale Concordia 1, 26100, Cremona, Italy
| | | | | | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospital, Geneva, Switzerland
| | | | | | - Vittorio Pengo
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
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27
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Mulè' G, Carollo C, Guarneri M, Cottone S. The changing landscape of thromboprophylaxis for atrial fibrillation: insights from the ISPAF-2 survey. Intern Emerg Med 2018; 13:1005-1007. [PMID: 30117102 DOI: 10.1007/s11739-018-1929-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 08/10/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Giuseppe Mulè'
- Unit of Nephrology and Hypertension - Biomedical Department of Internal Medicine and Medical Specialties (Di.Bi.M.I.S) - European Society of Hypertension Excellence Centre, University of Palermo, Via del Vespro, 129, 90127, Palermo, Italy.
| | - Caterina Carollo
- Unit of Nephrology and Hypertension - Biomedical Department of Internal Medicine and Medical Specialties (Di.Bi.M.I.S) - European Society of Hypertension Excellence Centre, University of Palermo, Via del Vespro, 129, 90127, Palermo, Italy
| | - Marco Guarneri
- Unit of Nephrology and Hypertension - Biomedical Department of Internal Medicine and Medical Specialties (Di.Bi.M.I.S) - European Society of Hypertension Excellence Centre, University of Palermo, Via del Vespro, 129, 90127, Palermo, Italy
| | - Santina Cottone
- Unit of Nephrology and Hypertension - Biomedical Department of Internal Medicine and Medical Specialties (Di.Bi.M.I.S) - European Society of Hypertension Excellence Centre, University of Palermo, Via del Vespro, 129, 90127, Palermo, Italy
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Marongiu F, Barcellona D. Direct oral anticoagulants: what can we learn? Intern Emerg Med 2018; 13:989-992. [PMID: 29500618 DOI: 10.1007/s11739-018-1811-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 02/25/2018] [Indexed: 11/25/2022]
Abstract
Direct oral anticoagulants (DOACs) represent an innovation because they avoid periodic laboratory monitoring, and also reduce cerebral bleeding. An examination of the performance of DOACs versus warfarin in randomized clinical trials dedicated to atrial fibrillation would reveal the poor performance of warfarin because the percentage of major bleeding is always above 3%; however, the percentage of major bleeding is less than half of that when the management is done in anticoagulation clinics (ACs). Several years ago, a common opinion was that ACs would disappear as soon as DOACs enter the market. We proposed then that ACs could be transformed into thrombosis centres (TCs) because we envisaged many new activities in terms of diagnostic tools and therapeutic choices. After the introduction of DOACs, the role of the ACs has been re-evaluated because their role may be crucial in selecting both the most appropriate diagnostic approach and the best therapeutic option (including anti-vitamin K drugs) for the single patient. TCs can organize a regular follow-up to improve patient adherence to DOACs. Marketing might have a role in the decision making of the single doctor. Efforts should be made for limiting the relationships between doctors and pharmaceutical companies. It seems reasonable to better prepare doctors, during their university courses, for them to develop a greater scientific culture that would enable them to critically read clinical studies and acquire an independent opinion. Ideally, an expert in haemostasis and thrombosis should handle new and old anticoagulants.
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Affiliation(s)
- Francesco Marongiu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Doris Barcellona
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.
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Cipriano A, Pecori A, Bionda AE, Bardini M, Frassi F, Leoli F, Lami V, Ghiadoni L, Santini M. Intracranial hemorrhage in anticoagulated patients with mild traumatic brain injury: significant differences between direct oral anticoagulants and vitamin K antagonists. Intern Emerg Med 2018. [PMID: 29520701 DOI: 10.1007/s11739-018-1806-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Prognosis after mild traumatic brain injury (MTBI) on oral anticoagulant therapy (OAT) is uncertain. We evaluated the rate of immediate and delayed traumatic intracranial hemorrhage (ICH) comparing vitamin K antagonists (VKAs) to direct oral anticoagulants (DOACs) and the safety of a clinical management protocol. In this single-center prospective observational study, we enrolled 220 patients on OAT with MTBI. After a first negative CT scan, asymptomatic patients underwent a close neurological observation; if neurologically stable, they were discharged without a second CT scan and followed up for 1 month. Out of the 220 patients, 206 met the inclusion criteria. 23 of them (11.2%) had a positive first CT scan for ICH. Only 1 (0.5%, 95% CI 0.0-1.4%) died because of ICH; no one required neurosurgical intervention. The observed prevalence rate of immediate ICH resulted statistically higher in VKAs-treated patients compared to those treated with DOACs (15.7 vs. 4.7%, RR 3.34, 95% CI 1.18-9.46, P < 0.05). In the 1-month follow-up, 5 out of the 183 patients with a negative CT scan were lost. Out of the remaining 178 patients, only 3 showed a delayed ICH (1.7%, 95% CI 0.0-3.6%), 1 of them died (0.6%, 95% CI 0.5-1.7%) and the others did not require neurosurgical intervention. DOACs resulted safer than VKAs also in the setting of MTBI. In our observation, the rate of delayed hemorrhage was relatively low. Patients presenting with a negative first CT scan and without neurological deterioration could be safely discharged after a short period of in-ward observation with a low rate of complications and without a second CT scan.
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Affiliation(s)
- Alessandro Cipriano
- Emergency Department, Nuovo Santa Chiara Hospital, U.O. Medicina d'Urgenza e Pronto Soccorso, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy.
| | - Alessio Pecori
- Emergency Department, Nuovo Santa Chiara Hospital, U.O. Medicina d'Urgenza e Pronto Soccorso, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Alessandra Eugenia Bionda
- Emergency Department, Nuovo Santa Chiara Hospital, U.O. Medicina d'Urgenza e Pronto Soccorso, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Michele Bardini
- Emergency Department, Nuovo Santa Chiara Hospital, U.O. Medicina d'Urgenza e Pronto Soccorso, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Francesca Frassi
- Emergency Department, Nuovo Santa Chiara Hospital, U.O. Medicina d'Urgenza e Pronto Soccorso, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Francesco Leoli
- Emergency Department, Nuovo Santa Chiara Hospital, U.O. Medicina d'Urgenza e Pronto Soccorso, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Valentina Lami
- Emergency Department, Nuovo Santa Chiara Hospital, U.O. Medicina d'Urgenza e Pronto Soccorso, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Lorenzo Ghiadoni
- Emergency Department, Nuovo Santa Chiara Hospital, U.O. Medicina d'Urgenza Universitaria, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Massimo Santini
- Emergency Department, Nuovo Santa Chiara Hospital, U.O. Medicina d'Urgenza e Pronto Soccorso, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
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Prisco D. A focus on direct oral anticoagulants: "old" and possible new indications and efforts for a better clinical management. Intern Emerg Med 2018; 13:985-988. [PMID: 30242604 DOI: 10.1007/s11739-018-1954-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 09/18/2018] [Indexed: 12/31/2022]
Affiliation(s)
- Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
- Interdisciplinary Internal Medicine, Careggi University Hospital, Florence, Italy.
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Imberti D, Becattini C, Bernardi E, Camporese G, Cuccia C, Dentali F, Paretti D. Multidisciplinary approach to the management of patients with pulmonary embolism and deep vein thrombosis: a consensus on diagnosis, traditional therapy and therapy with rivaroxaban. Intern Emerg Med 2018. [PMID: 29520700 DOI: 10.1007/s11739-018-1802-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Despite the availability of updated guidelines for the diagnosis and treatment of venous thromboembolism (VTE), the management of this disorder in clinical practice is often not standardized, given the different degree of compliance with official recommendations by the various involved specialists. The aim of this consensus paper, as a result of a board of experts in thromboembolism, is to define strategies to improve the quality of patients' care and the efficiency of healthcare resources utilization, by means of: (a) analysis of the guidelines for diagnosis and treatment of VTE; (b) analysis of diagnostic and therapeutic algorithms currently used in clinical practice by different specialists; (c) agreement on a common algorithm for diagnosis and treatment of VTE in different clinical settings; (d) definition of the possible role of the new oral anticoagulant agents (NOAC), such as rivaroxaban, based on their potential benefits for both acute and chronic therapy. The so-called "single drug approach" (as opposed to the traditional heparin/VKA combination), which can be adopted with these drugs, makes anticoagulation more convenient for both patients and healthcare providers, without the need for a close monitoring of the hemocoagulative status, and with a concomitant reduction of length of hospitalization and treatment costs. Among NOACs, in this paper we focused on rivaroxaban only because it was the unique available NOAC in Italy for the treatment of VTE at the time the manuscript was written. Concerning rivaroxaban, the results of two phase III, randomized and controlled trials confirm the non-inferiority of this drug compared to standard therapy (enoxaparin/warfarin) for the treatment of patients with pulmonary embolism (EINSTEIN PE Study) or deep vein thrombosis (EINSTEIN DVT Study) in terms of both efficacy and safety, supporting its use as an effective therapeutic option for these disorders.
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Affiliation(s)
- Davide Imberti
- Center for Haemostasis and Thrombosis, Hospital "G. da Saliceto" of Piacenza, Piacenza, Italy.
| | | | - Enrico Bernardi
- General Hospital of Conegliano and Vittorio Veneto, Vittorio Veneto, Italy
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Arioli D, Donelli D, Morini L, Leone MC, Negri EA. Drug plasma level measurement in management of severe bleeding during direct oral anticoagulant treatment: case report and perspective. Intern Emerg Med 2018; 13:1093-1096. [PMID: 29725952 DOI: 10.1007/s11739-018-1858-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 04/21/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Dimitriy Arioli
- Medicina II Cardiovascolare, Department of Internal Medicine, Arcispedale Santa Maria Nuova - IRCCS, Reggio Emilia, Italy
| | - Davide Donelli
- Alta Intensità Medica, Department of Internal Medicine, Arcispedale Santa Maria Nuova - IRCCS, Reggio Emilia, Italy.
- Laureando CdLM Medicina e Chirurgia, Università di Parma, Parma, Italy.
| | - Lorenzo Morini
- Alta Intensità Medica, Department of Internal Medicine, Arcispedale Santa Maria Nuova - IRCCS, Reggio Emilia, Italy
| | - Maria Cristina Leone
- Medicina II Cardiovascolare, Department of Internal Medicine, Arcispedale Santa Maria Nuova - IRCCS, Reggio Emilia, Italy
| | - Emanuele Alberto Negri
- Alta Intensità Medica, Department of Internal Medicine, Arcispedale Santa Maria Nuova - IRCCS, Reggio Emilia, Italy
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Sbrana F, Mannucci F, Airò E, Aquaro GD, Prediletto R. Cardiac tamponade due to apixaban therapy in patient with unknown pericardial hemangioma. Intern Emerg Med 2018; 13:297-299. [PMID: 28803417 DOI: 10.1007/s11739-017-1736-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 08/06/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Francesco Sbrana
- Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1, 56124, Pisa, Italy.
| | - Francesca Mannucci
- Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1, 56124, Pisa, Italy
| | - Edoardo Airò
- Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1, 56124, Pisa, Italy
| | | | - Renato Prediletto
- Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1, 56124, Pisa, Italy
- Institute of Clinical Physiology, National Research Council of Italy, Via Moruzzi 1, 56124, Pisa, Italy
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Raschi E, Diemberger I, Cosmi B, De Ponti F. ESC position paper on cardiovascular toxicity of cancer treatments: challenges and expectations. Intern Emerg Med 2018; 13:1-9. [PMID: 28942550 DOI: 10.1007/s11739-017-1755-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 09/16/2017] [Indexed: 12/19/2022]
Abstract
The recent position paper of the European Society of Cardiology (ESC) on cardiovascular toxicity of cancer treatments has attracted considerable interest by healthcare professionals, since it is the first concrete help in the difficult task of monitoring and approaching cardiovascular side effects of anticancer treatments. The ESC expert opinion was not intended as a clinical practice guideline; however, it reports major cardiovascular complications grouped into nine categories, addressing current clinical strategies for prevention and mitigation. In this point of view, we discuss key challenges emerging from critical appraisal of the ESC position paper: (1) the wide spectrum of cardiovascular toxicities associated with oncological drugs, focusing on targeted agents, (2) managing strategies in patients with cardiac implantable devices, (3) the underappreciated (but emerging) immune-related cardiovascular toxicities of checkpoint inhibitors, which may also result in severe heart failure and fulminant myocarditis, (4) the evolving role of anticoagulation in oncology, and the evidence supporting (or not) the use of direct-acting oral anticoagulants in cancer-associated thrombosis.
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Affiliation(s)
- Emanuel Raschi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio, 48, 40126, Bologna, BO, Italy
| | - Igor Diemberger
- Department of Specialist, Diagnostic and Experimental Medicine, Institute of Cardiology, S.Orsola-Malpighi University Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Benilde Cosmi
- Department of Specialist, Diagnostic and Experimental Medicine, Division of Angiology and Blood Coagulation, S.Orsola-Malpighi University Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Fabrizio De Ponti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio, 48, 40126, Bologna, BO, Italy.
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Sciascia S, Radin M, Schreiber K, Fenoglio R, Baldovino S, Roccatello D. Chronic kidney disease and anticoagulation: from vitamin K antagonists and heparins to direct oral anticoagulant agents. Intern Emerg Med 2017; 12:1101-1108. [PMID: 28929298 DOI: 10.1007/s11739-017-1753-2] [Citation(s) in RCA: 14] [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: 06/28/2017] [Accepted: 09/11/2017] [Indexed: 01/18/2023]
Abstract
Anticoagulation in patients with impaired kidney function can be challenging since drugs' pharmacokinetics and bioavailability are altered in this setting. Patients with chronic kidney disease (CKD) treated with conventional anticoagulant agents [vitamin K antagonist (VKA), low-molecular weight heparin (LMWH) or unfractionated heparin (UFH)] are at high risk of bleeding events (both non-major and major clinically relevant bleeding). While anticoagulation reduces the risk of thromboembolic events, the co-existing bleeding risk and the fact that the most commonly used anticoagulation agents are eliminated via the kidneys pose additional challenges. More recently, two classes of direct oral anticoagulant agents (DOACs) have been investigated for the prevention and management of venous thromboembolic events: the direct factor Xa inhibitors rivaroxaban, apixaban and edoxaban, and the direct thrombin inhibitor dabigatran. In this review, we discuss the complex challenges and the practical considerations associated with the management of anticoagulation treatment in patients with CKD, with a special focus on DOACs.
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Affiliation(s)
- Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy.
- Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital, University of Turin, Turin, Italy.
| | - Massimo Radin
- Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
| | - Karen Schreiber
- Centre for Thrombosis and Haemostasis, St. Thomas' Hospital, London, UK
- Department of Rheumatology, Copenhagen University Hospital at Rigshospitalet, Copenhagen, Denmark
| | - Roberta Fenoglio
- Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital, University of Turin, Turin, Italy
| | - Simone Baldovino
- Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
- Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital, University of Turin, Turin, Italy
| | - Dario Roccatello
- Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
- Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital, University of Turin, Turin, Italy
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Modesti PA, Donigaglia G, Fabiani P, Mumoli N, Colella A, Boddi M. The involvement of pharmacies in the screening of undiagnosed atrial fibrillation. Intern Emerg Med 2017; 12:1081-1086. [PMID: 28929326 DOI: 10.1007/s11739-017-1752-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 09/11/2017] [Indexed: 01/21/2023]
Abstract
Early identification of atrial fibrillation (AF) is now a priority in cardiovascular prevention because AF is common although often asymptomatic, and is associated with poor outcomes that are highly preventable with appropriate medical treatment. In Italy, AF prevalence among subjects aged ≥65 years ranges from 5 to 6% in observational studies based on the diagnosis recorded by general practitioners to 10-11% in studies where ECG screening is routinely offered. It is thus evident that a large number of subjects are not detected by conventional approach, and new strategies are required to increase early detection of AF. In particular, the changing position of pharmacies in the health system should be considered. Because of its small geographical size, insular nature and captive population, the Isle of Elba represents an ideal setting to test new strategies for stroke reduction. The Elba-FA project was thus designed to determine the feasibility and impact of the combined involvement of pharmacies and general practices to screen undiagnosed AF, with the ultimate aim of reducing the burden of stroke and arterial thromboembolism. The findings obtained with this approach might have broad implications for cardiovascular prevention at the general population level in Italy.
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Affiliation(s)
- Pietro Amedeo Modesti
- Dipartimento di Medicina Sperimentale e Clinica, Universita' degli Studi di Firenze, Largo Brambilla 3, 50134, Florence, Italy.
| | - Gianni Donigaglia
- Direttore di Zona Distretto Elba, ATNO, Portoferraio, Livorno, Italy
| | - Plinio Fabiani
- Unità Operativa di Medicina dell'Ospedale di Portoferraio, Livorno, Italy
| | - Nicola Mumoli
- Unità Operativa di Medicina dell'Ospedale di Portoferraio, Livorno, Italy
| | - Andrea Colella
- Dipartimento di Medicina Sperimentale e Clinica, Universita' degli Studi di Firenze, Largo Brambilla 3, 50134, Florence, Italy
| | - Maria Boddi
- Dipartimento di Medicina Sperimentale e Clinica, Universita' degli Studi di Firenze, Largo Brambilla 3, 50134, Florence, Italy
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Raschi E, Bianchin M, Fantoni C, Ageno W, De Ponti F, De Ponti R. Evolving cardiovascular uses of direct-acting oral anticoagulants: a paradigm shift on the horizon? Intern Emerg Med 2017; 12:923-934. [PMID: 28785902 DOI: 10.1007/s11739-017-1724-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 07/29/2017] [Indexed: 12/27/2022]
Abstract
Direct-acting oral anticoagulants (DOACs), by virtue of pharmacological properties perceived as innovative, are changing the therapeutic scenario of patients requiring short- and long-term anticoagulation. The evidence gathered so far (from pre-approval pivotal trials to real-world post-marketing observational data) consistently confirms that DOACs are overall comparable to vitamin-K antagonists (VKAs) in terms of safety, efficacy, effectiveness and unequivocally documents a clinically relevant reduced risk of intracranial bleeding in the settings of non-valvular atrial fibrillation (AF) and venous thromboembolism. The following issues are attracting considerable clinical interest: (a) identifying specific subpopulations of patients with AF most likely to benefit from one of these agents (the so-called tailored therapy), and (b) expanding therapeutic indications in emerging diseases characterized by arterial and venous thromboembolic risk. In these scenarios, the risk-benefit profile of DOACs, as compared to VKAs or heparins, is still incompletely characterized. In cardiology, the challenging task of selecting a suitable or even the most appropriate DOAC for patients with AF and a particular phenotype prompted experts to provide suggestions based on careful review of subgroups of patients from pivotal RCTs. However, in the past few months, variegated multicenter trials have been published (RE-CIRCUIT, PIONEER-AF-PCI, GEMINI-ACS-1), with potential influence on clinical practice. Therefore, this review aims to update the latest evidence on the evolving therapeutic uses of DOACs in the cardiovascular area, addressing potential impact for clinicians.
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Affiliation(s)
- Emanuel Raschi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio 48, 40126, Bologna, BO, Italy
| | - Matteo Bianchin
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio 48, 40126, Bologna, BO, Italy
| | - Cecilia Fantoni
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Fabrizio De Ponti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio 48, 40126, Bologna, BO, Italy.
| | - Roberto De Ponti
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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Moroni F, Masotti L, Vannucchi V, Chiarelli R, Seravalle C, Pesci A, Pallini F, Puliti S, Cimolato B, Fattorini L, Scerra C, Ristori F, Imbalzano ML, Spolveri S, Landini G, Grifoni E, Paciaroni M. Confidence in the Use of Direct Oral Anticoagulants in the Acute Phase of Nonvalvular Atrial Fibrillation-Related Ischemic Stroke Over the Years: A Real-World Single-Center Study. J Stroke Cerebrovasc Dis 2017; 27:76-82. [PMID: 28918086 DOI: 10.1016/j.jstrokecerebrovasdis.2017.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 07/27/2017] [Accepted: 08/03/2017] [Indexed: 10/18/2022] Open
Abstract
BACKGROUD AND AIM The use of direct oral anticoagulants (DOACs) in patients with nonvalvular atrial fibrillation (NVAF)-related acute ischemic stroke (AIS) is controversial. The aims of our study were to analyze physicians' confidence in prescribing DOACs in NVAF-related AIS, the characteristics of patients receiving DOACs, and their 90-day prognosis. MATERIAL AND METHODS Clinical records of consecutive patients admitted to our wards for NVAF-related AIS over the years 2014-2016 were reviewed. RESULTS One hundred forty-seven patients, 72.7% females, mean age ± standard deviation 83.4 ± 8.8 years, were admitted to our ward for atrial fibrillation (AF)-related AIS (38 in 2014, 47 in 2015, 62 in 2016). Of these patients, 141 had NVAF-related AIS. Median length of hospital stay was 8 days (interquartile range [IQR], 6-11). In-hospital mortality was 10.8%. Ninety-eight patients (69.5%) received DOACs for secondary prevention, with increasing percentages from 2014 (62.5%) to 2016 (88%). In 88% of them, DOACs were started during hospital stay, whereas in 12% DOACs were started during ambulatory follow-up. The median time for starting DOACs was 5 days (IQR, 3-8). In patients receiving DOACs, the median National Institutes of Health Stroke Scale score was 6 (IQR, 3-12), and large ischemic lesions were present in 48%; the median modified Rankin Scale score at hospital discharge was 3 (IQR, 1-4), whereas the score at 90 days was 2 (IQR, 1-3). At the 90-day follow-up, in patients receiving DOACs, overall mortality was 3.0%, stroke recurrence was 1%, and no patients had major intracranial or extracranial bleedings. CONCLUSION Our study suggests that physicians are becoming increasingly confident in the use of DOACs in NVAF-related AIS. The use of DOACs seems effective and safe even when started in the acute phase of stroke.
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Affiliation(s)
- Federico Moroni
- Internal Medicine and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy
| | - Luca Masotti
- Internal Medicine and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy; Internal Medicine, San Giuseppe Hospital, Empoli, Italy.
| | - Vieri Vannucchi
- Internal Medicine and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy
| | - Raffaella Chiarelli
- Internal Medicine and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy
| | - Cristiana Seravalle
- Internal Medicine and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy
| | - Alessandra Pesci
- Internal Medicine and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy
| | - Francesca Pallini
- Internal Medicine and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy
| | - Silvia Puliti
- Internal Medicine and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy
| | - Barbara Cimolato
- Internal Medicine and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy
| | - Lamberto Fattorini
- Internal Medicine and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy
| | - Cornelia Scerra
- Internal Medicine and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy
| | - Francesca Ristori
- Internal Medicine and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy
| | - Maria Letizia Imbalzano
- Internal Medicine and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy
| | | | - Giancarlo Landini
- Internal Medicine and Center of Thromboembolic Diseases, Santa Maria Nuova Hospital, Florence, Italy
| | - Elisa Grifoni
- Internal Medicine, San Giuseppe Hospital, Empoli, Italy
| | - Maurizio Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy
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Abstract
In the Hokusai-VTE trial, 733 patients were treated with the reduced dose edoxaban regimen, which maintained efficacy and safety compared with the 60 mg dose, and was safer than warfarin. The prophylactic doses of apixaban and rivaroxaban reduced the risk of recurrent venous thromboembolism (VTE) in the extended treatment trials. Dabigatran 110 mg was approved by the European Medicine Agency for VTE treatment. Further data from registries and real-world studies will help to clarify whether patients, with other specific characteristics, can benefit from the reduced dose of direct oral anticoagulants.
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Affiliation(s)
- Davide Imberti
- Internal Medicine Department, Piacenza Hospital, Haemostasis and Thrombosis Center, Piacenza, Italy
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Dentali F, Fantoni C. Is it reasonable to use a lower DOAC dose in some patients with VTE? NO. Intern Emerg Med 2017; 12:565-567. [PMID: 28656545 DOI: 10.1007/s11739-017-1695-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Accepted: 06/10/2017] [Indexed: 10/19/2022]
Abstract
The international guidelines recommend the use of direct oral anticoagulants (DOACs) over vitamin K antagonists for anticoagulation long-term therapy in patients diagnosed with venous thromboembolism (VTE), and for stroke prevention in patients with non-valvular atrial fibrillation (AF). Efficacy and safety of DOACS have been extensively evaluated in large phase III trials. According to the product label, dose reductions of DOACs are recommended for patients with AF and renal impairment, low body weight and concomitant use of interfering medications. Except for Edoxaban, dose reductions of DOACs are not recommended in patients with VTE based on the same indications for AF patients. The aim of this article is to discuss the indication of a lower DOAC dose in some patients with VTE. Observational studies and randomized control trials (RCTs) show that patients with AF are usually older, more often have chronic diseases, and more often are treated with several concomitant medications, potentially increasing their haemorrhagic risk. Furthermore, many VTE patients need a shorter period of anticoagulation therapy than AF patients. In real-life studies, VTE patients treated with inappropriate DOAC doses present a higher rate of VTE recurrence, and the same risk of bleeding compared to those treated with the correct dose. In light of this evidence, the use of lower DOAC dose in patients with VTE does not appear reasonable and may be potentially dangerous.
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Affiliation(s)
- Francesco Dentali
- Department of Clinical Medicine, University of Insubria - Ospedale di Circolo, Via Guicciardini 9, 21100, Varese, Italy.
| | - Chiara Fantoni
- Department of Clinical Medicine, University of Insubria - Ospedale di Circolo, Via Guicciardini 9, 21100, Varese, Italy
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