Intracranial hemorrhage and novel anticoagulants for atrial fibrillation: what have we learned?

Coagulation Tests and Reversal Agents in Patients Treated with Oral Anticoagulants: The Challenging Scenarios of Life-Threatening Bleeding and Unplanned Invasive Procedures

In clinical practice, the number of patients treated with direct oral anticoagulants (DOACs) has consistently increased over the years. Since anticoagulant therapy has been associated with an annual incidence of major bleeding (MB) events of approximately 2% to 3.5%, it is of paramount importance to understand how to manage anticoagulated patients with major or life-threatening bleeding. A considerable number of these patients' conditions necessitate hospitalization, and the administration of reversal agents may be imperative to manage and control bleeding episodes effectively. Importantly, effective strategies for reversing the anticoagulant effects of DOACs have been well recognized. Specifically, idarucizumab has obtained regulatory approval for the reversal of dabigatran, and andexanet alfa has recently been approved for reversing the effects of apixaban or rivaroxaban in patients experiencing life-threatening or uncontrolled bleeding events. Moreover, continuous endeavors are being made to develop supplementary reversal agents. In emergency scenarios where specific reversal agents might not be accessible, non-specific hemostatic agents such as prothrombin complex concentrate can be utilized to neutralize the anticoagulant effects of DOACs. However, it is paramount to emphasize that specific reversal agents, characterized by their efficacy and safety, should be the preferred choice when suitable. Moreover, it is worth noting that adherence to the guidelines for the reversal agents is poor, and there is a notable gap between international recommendations and actual clinical practices in this regard. This narrative review aims to provide physicians with a practical approach to managing specific reversal agents.

Can we collect health-related quality of life information from anticoagulated atrial fibrillation participants who have recently experienced a bleed? An observational feasibility study in primary and secondary care in Wales and through a UK online forum

OBJECTIVE

To evaluate the feasibility of recruiting participants diagnosed with atrial fibrillation (AF) taking oral anticoagulation therapies (OATs) and recently experiencing a bleed to collect health-related quality of life (HRQoL) information.

DESIGN

Observational feasibility study. The study aimed to determine the feasibility of recruiting participants with minor and major bleeds, the most appropriate route for recruitment and the appropriateness of the patient-reported outcome measures (PROMs) selected for collecting HRQoL information in AF patients, and the preferred format of the surveys.

SETTING

Primary care, secondary care and via an online patient forum.

PARTICIPANTS

The study population was adult patients (≥18) with AF taking OATs who had experienced a recent major or minor bleed within the last 4 weeks.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes - PROMs: EuroQol 5 Dimensions-5 Levels, Perception of Anticoagulant Treatment Questionnaire, part 2 only (part 2), atrial fibrillation effect on quality of life. Secondary outcomes - Location of bleed, bleed severity, current treatment, patient perceptions of HRQoL in relation to bleeding events.

RESULTS

We received initial expressions of interest from 103 participants. We subsequently recruited 32 participants to the study-14 from primary care and 18 through the AF forum. No participants were recruited through secondary care. Despite 32 participants consenting, only 26 initial surveys were completed. We received follow-up surveys from 11 participants (8 primary care and 3 AF forum). COVID-19 had a major impact on the study.

CONCLUSIONS

Primary care was the most successful route for recruitment. Most participants recruited to the study experienced a minor bleed. Further ways to recruit in secondary care should be explored, especially to capture more serious bleeds.

TRIAL REGISTRATION NUMBER

The study is registered in the Clinicaltrials.gov database, NCT04921176.

Meta-analysis comparing direct oral anticoagulants versus vitamin K antagonists in patients with left ventricular thrombus

Current American College of Cardiology/American Heart Association guidelines for stroke or ST-elevation myocardial infarction recommend the use of oral vitamin K antagonists (VKAs) as a first-line anticoagulant. Although several studies have compared the use of direct oral anticoagulants (DOACs) to VKAs for left ventricular thrombus (LVT) anticoagulation therapy, they are small scale and have produced conflicting results. Thus, this meta-analysis was performed to aggregate these studies to better compare the efficacy and safety of DOACs with VKAs in patients with LVT. Cochrane Library, Google Scholar, MEDLINE, and Web of Science database searches through January 10, 2021 were performed. Eight studies evaluating stroke or systemic embolism (SSE), six studies for LVT resolution, and five studies for bleeding were included. There were no statistically significant differences in SSE (OR 0.89; 95% CI 0.46, 1.71; p = 0.73; I² = 45%) and LVT resolution (OR 1.13; 95% CI 0.75, 1.71; p = 0.56; I² = 1%) between DOAC and VKA (reference group) therapy. DOAC use was significantly associated with lower bleeding event rates compared to VKA use (OR 0.61; 95% CI 0.40, 0.93; p = 0.02; I² = 0%). DOACs may be feasible alternative anticoagulants to vitamin K antagonists for LV thrombus treatment. Randomized controlled trials directly comparing DOACs with VKAs are needed.

Oral anticoagulant therapy and outcome in patients with stroke. A retrospective nation-wide cohort study in Austria 2012-2017

Purpose

Patients with stroke are at high risk of recurrence of vascular events. Non‐vitamin K oral anticoagulant (NOAC) and vitamin K antagonists (VKA) are used as secondary prophylaxis. The aim of this study was to evaluate the utilization of NOAC and VKA, and their impact on re‐stroke or death in Austria.

Methods

We analyzed retrospective data between 2012 and 2017 from medical services covered by the health insurance funds, which provides health care for all residents in Austria. Patients without anticoagulant medication 3 months preceding the index event were eligible.

Results

76 354 patients were discharged with a hospital diagnosis of stroke. From these, 16 436 patients with a median age of 78 years received VKA or NOAC. After adjustment, the recurrence of stroke was less frequent in patients with NOAC compared to those with VKA (HR 0.87; 95%CI 0.77–0.97). However, there was no difference in mortality rate after adjustment for age, sex, and co‐morbidities for patients with NOAC (HR 1.0; 95%CI 0.92–1.08). Diabetes (HR 1.25, 95%CI 1.08–1.45; HR 1.25, 95% CI 1.13–1.38) and cardiovascular disease (HR 1.43, 95%CI 1.24–1.65; HR 1.27, 95%CI 1.16–1.39) were significantly associated with re‐stroke or death. Younger age (p = 0.0028; HR 0.99, 95%CI 0.99–0.99) was significantly associated with re‐stroke, and advanced age (p < 0.0001; HR 1.09, 95%CI 1.08–1.09) with death.

Conclusion

NOAC prescription is related with a reduced risk of re‐stroke but increased mortality compared to patients with VKA. The event risk is associated with diabetes, cardiovascular disease and age.

How do you manage ANTICOagulant therapy in neurosurgery? The ANTICO survey of the Italian Society of Neurosurgery (SINCH)

BACKGROUND

Anticoagulant assumption is a concern in neurosurgical patient that implies a delicate balance between the risk of thromboembolism versus the risk of peri- and postoperative hemorrhage.

METHODS

We performed a survey among 129 different neurosurgical departments in Italy to evaluate practice patterns regarding the management of neurosurgical patients taking anticoagulant drugs. Furthermore, we reviewed the available literature, with the aim of providing a comprehensive but practical summary of current recommendations.

RESULTS

Our survey revealed that there is a lack of knowledge, mostly regarding the indication and the strategies of anticoagulant reversal in neurosurgical clinical practice. This may be due a lack of national and international guidelines for the care of anticoagulated neurosurgical patients, along with the fact that coagulation and hemostasis are not simple topics for a neurosurgeon.

CONCLUSIONS

To overcome this issue, establishment of hospital-wide policy concerning management of anticoagulated patients and developed in an interdisciplinary manner are strongly recommended.

Restarting Oral Anticoagulation in Patients With Atrial Fibrillation After an Intracranial Hemorrhage

Atrial fibrillation is the most common sustained cardiac arrhythmia in the general population. In western countries with aging populations, atrial fibrillation poses a significant health concern, as it is associated with a high risk of thromboembolism, stroke, congestive heart failure, and myocardial infarction. Thrombi are generated in the left atrial appendage, and subsequent embolism into the cerebral circulation is a major cause of ischemic stroke. Therefore, patients have a lifetime risk of stroke, and those at high risk, defined as a CHA2DS2-VASc2 (congestive heart failure, hypertension, age >75 years, diabetes mellitus, stroke/transient ischemic attack/thromboembolism, vascular disease, age 65-74 yrs, sex category) ≥2, are usually placed on oral anticoagulants. Unfortunately, long-term anticoagulation poses bleeding risks, of which intracranial hemorrhage (ICH) is the most feared and deadly complication.In patients who survive an ICH, the question of oral anticoagulation resumption arises. It is a therapeutic dilemma in which clinicians must decide how to manage the risk of thromboembolism versus recurrent hemorrhage. Although there is a substantial amount of retrospective data on the topic of resumption of anticoagulation, there are, at this time, no randomized controlled trials addressing the issue. We therefore sought to address ICH risk and management, summarize high quality existing evidence on restarting oral anticoagulation, and suggest an approach to clinical decision-making.

Hemorrhagic stroke

Hemorrhagic stroke comprises about 20% of all strokes, with intracerebral hemorrhage (ICH) being the most common type. Frequency of ICH is increased where hypertension is untreated. ICH in particularly has a disproportionately high risk of early mortality and long-term disability. Until recently, there has been a paucity of randomized controlled trials (RCTs) to provide evidence for the efficacy of various commonly considered interventions in ICH, including acute blood pressure management, coagulopathy reversal, and surgical hematoma evacuation. Evidence-based guidelines do exist for ICH and these form the basis for a framework of care. Current approaches emphasize control of extremely high blood pressure in the acute phase, rapid reversal of vitamin K antagonists, and surgical evacuation of cerebellar hemorrhage. Lingering questions, many of which are the topic of ongoing clinical research, include optimizing individual blood pressure targets, reversal strategies for newer anticoagulant medications, and the role of minimally invasive surgery. Risk stratification models exist, which derive from findings on clinical exam and neuroimaging, but care should be taken to avoid a self-fulfilling prophecy of poor outcome from limiting treatment due to a presumed poor prognosis. Cerebral venous thrombosis is an additional subtype of hemorrhagic stroke that has a unique set of causes, natural history, and treatment and is discussed as well.

Re-initiation of anticoagulation after central nervous system hemorrhage during treatment with direct oral anticoagulants: a single hospital cohort study

BACKGROUND

Central nervous system (CNS) hemorrhage is a serious complication related to direct oral anticoagulant (DOAC) therapy. Current recommendations about re-initiation of anticoagulation treatment are limited to expert opinions. For this purpose, we analyzed the data of all consecutive DOAC patients with CNS hemorrhage, in whom DOACs were reinitiated.

METHODS

Over a 6-year period (2012-2018), all consecutive patients with CNS hemorrhage (subdural, subarachnoid, intracerebral, spinal), while receiving DOACs, were included in this observational single-center cohort study. DOAC therapy was reinitiated only in patients with well-controlled arterial hypertension and diabetes, as well as exclusion of vascular malformations and cerebral amyloid angiopathy. The composite primary endpoint comprised of recurrent CNS hemorrhage, ischemic stroke, and mortality; secondary endpoints were separate aforementioned outcomes.

RESULTS

Of the 54 patients included, 18 died within a month of CNS hemorrhage. The average observational time was 590 days. DOACs were reinitiated in 13/36 patients (36%); of these patients, three died: none due to ischemic stroke or recurrent CNS bleeding. In 23 patients, anticoagulation was not reinitiated; of these patients, 10 died: three from recurrent CNS hemorrhage, one due to ischemic stroke, and six from causes unrelated to stroke.

CONCLUSIONS

In carefully selected patients, re-initiation of DOAC therapy did not increase the rate of both endpoints. Recommendations for DOAC re-initiation, which include hypertension and diabetes control, as well as treated vascular malformations, and excluded cerebral amyloid angiopathy, appear to be valid in clinical practice.

The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation

The current manuscript is the second update of the original Practical Guide, published in 2013 [Heidbuchel et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace 2013;15:625-651; Heidbuchel et al. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015;17:1467-1507]. Non-vitamin K antagonist oral anticoagulants (NOACs) are an alternative for vitamin K antagonists (VKAs) to prevent stroke in patients with atrial fibrillation (AF) and have emerged as the preferred choice, particularly in patients newly started on anticoagulation. Both physicians and patients are becoming more accustomed to the use of these drugs in clinical practice. However, many unresolved questions on how to optimally use these agents in specific clinical situations remain. The European Heart Rhythm Association (EHRA) set out to coordinate a unified way of informing physicians on the use of the different NOACs. A writing group identified 20 topics of concrete clinical scenarios for which practical answers were formulated, based on available evidence. The 20 topics are as follows i.e., (1) Eligibility for NOACs; (2) Practical start-up and follow-up scheme for patients on NOACs; (3) Ensuring adherence to prescribed oral anticoagulant intake; (4) Switching between anticoagulant regimens; (5) Pharmacokinetics and drug-drug interactions of NOACs; (6) NOACs in patients with chronic kidney or advanced liver disease; (7) How to measure the anticoagulant effect of NOACs; (8) NOAC plasma level measurement: rare indications, precautions, and potential pitfalls; (9) How to deal with dosing errors; (10) What to do if there is a (suspected) overdose without bleeding, or a clotting test is indicating a potential risk of bleeding; (11) Management of bleeding under NOAC therapy; (12) Patients undergoing a planned invasive procedure, surgery or ablation; (13) Patients requiring an urgent surgical intervention; (14) Patients with AF and coronary artery disease; (15) Avoiding confusion with NOAC dosing across indications; (16) Cardioversion in a NOAC-treated patient; (17) AF patients presenting with acute stroke while on NOACs; (18) NOACs in special situations; (19) Anticoagulation in AF patients with a malignancy; and (20) Optimizing dose adjustments of VKA. Additional information and downloads of the text and anticoagulation cards in different languages can be found on an EHRA website (www.NOACforAF.eu).

Treatment Approaches to Lacunar Stroke

Lacunar strokes are appropriately named for their ability to cavitate and form ponds or "little lakes" (Latin: lacune -ae meaning pond or pit is a diminutive form of lacus meaning lake). They account for a substantial proportion of both symptomatic and asymptomatic ischemic strokes. In recent years, there have been several advances in the management of large vessel occlusions. New therapies such as non-vitamin K antagonist oral anticoagulants and left atrial appendage closure have recently been developed to improve stroke prevention in atrial fibrillation; however, the treatment of small vessel disease-related strokes lags frustratingly behind. Since Fisher characterized the lacunar syndromes and associated infarcts in the late 1960s, there have been no therapies specifically targeting lacunar stroke. Unfortunately, many therapeutic agents used for the treatment of ischemic stroke in general offer only a modest benefit in reducing recurrent stroke while adding to the risk of intracerebral hemorrhage and systemic bleeding. Escalation of antithrombotic treatments beyond standard single antiplatelet agents has not been effective in long-term lacunar stroke prevention efforts, unequivocally increasing intracerebral hemorrhage risk without providing a significant benefit. In this review, we critically review the available treatments for lacunar stroke based on evidence from clinical trials. For several of the major drugs, we summarize the adverse effects in the context of this unique patient population. We also discuss the role of neuroprotective therapies and neural repair strategies as they may relate to recovery from lacunar stroke.

A proposed amendment to the current guidelines for mild traumatic brain injury: reducing computerized tomographies while maintaining safety

PURPOSE

Head trauma is a common complaint in emergency departments. Identifying patients with serious injuries can be difficult and generates many computerized tomographies. Reducing the number of computerized tomographies decreases both cost and radiation exposure. The aim of this study was to evaluate whether the current Scandinavian Neurotrauma Committee guidelines could be revised in such a way that would enable hospitals to perform fewer computerized tomographies while maintaining the ability to identify all patients requiring neurological intervention.

METHODS

A retrospective study of the medical records of adult patients suffering a traumatic brain injury was performed. A total of 1671 patients over a period of 365 days were included, and 25 parameters were extracted. Multitrauma patients managed with ATLS™ were excluded. The Scandinavian Neurotrauma Committee guidelines were amended with the previously derived "low-risk proposal" and applied retrospectively to the cohort.

RESULTS

Incidence of intracranial hemorrhage was 5.6% (93/1671). Application of the current Scandinavian Neurotrauma Committee guidelines would have resulted in 860 computerized tomographies and would have missed 11 intracranial hemorrhages. The proposed amendment with the low-risk proposal would have resulted in 748 CT scans and would have missed 19 intracranial hemorrhages (a relative reduction of 13%). None of the missed intracranial hemorrhages required neurological intervention.

CONCLUSION

For patients with mild and moderate traumatic brain injuries, application of the Scandinavian Neurotrauma Committee guidelines amended with the low-risk proposal may result in a significant reduction of computerized tomographies without missing any patients in need of neurological intervention.

Bleeding risk assessment for stroke patients on antithrombotic therapy

INTRODUCTION

After an ischemic cerebrovascular event the risk of new ischemic events is high, therefore antithrombotic therapy are indicated to prevent stroke recurrence.

DISCUSSION

Despite its clear benefit, these therapies increase the risk of bleeding. Therefore, it is essential to identify high hemorrhagic risk patients. There are different predictive models of hemorrhage, in particular of intracranial hemorrhage, associated with the use of antiaggregants in patients who have presented an ischemic stroke or TIA, such as the CCSC, intracranial scales -B2LEED3S score or S2TOP-BLEED. However, though main international guidelines recommend the use of scales, in particular, the HAS-BLED score, to assess the risk of bleeding in anticoagulated patients, there is no specific recommendation in the case of the use of antiplatelet drugs.

CONCLUSIONS

In this review we present the main models currently available for the prediction of bleeding of antithrombotic therapy in patients who have had a stroke or TIA.

Postoperative hemorrhage after right upper lobectomy associated with apixaban use: a case report

A 76-year-old Japanese man underwent right upper lung lobectomy for lung cancer. He had a medical history of atrial fibrillation and myocardial infarction, and was treated with medications including apixaban (5 mg twice daily). His postoperative course was uneventful, and he left the hospital on the ninth day postoperatively. Apixaban was restarted on postoperative day (POD) 10. On POD18, he was evaluated as an outpatient. He complained of fatigue, and his hemoglobin level decreased from 13.5 to 8.5 mg/dL. Chest plain radiography showed massive fluid in the right thoracic cavity. His condition was thought to be a postoperative bleeding complication due to apixaban; thus, we stopped apixaban and performed red blood cell transfusion and thoracic drainage. Postoperative hemorrhage associated with apixaban use is rare.

Hematoma Expansion Following Intracerebral Hemorrhage: Mechanisms Targeting the Coagulation Cascade and Platelet Activation

Hematoma expansion (HE), defined as a greater than 33% increase in intracerebral hemorrhage (ICH) volume within the first 24 hours, results in significant neurological deficits, and enhancement of ICH-induced primary and secondary brain injury. An escalation in the use of oral anticoagulants has led to a surge in the incidences of oral anticoagulation-associated ICH (OAT-ICH), which has been associated with a greater risk for HE and worse functional outcomes following ICH. The oral anticoagulants in use include vitamin K antagonists, and direct thrombin and factor Xa inhibitors. Fibrinolytic agents are also frequently administered. These all act via differing mechanisms and thus have varying degrees of impact on HE and ICH outcome. Additionally, antiplatelet medications have also been increasingly prescribed, and result in increased bleeding risks and worse outcomes after ICH. Aspirin, thienopyridines, and GPIIb/IIIa receptor blockers are some of the most common agents in use clinically, and also have different effects on ICH and hemorrhage growth, based on their mechanisms of action. Recent studies have found that reduced platelet activity may be more effective in predicting ICH risk, hemorrhage expansion, and outcomes, than antiplatelet agents, and activating platelets may thus be a novel target for ICH therapy. This review explores how dysfunctions or alterations in the coagulation and platelet cascades can lead to, and/or exacerbate, hematoma expansion following intracerebral hemorrhage, and describe the mechanisms behind these effects and the drugs that induce them. We also discuss potential future therapy aimed at increasing platelet activity after ICH.

Thromboembolism and Mortality in the Tasmanian Atrial Fibrillation Study

BACKGROUND

Although utilization of anticoagulation in patients with atrial fibrillation (AF) has increased in recent years, contemporary data regarding thromboembolism and mortality incidence rates are limited outside of clinical trials. This study aimed to investigate the impact of the direct oral anticoagulants (DOACs) on the clinical outcomes of patients with AF included in the Tasmanian Atrial Fibrillation Study.

METHODS

The medical records of all patients with a primary or secondary diagnosis of AF who presented to public hospitals in Tasmania, Australia, between 2011 and 2015, were retrospectively reviewed. We investigated overall thromboembolic events (TEs), ischemic stroke/transient ischemic attack (IS/TIA), and mortality incidence rates in patients admitted to the Royal Hobart Hospital, the main teaching hospital in the state. We compared outcomes in 2 time periods: prior to the availability of DOACs (pre-DOAC; 2011 to mid-2013) and following their general availability after government subsidization (post-DOAC; mid-2013 to 2015).

RESULTS

Of the 2390 patients with AF admitted during the overall study period, 942 patients newly prescribed an antithrombotic medication (465 and 477 from the pre-DOAC and post-DOAC time periods, respectively) were followed. We observed a significant decrease in the incidence rates of overall TE (3.2 vs 1.7 per 100 patient-years [PY]; P < .001) and IS/TIA (2.1 vs 1.3 per 100 PY; P = .022) in the post-DOAC compared to the pre-DOAC period. All-cause mortality was significantly lower in the post-DOAC period (2.9 vs 2.2 per 100 PY, P = .028). Increasing age, prior stroke, and admission in the pre-DOAC era were all risk factors for TE, IS/TIA, and mortality in this study population. The risk of IS/TIA was more than doubled (hazard ratio: 2.54; 95% confidence interval: 1.17-5.52) in current smokers compared to ex- and nonsmokers.

CONCLUSION

Thromboembolic event and all-cause mortality rates were lower following the widespread availability of DOACs in this population.

Early Outcome after Intracranial Hemorrhage Related to Non-Vitamin K Oral Anticoagulants

BACKGROUND

Intracranial hemorrhage (ICH) is a serious, life-threatening, but fortunately rare complication of non-vitamin K oral anticoagulant (NOAC) therapy. There are limited data on NOAC-related ICH prognosis.

METHODS

All consecutive patients admitted to a single center due to acute NOAC-related ICH from September 2012 until the beginning of 2017 were included. Risk factors, type of NOAC, and location of ICH were evaluated. Risk for ischemic and bleeding events and clinical status upon admission and at discharge were evaluated using standard scales.

RESULTS

Thirty-four patients aged 77.8 ± 8.3 years with NOAC-related ICH were included. The main predisposing risk factors were age and arterial hypertension. The median CHA2DS2-VASc score was 3.4 and the median HAS-BLED score was 1.8. Eighteen patients were treated with rivaroxaban, 11 with dabigatran, and 5 with apixaban. Ten patients (29%) had a favorable outcome with a modified Rankin Scale score ≤2 and 13 patients (38%) died. The location of the ICH was mainly intraparenchymal and subdural.

CONCLUSIONS

Our retrospective single-center study shows that the mortality rate with NOAC-related ICH is <40%, which makes it comparable to that with vitamin K antagonist-related ICH.

Readmissions in Patients with Anticoagulated Intracranial Hemorrhage: A Retrospective Review

OBJECTIVE

To determine the effect of direct oral anticoagulants (DOACs) compared with warfarin on the 30-day readmission rates in patients with traumatic intracranial hemorrhage (ICH).

METHODS

We conducted a retrospective review of patients from our hospital's trauma database admitted between June 2011 and October 2015 to our level II trauma center after sustaining a traumatic ICH while receiving anticoagulant therapy. Patients were stratified based on the anticoagulation drug (DOAC or warfarin) prescribed on admission. The readmission rates between the 2 groups were compared using χ² analysis and multivariate logistic regression. Patients who died during their initial admission were excluded.

RESULTS

Over the 4-year period, 160 patients were admitted with traumatic ICH. Seventy-nine were receiving warfarin and 57 were receiving a DOAC at admission. Data collected included age, sex, injury severity score, admission Glasgow Coma Score, Abbreviated Injury Scale (head), mechanism of injury, hospital and intensive care unit lengths of stay, discharge destination (eg, home, rehabilitation facility, nursing facility), comorbidities, operative interventions, readmissions, and reasons for the readmissions. The rate of readmission for rebleeding of ICH was significantly lower in the DOAC group compared with the warfarin group (5.3% vs. 17.7%; P = 0.04). Multivariate logistic regression suggests that warfarin use, but not DOAC use, is associated with increased readmission both for all causes and for ICH rebleeding.

CONCLUSIONS

Warfarin use is associated with higher readmission rates in patients with intracranial bleeding for both all-cause readmissions and for intracranial rebleeding.

Analysis of Recurrent Stroke Volume and Prognosis between Warfarin and Four Non-Vitamin K Antagonist Oral Anticoagulants' Administration for Secondary Prevention of Stroke

OBJECTIVE

We investigated recurrent stroke volume with nonvalvular atrial fibrillation (NVAF) patients treated with non-vitamin K antagonist oral anticoagulants (NOACs) about clinical backgrounds and number of recurrent stroke.

METHODS

We administered 4 NOACs, dabigatran, rivaroxaban, apixaban, and edoxaban in 101 postcardioembolic strokes with NVAF. In a retrospective study, we measured recurrent stroke volume with magnetic resonance imaging volumetric software and compared them between 10 vitamin K anticoagulant (VKA: warfarin) cases and 13 NOAC cases under anticoagulant therapy.

RESULTS

Of 101 cases, 31 were started with a VKA and switched to NOACs after 10 recurrent strokes. Other 70 cases were directly started with NOACs and 13 cases with NOACs as first anticoagulants had recurrent stroke. The frequency of recurrent stroke during anticoagulant therapy is not different between the VKA group and the 3 NOACs group. Recurrent stroke volume is significantly larger in the VKA group (26.4 cm³) than in the NOACs group (1.2 cm³).

CONCLUSIONS

Secondary prevention with NOACs after stroke might be more beneficial than a VKA by reducing recurrent infarct volume.

Direct oral anticoagulant- vs vitamin K antagonist-related nontraumatic intracerebral hemorrhage

OBJECTIVE

To compare the neuroimaging profile and clinical outcomes among patients with intracerebral hemorrhage (ICH) related to use of vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) for nonvalvular atrial fibrillation (NVAF).

METHODS

We evaluated consecutive patients with NVAF with nontraumatic, anticoagulant-related ICH admitted at 13 tertiary stroke care centers over a 12-month period. We also performed a systematic review and meta-analysis of eligible observational studies reporting baseline characteristics and outcomes among patients with VKA- or DOAC-related ICH.

RESULTS

We prospectively evaluated 161 patients with anticoagulation-related ICH (mean age 75.6 ± 9.8 years, 57.8% men, median admission NIH Stroke Scale [NIHSS_adm] score 13 points, interquartile range 6-21). DOAC-related (n = 47) and VKA-related (n = 114) ICH did not differ in demographics, vascular risk factors, HAS-BLED and CHA₂DS₂-VASc scores, and antiplatelet pretreatment except for a higher prevalence of chronic kidney disease in VKA-related ICH. Patients with DOAC-related ICH had lower median NIHSS_adm scores (8 [3-14] vs 15 [7-25] points, p = 0.003), median baseline hematoma volume (12.8 [4-40] vs 24.3 [11-58.8] cm³, p = 0.007), and median ICH score (1 [0-2] vs 2 [1-3] points, p = 0.049). Severe ICH (>2 points) was less prevalent in DOAC-related ICH (17.0% vs 36.8%, p = 0.013). In multivariable analyses, DOAC-related ICH was independently associated with lower baseline hematoma volume (p = 0.006), lower NIHSS_adm scores (p = 0.022), and lower likelihood of severe ICH (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.13-0.87, p = 0.025). In meta-analysis of eligible studies, DOAC-related ICH was associated with lower baseline hematoma volumes on admission CT (standardized mean difference = -0.57, 95% CI -1.02 to -0.12, p = 0.010) and lower in-hospital mortality rates (OR = 0.44, 95% CI 0.21-0.91, p = 0.030).

CONCLUSIONS

DOAC-related ICH is associated with smaller baseline hematoma volume and lesser neurologic deficit at hospital admission compared to VKA-related ICH.

Compared to warfarin, direct oral anticoagulants are associated with lower mortality in patients with blunt traumatic intracranial hemorrhage: A TQIP study

BACKGROUND

Falls represent the leading cause of traumatic brain injury in adults older than 65, with nearly one third experiencing a fall each year. Evidence suggests that up to 0.5% of anticoagulated patients suffer from intracranial hemorrhage (ICH) annually. Direct oral anticoagulants (DOACs) have become an increasingly popular alternative to warfarin for anticoagulation; however, there is a dearth of research regarding the safety of DOACs, in particular on the outcome of traumatic ICH while taking DOACs.

METHODS

We queried our Trauma Quality Improvement Project registry for patients who presented with traumatic intracranial hemorrhage during anticoagulant use. Patients were grouped into those prescribed warfarin and patients prescribed DOAC medications. The groups were compared with respect to age, gender, Glasgow Coma Score (GCS) on arrival, Abbreviated Injury Scale (AIS) (head), Injury Severity Score (ISS), mortality, need for operative intervention, hospital and ICU lengths of stay, proportion of patients transfused (and their transfusion requirements), and rates of discharge to skilled nursing facility. Poisson regression was conducted to determine the relationship between mortality and treatment group while controlling for covariates (comorbidities, ISS).

RESULTS

There were no differences between DOAC and warfarin groups in terms of age, gender, median ISS, median AIS head, or median admission GCS. Mechanisms of injury, median hospital and ICU lengths of stay, ICU free days, and transfusion requirements were also not significantly different.DOAC use was associated with significantly lower mortality (4.9% vs. 20.8%; p < 0.008) and a lower rate of operative intervention (8.2% vs. 26.7%; p = 0.023) when compared with warfarin. Excluding patients who died, the observed rate of discharge to skilled nursing facility was lower in the DOAC group (28.8% compared with 39.7%; p = 0.03). Multivariate Poisson regression analysis demonstrated that warfarin use was associated with an increased mortality when controlling for injury severity, and comorbidities.

CONCLUSIONS

We report improved mortality and reduced rates of operative intervention in patients with traumatic ICH associated with DOACs compared with a similar group taking warfarin. We also noted an association with decreased rate of discharge to SNF in patients taking DOACs compared with warfarin.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Intracerebral Hemorrhagic Expansion Occurs in Patients Using Non-Vitamin K Antagonist Oral Anticoagulants Comparable with Patients Using Warfarin

BACKGROUND

Non-vitamin K antagonist oral anticoagulant (NOAC) use has significantly reduced intracerebral hemorrhagic (ICH) risk compared with standard anticoagulant treatment. Hematoma expansion (HE) is a known predictor of mortality in warfarin-associated ICH. Little is known about HE in patients using NOACs.

METHODS

We conducted a retrospective chart review of patients with ICH admitted to Cedars-Sinai Medical Center from October 2010 to June 2016. We identified patients with concomitant administration of an oral anticoagulant and collected data including evidence of HE on imaging and modified Rankin Scale (mRS) at discharge. We defined HE as relative (≥33% increase) or absolute expansion (≥12 mL). We compared outcomes of patients with and without HE.

RESULTS

Out of 814 patients with ICH who were admitted, we identified 9 patients with recent NOAC use and 18 intentionally matched controls on warfarin. We found no significant differences in National Institutes of Health Stroke Scale or ICH score on presentation (median [interquartile range] 15 [5,21] versus 7 [1.25,19.5] [P = .41] and 2 [1,4] versus 1 [1,3] [P = .33]) between patients on NOACs and those on warfarin. Four out of the 9 patients on NOAC and 5 of the 18 patients on warfarin demonstrated HE, with no significant difference (P = .42). There were no significant differences in mRS on discharge between groups (P = .52).

CONCLUSIONS

In our coagulopathic NOAC patient population, HE occurs within 6 hours in 44% of patients. This case series did not have sufficient statistical power to detect significant differences between the groups. To our knowledge, this is one of the largest case series reporting on HE with concomitant NOAC use.

Outcomes of Geriatric Trauma Patients on Preinjury Anticoagulation: A Multicenter Study

Outpatient anticoagulation in the geriatric trauma patient is a challenging clinical problem. The aim of this study is to determine clinical outcomes associated with class of preinjury anticoagulants (PA) used by this population. This is a multicenter retrospective cohort study among four Level II trauma centers. A total of 1642 patients were evaluated; 684 patients were on anticoagulation and 958 patients were not. Patients on PA were compared with those who were not. Drug classes were divided into thromboxane A2 inhibitors, vitamin K factor-dependent inhibitors, antithrombin III activation, platelet P2Y12 inhibitors, and thrombin inhibitors. Multivariate regression was used to adjust for age, gender, race, mechanism of injury, and Injury Severity Score. No single or combination of anticoagulation agents had a significant association with mortality; however, there were positive trends toward increased mortality were noted for all antiplatelet groups involving thromboxane A2 inhibitors and platelet P2Y12 inhibitors classes. The likelihood of complications was significantly higher with platelet P2Y12 inhibitors adjusted odds ratio (aOR) 2.39 [95% confidence interval (CI) 1.32, 4.3]. The likelihood of blood transfusion was increased with vitamin K inhibitors aOR 2.89 (95% CI 1.3, 6.5), P2Y12 inhibitors aOR 2.76 (95% CI 1.12, 6.76), and combined thromboxane A2 and P2Y12 inhibitors aOR 2.89 (95% CI 1.13, 7.46). P2Y12 inhibitors were also more likely associated with traumatic brain injury aOR 2.16 (95% CI 1.01, 4.6). All classes of PA were associated with solid organ injury. There were no significant differences in the use of antiplatelet agents between patients with major indications for PA and those without major indications. Geriatric trauma patients on outpatient anticoagulants have a higher likelihood of developing complications, packed red blood cell transfusions, traumatic brain injury, and solid organ injury. Attention should be paid to patients on platelet P2Y12 inhibitors, vitamin K inhibitors, and thromboxane A2 inhibitor agents combined with platelet P2Y12 inhibitors. Opportunities exist to address the use of antiplatelet agents among patients without major indications to improve patient outcomes.

Outcome of intracerebral hemorrhage associated with different oral anticoagulants

Objective:

In an international collaborative multicenter pooled analysis, we compared mortality, functional outcome, intracerebral hemorrhage (ICH) volume, and hematoma expansion (HE) between non–vitamin K antagonist oral anticoagulation–related ICH (NOAC-ICH) and vitamin K antagonist–associated ICH (VKA-ICH).

Methods:

We compared all-cause mortality within 90 days for NOAC-ICH and VKA-ICH using a Cox proportional hazards model adjusted for age; sex; baseline Glasgow Coma Scale score, ICH location, and log volume; intraventricular hemorrhage volume; and intracranial surgery. We addressed heterogeneity using a shared frailty term. Good functional outcome was defined as discharge modified Rankin Scale score ≤2 and investigated in multivariable logistic regression. ICH volume was measured by ABC/2 or a semiautomated planimetric method. HE was defined as an ICH volume increase >33% or >6 mL from baseline within 72 hours.

Results:

We included 500 patients (97 NOAC-ICH and 403 VKA-ICH). Median baseline ICH volume was 14.4 mL (interquartile range [IQR] 3.6–38.4) for NOAC-ICH vs 10.6 mL (IQR 4.0–27.9) for VKA-ICH (p = 0.78). We did not find any difference between NOAC-ICH and VKA-ICH for all-cause mortality within 90 days (33% for NOAC-ICH vs 31% for VKA-ICH [p = 0.64]; adjusted Cox hazard ratio (for NOAC-ICH vs VKA-ICH) 0.93 [95% confidence interval (CI) 0.52–1.64] [p = 0.79]), the rate of HE (NOAC-ICH n = 29/48 [40%] vs VKA-ICH n = 93/140 [34%] [p = 0.45]), or functional outcome at hospital discharge (NOAC-ICH vs VKA-ICH odds ratio 0.47; 95% CI 0.18–1.19 [p = 0.11]).

Conclusions:

In our international collaborative multicenter pooled analysis, baseline ICH volume, hematoma expansion, 90-day mortality, and functional outcome were similar following NOAC-ICH and VKA-ICH.

Decision-making about the use of non-vitamin K oral anticoagulant therapies for patients with atrial fibrillation

Until recently, vitamin K antagonists, warfarin being the most commonly used agent in the United States, have been the only oral anticoagulant therapies available to prevent stroke in patients with atrial fibrillation (AF). In the last 5 years four new, non-vitamin K oral anticoagulants, the so-called NOACs or novel oral anticoagulants, have come to market and been approved by the Federal Drug Administration. Despite comparable if not superior efficacy in preventing AF-related stroke, and generally lower risks of major hemorrhage, particularly intracranial bleeding, the uptake of these agents has been slow. A number of barriers stand in the way of the more widespread use of these novel agents. Chief among them is concern about the lack of antidotes or reversal agents. Other concerns include the need for strict medication adherence, since missing even a single dose can lead to a non-anticoagulated state; out-of-pocket costs for patients; the lack of easily available laboratory tests to quantitatively assess the level of anticoagulant activity when these agents are being used; contraindications to use in patients with severe chronic kidney disease; and black-box warnings about the increased risk of thromboembolic events if these agents are discontinued prematurely. Fortunately, a number of reversal agents are in the pipeline. Three reversal agents, idarucizumab, andexanet alfa, and aripazine, have already progressed to human studies and show great promise as either antidotes for specific drugs or as universal reversal agents. The availability of these reversal agents will likely increase the clinical use of the non-vitamin K oral anticoagulants. In light of the many complex and nuanced issues surrounding the choice of an optimal anticoagulant for any AF patient, a patient-centered/shared decision-making approach will be useful.

New Oral Anticoagulants and Their Reversal Agents

OPINION STATEMENT

Direct oral anticoagulants (DOAC) are an attractive therapeutic option for anticoagulant treatment in the setting of venous thromboembolism or non-valvular atrial fibrillation. These drugs overall appear to have a lower risk of life-threatening hemorrhage than the vitamin K antagonists. In addition, they demonstrate more predictable and stable pharmacokinetics. Measurement of the degree of anticoagulation is desirable in patients with DOAC-associated hemorrhage, but commonly available coagulation assays show poor sensitivity for degree of DOAC effect. DOAC-specific tests are time consuming and not widely available. All coagulation tests should be interpreted considering the timing of last intake and renal function. When life-threatening bleeding occurs, hemostasis should be restored as rapidly as possible. Non-specific prohemostatic drugs may have a role in DOAC reversal, and specific antidotes are at different stages of development. In this review, we provide a summary of DOAC characteristics and an overview of the different therapeutic options available for DOAC reversal.

Non-Vitamin K Oral Anticoagulants in Stroke Patients: Practical Issues

Non-vitamin-K oral anticoagulants (NOACs) represent a major advance in the prevention of stroke in patients with atrial fibrillation (AF), offering a similar, if not superior, efficacy and safety profile and several practical advantages over oral vitamin K antagonists (VKAs). The rapid onset of action of the NOACs, their relatively short half-live, and the availability of specific reversal agents may be advantageous when managing acute ischemic strokes, and in the post-stroke, post-transient ischemic attack, and post-intracranial hemorrhage settings. In this review article, we offer practical guidance on the use of NOACs in these settings, focusing on managing the acute event and on initiating or resuming anticoagulation for secondary prevention. We also assess the use of NOACs to prevent stroke and bleeding in patients with AF who have chronic kidney disease, are elderly, or cognitively impaired, and we offer guidance on optimizing the use of NOACs and VKAs in these patient groups in the absence of evidence-based guidelines.

Direct Oral Anticoagulants in Dental Patients Including the Frail Elderly Population

Direct oral anticoagulants (DOACs) have led to a paradigm shift in the field of anticoagulation, providing safe and convenient anticoagulation without the need for regular blood testing. Currently, there are three major DOACs available-Factor Xa inhibitors (apixaban and rivaroxaban) and direct thrombin inhibitors (dabigatran)-that are available for use in atrial fibrillation and venous thromboembolism. While these agents have been shown to be as effective as warfarin, with a similar or better bleeding profile, there remains some concern of the use of these drugs in vulnerable populations, such as the frail elderly patients; particularly since reversal agents and drug monitoring are not routinely available. We aim to provide a review of the use of DOACs and the impact of DOACs on dental treatment in the elderly population.

Volume and functional outcome of intracerebral hemorrhage according to oral anticoagulant type

OBJECTIVE

To compare intracerebral hemorrhage (ICH) volume and clinical outcome of non-vitamin K oral anticoagulants (NOAC)-associated ICH to warfarin-associated ICH.

METHODS

In this multicenter cross-sectional observational study of patients with anticoagulant-associated ICH, consecutive patients with NOAC-ICH were compared to those with warfarin-ICH selected from a population of 344 patients with anticoagulant-associated ICH. ICH volume was measured by an observer blinded to clinical details. Outcome measures were ICH volume and clinical outcome adjusted for confounding factors.

RESULTS

We compared 11 patients with NOAC-ICH to 52 patients with warfarin-ICH. The median ICH volume was 2.4 mL (interquartile range [IQR] 0.3-5.4 mL) for NOAC-ICH vs 8.9 mL (IQR 4.0-21.3 mL) for warfarin-ICH (p = 0.0028). In univariate linear regression, use of warfarin (difference in cube root volume 1.61; 95% confidence interval [CI] 0.69 to 2.53) and lobar ICH location (compared with nonlobar ICH; difference in cube root volume 1.52; 95% CI 2.20 to 0.85) were associated with larger ICH volumes. In multivariable linear regression adjusting for confounding factors (sex, hypertension, previous ischemic stroke, white matter disease burden, and premorbid modified Rankin Scale score [mRS]), warfarin use remained independently associated with larger ICH (cube root) volumes (coefficient 0.64; 95% CI 0.24 to 1.25; p = 0.042). Ordered logistic regression showed an increased odds of a worse clinical outcome (as measured by discharge mRS) in warfarin-ICH compared with NOAC-ICH: odds ratio 4.46 (95% CI 1.10 to 18.14; p = 0.037).

CONCLUSIONS

In this small prospective observational study, patients with NOAC-associated ICH had smaller ICH volumes and better clinical outcomes compared with warfarin-associated ICH.

New Target-Specific Oral Anticoagulants and Intracranial Bleeding: Management and Outcome in a Single-Center Case Series

INTRODUCTION

New target-specific anticoagulants such as the direct thrombin inhibitor dabigatran and the factor Xa inhibitor rivaroxaban are used in an increasing number of patients. Several studies comparing these new oral anticoagulants with vitamin K antagonists revealed a lower risk of severe bleeding complications and reduced thromboembolic events. However, the lack of antidotes is a challenging issue in the treatment of traumatic or spontaneous intracranial hemorrhage.

METHODS

A retrospective analysis of patients with intracranial bleeding under new oral anticoagulants was performed; these patients were admitted to our department between January 2011 and November 2014. Treatment, reversal management of blood coagulopathy, and outcome of the patients were analyzed.

RESULTS

Seventeen patients were included. The median age was 80.4 years. Seven patients were treated with dabigatran and 10 with rivaroxaban. Eight patients had traumatic intracranial bleeding and 9 patients had spontaneous intracranial hemorrhage. Complex perioperative hematologic treatment followed. In 9 cases, the clinical outcome was devastating with severe neurologic deficits (n = 2), comatose status (n = 4), or death (n = 3). Patients with the indication for acute surgical treatment had a high risk for a critical clinical outcome.

CONCLUSIONS

Only a few case reports have analyzed the clinical course and the outcome after intracranial bleeding under new target-specific oral anticoagulants. Here, one of the first larger series is presented. Because of the lack of reversibility of the anticoagulative effects and the overall risks with geriatric patients, surgical treatment should be delayed as long as possible and comorbidities have to be considered.

Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation

The current manuscript is an update of the original Practical Guide, published in June 2013[Heidbuchel H, Verhamme P, Alings M, Antz M, Hacke W, Oldgren J, et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace 2013;15:625-51; Heidbuchel H, Verhamme P, Alings M, Antz M, Hacke W, Oldgren J, et al. EHRA practical guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation: executive summary. Eur Heart J 2013;34:2094-106]. Non-vitamin K antagonist oral anticoagulants (NOACs) are an alternative for vitamin K antagonists (VKAs) to prevent stroke in patients with non-valvular atrial fibrillation (AF). Both physicians and patients have to learn how to use these drugs effectively and safely in clinical practice. Many unresolved questions on how to optimally use these drugs in specific clinical situations remain. The European Heart Rhythm Association set out to coordinate a unified way of informing physicians on the use of the different NOACs. A writing group defined what needs to be considered as 'non-valvular AF' and listed 15 topics of concrete clinical scenarios for which practical answers were formulated, based on available evidence. The 15 topics are (i) practical start-up and follow-up scheme for patients on NOACs; (ii) how to measure the anticoagulant effect of NOACs; (iii) drug-drug interactions and pharmacokinetics of NOACs; (iv) switching between anticoagulant regimens; (v) ensuring adherence of NOAC intake; (vi) how to deal with dosing errors; (vii) patients with chronic kidney disease; (viii) what to do if there is a (suspected) overdose without bleeding, or a clotting test is indicating a risk of bleeding?; (xi) management of bleeding complications; (x) patients undergoing a planned surgical intervention or ablation; (xi) patients undergoing an urgent surgical intervention; (xii) patients with AF and coronary artery disease; (xiii) cardioversion in a NOAC-treated patient; (xiv) patients presenting with acute stroke while on NOACs; and (xv) NOACs vs. VKAs in AF patients with a malignancy. Additional information and downloads of the text and anticoagulation cards in >16 languages can be found on an European Heart Rhythm Association web site (www.NOACforAF.eu).

Apixaban for the prophylaxis and treatment of deep vein thrombosis and pulmonary embolism: an evidence-based review

Venous thromboembolism (VTE) results in significant morbidity and mortality. The prevention and treatment of VTE is managed with anticoagulant therapy, historically parenteral anticoagulants such as unfractionated heparin, low molecular weight heparin, and fondaparinux, and oral vitamin K antagonists such as warfarin. In the last few years, several target-specific oral anticoagulants have been developed, including the direct thrombin inhibitor dabigatran and anti-Xa inhibitors rivaroxaban, apixaban, and edoxaban. The target-specific oral anticoagulants have proven to be noninferior to vitamin K antagonists and heparins in the prevention and treatment of VTE. This review will focus on the pharmacology, clinical trial data, and laboratory assessment of apixaban. Moreover, perioperative management, use in special populations, and management of bleeding complications in patients taking apixaban for the prevention and treatment of VTE will also be discussed.

Effective practical management of patients with atrial fibrillation when using new oral anticoagulants

Practical management of stroke prevention in patients with non-valvular atrial fibrillation (AF) requires physicians to find the optimal balance between maximizing prevention of ischaemic stroke and minimizing the risk of bleeding. Vitamin K antagonists have traditionally been used for stroke prevention in patients with AF; however, they have been associated with increased risk of bleeding, particularly intracranial haemorrhage. New oral anticoagulants (OACs) have shown similar efficacy to the vitamin K antagonist warfarin but with a reduced risk of bleeding, particularly life-threatening bleeding such as intracranial haemorrhage. Decisions about which new OAC therapy to use may be influenced by patient characteristics such as age, renal function, co-medication use, and bleeding risk. This review uses a case-based approach to highlight the practical management issues to be considered by the physician when selecting a new OAC for stroke prevention in patients with non-valvular AF.

A meta-analysis of randomized controlled trials of the risk of bleeding with apixaban versus vitamin K antagonists

Apixaban is one of the new oral anticoagulants, which is prescribed as an alternative to vitamin K antagonists (VKAs). Concerns regarding its bleeding profile persist and require further evaluation. Therefore, we conducted a meta-analysis of randomized controlled trials (RCTs) to compare the risks of bleeding and all-cause mortality between apixaban and VKAs. The MEDLINE, EMBASE, and Cochrane Library of Clinical Trials databases were systematically searched for RCTs comparing the risks of bleeding and all-cause mortality of apixaban (2.5 or 5 mg twice daily) with those of VKAs. We included RCTs conducted in adults and published in English or French. Data were pooled across RCTs using random-effects meta-analytical models. Our systematic search identified 5 RCTs meeting our inclusion criteria (n = 24,435). They included patients with atrial fibrillation (n = 18,358), total knee replacement surgery (n = 458), and venous thromboembolism (n = 5,619). Data pooled across RCTs revealed that apixaban was associated with reduced risks of any bleeding (relative risk [RR] 0.73, 95% confidence interval [CI] 0.59 to 0.90) and a composite of major or clinically relevant nonmajor bleeding (RR 0.60, 95% CI 0.40 to 0.88). Apixaban was also associated with a lower risk of intracranial bleeding (RR 0.42, 95% CI 0.31 to 0.58) whereas analyses of major and minor bleeding were inconclusive. Moreover, apixaban was associated with decreased all-cause mortality (RR 0.89, 95% CI 0.81 to 0.99) although this finding was driven by the results of the ARISTOTLE trial. In conclusion, our meta-analysis found that apixaban is associated with a lower risk of bleeding than VKAs, providing some reassurance regarding its safety.

Clinical utility of apixaban in the prevention and treatment of venous thromboembolism: current evidence

Anticoagulation with heparin and vitamin K antagonist has been the mainstay of prevention and treatment of venous thromboembolism (VTE) for many years. In recent years, novel oral anticoagulants such as dabigatran etexilate (a direct thrombin inhibitor) and rivaroxaban, apixaban, and edoxaban (a direct factor Xa inhibitor) have emerged for the prevention and treatment of VTE. Novel oral anticoagulants have been shown to be noninferior to vitamin K antagonist or heparin in the prevention and treatment of VTE. This review specifically examines the role of apixaban in the prevention and treatment of VTE based on the available literature. The management of apixaban in the perioperative setting is also explored because some patients on apixaban may require surgical intervention. Finally, we discuss the management of apixaban-induced major bleeding complications, the relevance of drug–drug interactions, and patient education.