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Ghule P, Panic J, Malone DC. Risk of bleeding with concomitant use of oral anticoagulants and aspirin: A systematic review and meta-analysis. Am J Health Syst Pharm 2024; 81:494-508. [PMID: 38263263 DOI: 10.1093/ajhp/zxae010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Indexed: 01/25/2024] Open
Abstract
PURPOSE Oral anticoagulants (OACs) and aspirin can trigger bleeding events when used alone or in combination. The purpose of this study was to compare the risk of any type of bleeding in individuals exposed to a combination of OAC and aspirin with the risk in those taking an OAC or aspirin alone. METHODS MEDLINE and Web of Science were queried in January 2021 for eligible articles. Studies were included if they were either randomized controlled trials (RCTs) or observational studies and evaluated the number of any bleeding events in two groups, one with exposure to both OAC and aspirin and one with exposure to OAC alone or aspirin alone. Pooled odds ratios were calculated using a random-effects model. RESULTS Forty-two studies were included. In an analysis of 15 RCTs and 19 observational studies evaluating OAC plus aspirin versus OAC alone, a significant difference in the risk of bleeding was observed in the combination groups, with an odds ratio [OR] of, 1.36 (95% CI, 1.15-1.59) for RCTs and an OR of 1.42 (95% CI-, 1.09-1.87) for observational studies. When OAC plus aspirin was compared to aspirin alone, a higher rate of bleeding was found in the combination group (OR, 2.36; 95%CI, 1.91-2.92) in the analysis of 15 RCTs, but no significant difference was found among 10 observational studies (OR, 1.93; 95% Cl, 0.99-3.75). CONCLUSION The risk of any type of bleeding was significantly increased among patients taking aspirin plus OAC compared to those taking OAC alone in both RCTs and observational studies. Evaluation of RCTs comparing OAC plus aspirin to aspirin alone suggests increased bleeding risk as well.
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Affiliation(s)
- Priyanka Ghule
- College of Pharmacy, University of Utah, Salt Lake City, UH, USA
| | - Jennifer Panic
- Froedtert and the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Daniel C Malone
- College of Pharmacy, University of Utah, Salt Lake City, UH, USA
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2
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Verstraete A, Herregods MC, Verbrugghe P, Lamberigts M, Vanassche T, Meyns B, Oosterlinck W, Rega F, Adriaenssens T, Van Hoof L, Keuleers S, Vandenbriele C, Sinnaeve P, Janssens S, Dubois C, Meuris B, Verhamme P. Antithrombotic Treatment After Surgical and Transcatheter Heart Valve Repair and Replacement. Front Cardiovasc Med 2021; 8:702780. [PMID: 34422930 PMCID: PMC8375148 DOI: 10.3389/fcvm.2021.702780] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/05/2021] [Indexed: 12/14/2022] Open
Abstract
New antithrombotic drugs have been developed, new valve types have been designed and minimally invasive transcatheter techniques have emerged, making the choice of antithrombotic therapy after surgical or transcatheter heart valve repair and replacement increasingly complex. Moreover, due to a lack of large randomized controlled trials many recommendations for antithrombotic therapy are based on expert opinion, reflected by divergent recommendations in current guidelines. Therefore, decision-making in clinical practice regarding antithrombotic therapy for prosthetic heart valves is difficult, potentially resulting in sub-optimal patient treatment. This article compares the 2017 ESC/EACTS and 2020 ACC/AHA guidelines on the management of valvular heart disease and summarizes the available evidence. Finally, we established a convenient consensus on antithrombotic therapy after valve interventions based on over 800 annual cases of surgical and transcatheter heart valve repair and replacement and a multidisciplinary team discussion between the department of cardiovascular diseases and cardiac surgery of the University Hospitals Leuven, Belgium.
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Affiliation(s)
- Andreas Verstraete
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | | | - Peter Verbrugghe
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Marie Lamberigts
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Thomas Vanassche
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Wouter Oosterlinck
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Tom Adriaenssens
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Lucas Van Hoof
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Siegmund Keuleers
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | | | - Peter Sinnaeve
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Stefan Janssens
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Christophe Dubois
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Bart Meuris
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Peter Verhamme
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
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3
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Sharma R, Matsushita K, Wu A, Jack CR, Griswold M, Mosley TH, Fornage M, Gottesman RF. Common Medications and Intracerebral Hemorrhage: The ARIC Study. J Am Heart Assoc 2021; 10:e014270. [PMID: 33586464 PMCID: PMC8174245 DOI: 10.1161/jaha.120.014270] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 11/23/2020] [Indexed: 01/28/2023]
Abstract
Background Antiplatelets, anticoagulants, and statins are commonly prescribed for various indications. The associations between these medications and the risk of intracerebral hemorrhage (ICH) and cerebral microbleeds (CMBs) are unclear. Methods and Results We performed a retrospective study of the ARIC (Atherosclerosis Risk in Communities) study cohort, recruited from 4 US communities in 1987 to 1989 with follow-up. In 2011 to 2013, a subset (N=1942) underwent brain magnetic resonance imaging with CMB evaluation. Time-varying and any antiplatelet, anticoagulant, or statin use was evaluated at subsequent study visits in participants not on each medication at baseline. To determine the hazard of ICH and odds of CMB by medication use, logistic and Cox proportional hazard models were built, respectively, adjusting for the propensity to take the medication, concomitant use of other medications, and cognitive, genetic, and radiographic data. Of 15 719 individuals during up to 20 years of follow-up, 130 participants experienced an ICH. The adjusted hazard of ICH was significantly lower among participants taking an antiplatelet at the most recent study visit before ICH versus nonusers (hazard ratio [HR], 0.53; 95% CI, 0.30-0.92). Statin users had a significantly lower hazard of an ICH compared with nonusers (adjusted HR, 0.13; 95% CI, 0.05-0.34). There was no association of CMB and antiplatelet, anticoagulant, or statin use in adjusted models. Conclusions In this US community-based study, antiplatelet and statin use were associated with lower ICH hazard, whereas no association was noted between CMBs and antiplatelets, anticoagulants, and statins. Further study is needed to understand the differential roles of these medications in cerebral microhemorrhages and macrohemorrhages.
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Affiliation(s)
- Richa Sharma
- Department of NeurologyYale University School of MedicineNew HavenCT
| | - Kunihiro Matsushita
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
| | - Aozhou Wu
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
| | | | - Michael Griswold
- Department of MedicineUniversity of Mississippi Medical CenterJacksonMS
| | - Thomas H. Mosley
- Department of MedicineUniversity of Mississippi Medical CenterJacksonMS
| | - Myriam Fornage
- Institute of Molecular MedicineUniversity of Texas at HoustonTX
| | - Rebecca F. Gottesman
- Department of NeurologyJohns Hopkins University School of MedicineBaltimoreMD
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
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4
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Wiggins LM, Kumar SR, Starnes VA. The Ross Procedure in Children: The Gold Standard? Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2021; 24:62-66. [PMID: 34116784 DOI: 10.1053/j.pcsu.2021.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 03/04/2021] [Accepted: 03/09/2021] [Indexed: 11/11/2022]
Abstract
The management of aortic valve disease in the pediatric population is complex and requires an individualized approach and opportune application of techniques focused on each individual patient's specific anatomy, pathology, and clinical presentation. Though some patients may require variations in the approach to management, the ultimate goal should be to perform a Ross procedure when aortic valve replacement is indicated.
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Affiliation(s)
- Luke M Wiggins
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California; Heart Institute, Children's Hospital Los Angeles, Los Angeles, California.
| | - S Ram Kumar
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California; Heart Institute, Children's Hospital Los Angeles, Los Angeles, California
| | - Vaughn A Starnes
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California; Heart Institute, Children's Hospital Los Angeles, Los Angeles, California
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5
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Guimarães HP, de Barros E Silva PGM, Liporace IL, Sampaio RO, Tarasoutchi F, Paixão M, Hoffmann-Filho CR, Patriota R, Leiria TLL, Lamprea D, Precoma DB, Atik FA, Silveira FS, Farias FR, Barreto DO, Almeida AP, Zilli AC, de Souza Neto JD, Cavalcante MA, Figueira FAMS, Junior RA, Moisés VA, Mesas CE, Ardito RV, Kalil PSA, Paiva MSMO, Maldonado JGA, de Lima CEB, D'Oliveira Vieira R, Laranjeira L, Kojima F, Damiani L, Nakagawa RH, Dos Santos JRY, Sampaio BS, Campos VB, Saraiva JFK, Fonseca FH, Pinto IM, Magalhães CC, Ferreira JFM, Lopes RD, Pavanello R, Cavalcanti AB, Berwanger O. A randomized clinical trial to evaluate the efficacy and safety of rivaroxaban in patients with bioprosthetic mitral valve and atrial fibrillation or flutter: Rationale and design of the RIVER trial. Am Heart J 2021; 231:128-136. [PMID: 33045224 DOI: 10.1016/j.ahj.2020.10.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 10/05/2020] [Indexed: 02/06/2023]
Abstract
The efficacy and safety of rivaroxaban in patients with bioprosthetic mitral valves and atrial fibrillation or flutter remain uncertain. DESIGN: RIVER was an academic-led, multicenter, open-label, randomized, non-inferiority trial with blinded outcome adjudication that enrolled 1005 patients from 49 sites in Brazil. Patients with a bioprosthetic mitral valve and atrial fibrillation or flutter were randomly assigned (1:1) to rivaroxaban 20 mg once daily (15 mg in those with creatinine clearance <50 mL/min) or dose-adjusted warfarin (target international normalized ratio 2.0-30.); the follow-up period was 12 months. The primary outcome was a composite of all-cause mortality, stroke, transient ischemic attack, major bleeding, valve thrombosis, systemic embolism, or hospitalization for heart failure. Secondary outcomes included individual components of the primary composite outcome, bleeding events, and venous thromboembolism. SUMMARY: RIVER represents the largest trial specifically designed to assess the efficacy and safety of a direct oral anticoagulant in patients with bioprosthetic mitral valves and atrial fibrillation or flutter. The results of this trial can inform clinical practice and international guidelines.
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Affiliation(s)
- Helio P Guimarães
- Research Institute - Heart Hospital (HCor), São Paulo, Brazil; Hospital Israelita Albert Einstein, São Paulo-SP, Brazil.
| | | | | | | | | | - Milena Paixão
- Incor - Instituto do Coração do HCFMUSP, São Paulo, Brazil
| | | | - Rodrigo Patriota
- Hospital Metropolitano Sul Dom Helder Câmara, Cabo de Santo Agostinho, Brazil
| | - Tiago L L Leiria
- Instituto de Cardiologia do Rio Grande do Sul (FUC), Porto Alegre, Brazil
| | | | - Dalton B Precoma
- Sociedade Hospitalar Angelina Caron, Campina Grande do Sul, Brazil
| | - Fernando A Atik
- Instituto de Cardiologia do Distrito Federal, Brasília, Brazil
| | | | | | | | - Adail P Almeida
- Unidade Médico Cirúrgica - Unimec, Vitória da Conquista, Brazil
| | | | | | | | | | - Roque A Junior
- HUPES-Hospital Universitário Prof Edgard Santos, Salvador, Brazil
| | | | - Cezar E Mesas
- Hospital de Universidade Estadual de Londrina, Londrina, Brazil
| | - Roberto V Ardito
- IMC - Instituto de Moléstias Cardiovasculares, São José do Rio Preto, Brazil
| | | | | | - Jaime G A Maldonado
- Serviço de Eletrofisiologia e Marca-Passo do Hospital Universitário Francisca Mendes (HUFM)-Manaus, Brazil
| | | | | | | | - Flávia Kojima
- Research Institute - Heart Hospital (HCor), São Paulo, Brazil
| | - Lucas Damiani
- Research Institute - Heart Hospital (HCor), São Paulo, Brazil
| | | | | | - Bruna S Sampaio
- Research Institute - Heart Hospital (HCor), São Paulo, Brazil
| | | | - Jose F K Saraiva
- Instituto de Pesquisa Clínica de Campinas, Campinas, Brazil; Sociedade de Cardiologia do Estado de São Paulo (SOCESP), Sao Paulo, Brazil
| | - Francisco H Fonseca
- UNIFESP, São Paulo, Brazil; Sociedade de Cardiologia do Estado de São Paulo (SOCESP), Sao Paulo, Brazil
| | - Ibraim M Pinto
- Sociedade de Cardiologia do Estado de São Paulo (SOCESP), Sao Paulo, Brazil
| | - Carlos C Magalhães
- Sociedade de Cardiologia do Estado de São Paulo (SOCESP), Sao Paulo, Brazil
| | - Joao F M Ferreira
- Incor - Instituto do Coração do HCFMUSP, São Paulo, Brazil; Sociedade de Cardiologia do Estado de São Paulo (SOCESP), Sao Paulo, Brazil
| | | | - Ricardo Pavanello
- Research Institute - Heart Hospital (HCor), São Paulo, Brazil; Sociedade de Cardiologia do Estado de São Paulo (SOCESP), Sao Paulo, Brazil
| | | | - Otavio Berwanger
- Research Institute - Heart Hospital (HCor), São Paulo, Brazil; Hospital Israelita Albert Einstein, São Paulo-SP, Brazil; Sociedade de Cardiologia do Estado de São Paulo (SOCESP), Sao Paulo, Brazil
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6
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Antithrombotics in intracerebral hemorrhage in the era of novel agents and antidotes: A review. JOURNAL OF POPULATION THERAPEUTICS AND CLINICAL PHARMACOLOGY 2020; 27:e1-e18. [PMID: 32320168 DOI: 10.15586/jptcp.v27i2.660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 02/17/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH)1 is characterized by the pathological accumulation of blood within the brain parenchyma, most commonly associated with hypertension, arteriovenous malformations, or trauma. However, it can also present in patients receiving antithrombotic drugs, either anticoagulants such as acenocoumarol/warfarin-novel oral anticoagulants or antiplatelets, for the prevention and treatment of thromboembolic disease. OBJECTIVE The purpose of this review is to present current bibliographic data regarding ICH irrespective of the cause, as well as post-hemorrhage use of antithrombotic agents. Moreover, this review attempts to provide guidelines concerning the termination, inversion, and of course resumption of antithrombotic therapy. METHODS AND MATERIALS We reviewed the most recently presented available data for patients who dealt with intracerebral hemorrhagic events while on antithrombotic agents (due to atrial fibrillation, prosthetic mechanical valves or recent/recurrent deep vein thrombosis). Furthermore, we examined and compared the thromboembolic risk, the bleeding risk, as well as the re-bleeding risk in two groups: patients receiving antithrombotic therapy versus patients not on antithrombotic therapy. CONCLUSION Antithrombotic therapy is of great importance when indicated, though it does not come without crucial side-effects, such as ICH. Optimal timing of withdrawal, reversal, and resumption of antithrombotic treatment should be determined by a multidisciplinary team consisting of a stroke specialist, a cardiologist, and a neurosurgeon, who will individually approach the needs and risks of each patient.
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7
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Myers PO, Mokashi SA, Horgan E, Borisuk M, Mayer JE, del Nido PJ, Baird CW. Outcomes after mechanical aortic valve replacement in children and young adults with congenital heart disease. J Thorac Cardiovasc Surg 2019; 157:329-340. [DOI: 10.1016/j.jtcvs.2018.08.077] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 04/03/2018] [Accepted: 08/01/2018] [Indexed: 11/30/2022]
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8
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Shaikh SI, Kumari RV, Hegade G, Marutheesh M. Perioperative Considerations and Management of Patients Receiving Anticoagulants. Anesth Essays Res 2017; 11:10-16. [PMID: 28298749 PMCID: PMC5341681 DOI: 10.4103/0259-1162.179313] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Anticoagulants remain the primary strategy for the prevention and treatment of thrombosis. Unfractionated heparin, low molecular weight heparin (LMWH), fondaparinux, and warfarin have been studied and employed extensively with direct thrombin inhibitors typically reserved for patients with complications or those requiring interventions. Novel oral anticoagulants have emerged from clinical development and are expected to replace older agents with their ease to use and more favorable pharmacodynamic profiles. Increasingly, anesthesiologists are being requested to anesthetize patients who are on some form of anticoagulants and hence it is important to have sound understanding of pharmacology, dosing, monitoring, and toxicity of anticoagulants. We searched the online databases including PubMed Central, Cochrane, and Google Scholar using anticoagulants, perioperative management, anesthetic considerations, and LMWH as keywords for the articles published between 1994 and 2015 while writing this review. In this article, we will review the different classes of anticoagulants and how to manage them in the perioperative settings.
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Affiliation(s)
- Safiya Imtiaz Shaikh
- Department of Anaesthesiology, Karnataka Institute of Medical Sciences, Hubli, Karnataka, India
| | - R Vasantha Kumari
- Department of Anaesthesiology, Karnataka Institute of Medical Sciences, Hubli, Karnataka, India
| | - Ganapati Hegade
- Department of Anaesthesiology, Karnataka Institute of Medical Sciences, Hubli, Karnataka, India
| | - M Marutheesh
- Department of Anaesthesiology, Karnataka Institute of Medical Sciences, Hubli, Karnataka, India
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9
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Bové T, Van Belleghem Y, François K, Caes F, De Pauw M, Taeymans Y, Van Nooten GJ. Low target-INR anticoagulation is safe in selected aortic valve patients with the Medtronic Open Pivot mechanical prosthesis: long-term results of a propensity-matched comparison with standard anticoagulation. Interact Cardiovasc Thorac Surg 2017; 24:862-868. [DOI: 10.1093/icvts/ivx028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 01/02/2017] [Indexed: 11/14/2022] Open
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10
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Halaszynski TM. Administration of Coagulation-Altering Therapy in the Patient Presenting for Oral Health and Maxillofacial Surgery. Oral Maxillofac Surg Clin North Am 2016; 28:443-460. [PMID: 27745616 DOI: 10.1016/j.coms.2016.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Oral health care providers are concerned with how to manage patients prescribed coagulation-altering therapy during the perioperative/periprocedural period for dental and oral surgery interventions. Management and recommendation can be based on medication pharmacology and the clinical relevance of coagulation factor levels/deficiencies. Caution should be used with concurrent use of medications that affect other components of the clotting mechanisms; prompt diagnosis and any necessary intervention to optimize outcome is warranted. However, evidence-based data on management of anticoagulation therapy during oral and maxillofacial surgery/interventions is lacking. Therefore, clinical understanding and judgment are needed along with appropriate guidelines matching patient- and intervention-specific recommendations.
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Affiliation(s)
- Thomas M Halaszynski
- Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, TMP 3 Library, New Haven, CT 203 785-2804, USA.
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11
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Elkayam U, Singh H, Irani A, Akhter MW. Anticoagulation in Pregnant Women With Prosthetic Heart Valves. J Cardiovasc Pharmacol Ther 2016; 9:107-15. [PMID: 15309247 DOI: 10.1177/107424840400900206] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Pregnancy is associated with an increased risk of thrombosis in women with mechanical prosthetic heart valves. Effective anticoagulation is therefore critical in such patients but remains problematic, since oral anticoagulation and both unfractionated and low-molecular-weight heparin may be associated with important fetal and maternal side effects. Purpose: To review information related to the use of anticoagulation with both warfarin and heparin and reassess the safety and efficacy of these therapies in pregnant women with mechanical prosthetic heart valves. Data source and selection: A MEDLINE search from 1966 to October 2003 for English and non-English language articles that reported the use of anticoagulation in pregnancy was conducted. Articles were included if they reported use of anticoagulation in pregnancy with emphasis on those that included women with mechanical prosthetic heart valves. Conclusions: Anticoagulation prophylaxis with both warfarin and heparin (unfractionated heparin and low-molecular-weight heparin) may be associated with important fetal and maternal side effects. Optional regimens for the treatment of low-risk and high-risk patients are proposed to minimize potential complications.
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Affiliation(s)
- Uri Elkayam
- Division of Cardiovascular Medicine, Department of Medicine, University of Southern California, Keck School of Medicine, Los Angeles, California 90033, USA.
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12
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Li J, Halaszynski T. Neuraxial and peripheral nerve blocks in patients taking anticoagulant or thromboprophylactic drugs: challenges and solutions. Local Reg Anesth 2015; 8:21-32. [PMID: 26347411 PMCID: PMC4531015 DOI: 10.2147/lra.s55306] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Incidence of hemorrhagic complications from neuraxial blockade is unknown, but classically cited as 1 in 150,000 epidurals and 1 in 220,000 spinals. However, recent literature and epidemiologic data suggest that for certain patient populations the frequency is higher (1 in 3,000). Due to safety concerns of bleeding risk, guidelines and recommendations have been designed to reduce patient morbidity/mortality during regional anesthesia. Data from evidence-based reviews, clinical series and case reports, collaborative experience of experts, and pharmacology used in developing consensus statements are unable to address all patient comorbidities and are not able to guarantee specific outcomes. No laboratory model identifies patients at risk, and rarity of neuraxial hematoma defies prospective randomized study so “patient-specific” factors and “surgery-related” issues should be considered to improve patient-oriented outcomes. Details of advanced age, older females, trauma patients, spinal cord and vertebral column abnormalities, organ function compromise, presence of underlying coagulopathy, traumatic or difficult needle placement, as well as indwelling catheter(s) during anticoagulation pose risks for significant bleeding. Therefore, balancing between thromboembolism, bleeding risk, and introduction of more potent antithrombotic medications in combination with regional anesthesia has resulted in a need for more than “consensus statements” to safely manage regional interventions during anticoagulant/thromboprophylactic therapy.
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Affiliation(s)
- Jinlei Li
- Department of Anesthesiology, Yale University, Yale New Haven Hospital, New Haven, CT, USA
| | - Thomas Halaszynski
- Department of Anesthesiology, Yale University, Yale New Haven Hospital, New Haven, CT, USA
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13
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Toeg H, Boodhwani M. Review of anticoagulation options for mechanical valve prosthesis. Interv Cardiol 2015. [DOI: 10.2217/ica.15.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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14
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Combined low-dose aspirin and warfarin anticoagulant therapy of postoperative atrial fibrillation following mechanical heart valve replacement. ACTA ACUST UNITED AC 2014; 34:902-906. [DOI: 10.1007/s11596-014-1371-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 10/18/2014] [Indexed: 10/24/2022]
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15
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Reduced anticoagulation after mechanical aortic valve replacement: Interim results from the Prospective Randomized On-X Valve Anticoagulation Clinical Trial randomized Food and Drug Administration investigational device exemption trial. J Thorac Cardiovasc Surg 2014; 147:1202-1210; discussion 1210-1. [DOI: 10.1016/j.jtcvs.2014.01.004] [Citation(s) in RCA: 187] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 12/27/2013] [Accepted: 01/06/2014] [Indexed: 11/23/2022]
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16
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Bradley SM. Aortic Valve Insufficiency in the Teenager and Young Adult. World J Pediatr Congenit Heart Surg 2013; 4:397-402. [DOI: 10.1177/2150135113488781] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The contents of this article were presented in the session “Aortic insufficiency in the teenager” at the congenital parallel symposium of the 2013 Society of Thoracic Surgeons (STS) annual meeting. The accompanying articles detail the approaches of aortic valve repair and the Ross procedure.1,2 The current article focuses on prosthetic valve replacement. For many young patients requiring aortic valve surgery, either aortic valve repair or a Ross procedure provides a good option. The advantages include avoidance of anticoagulation and potential for growth. In other patients, a prosthetic valve is an appropriate alternative. This article discusses the current state of knowledge regarding mechanical and bioprosthetic valve prostheses and their specific advantages relative to valve repair or a Ross procedure. In current practice, young patients requiring aortic valve surgery frequently undergo valve replacement with a prosthetic valve. In STS adult cardiac database, among patients ≤30 years of age undergoing aortic valve surgery, 34% had placement of a mechanical valve, 51% had placement of a bioprosthetic valve, 9% had aortic valve repair, and 2% had a Ross procedure. In the STS congenital database, among patients 12 to 30 years of age undergoing aortic valve surgery, 21% had placement of a mechanical valve, 18% had placement of a bioprosthetic valve, 30% had aortic valve repair, and 24% had a Ross procedure. In the future, the balance among these options may be altered by design improvements in prosthetic valves, alternatives to warfarin, the development of new patch materials for valve repair, and techniques to avoid Ross autograft failure.
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Affiliation(s)
- Scott M. Bradley
- Pediatric Cardiac Surgery, Medical University of South Carolina, Charleston, SC, USA
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Abstract
BACKGROUND Patients with prosthetic heart valves are at increased risk for valve thrombosis and arterial thromboembolism. Oral anticoagulation alone, or the addition of antiplatelet drugs, has been used to minimise this risk. An important issue is the effectiveness and safety of the latter strategy. OBJECTIVES This is an update of our previous review; the goal was to create a valid synthesis of all available, methodologically sound data to further assess the safety and efficacy of combined oral anticoagulant and antiplatelet therapy versus oral anticoagulant monotherapy in patients with prosthetic heart valves. SEARCH METHODS We updated the previous searches from 2003 and 2010 on 16 January 2013 and searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (2012, Issue 12), MEDLINE (OVID, 1946 to January Week 1 2013), and EMBASE (OVID, 1980 to 2013 Week 02). We have also looked at reference lists of individual reports, review articles, meta-analyses, and consensus statements. We included reports published in any language or in abstract form. SELECTION CRITERIA All reports of randomised controlled trials comparing standard-dose oral anticoagulation to standard-dose oral anticoagulation and antiplatelet therapy in patients with one or more prosthetic heart valves. DATA COLLECTION AND ANALYSIS Two review authors independently performed the search strategy, assessed trials for inclusion and study quality, and extracted data. We collected adverse effects information from the trials. MAIN RESULTS One new study has been identified and included in this update. In total, 13 studies involving 4122 participants were included in this review update. Years of publication ranged from 1971 to 2011. Compared with anticoagulation alone, the addition of an antiplatelet agent reduced the risk of thromboembolic events (odds ratio (OR) 0.43, 95% confidence interval (CI) 0.32 to 0.59; P < 0.00001) and total mortality (OR 0.57, 95% CI 0.42 to 0.78; P = 0.0004). Aspirin and dipyridamole reduced these events similarly. The risk of major bleeding was increased when antiplatelet agents were added to oral anticoagulants (OR 1.58, 95% CI 1.14 to 2.18; P = 0.006).For major bleeding, there was no evidence of heterogeneity between aspirin and dipyridamole and in the comparison of trials performed before and after 1990, around the time when anticoagulation standardisation with the international normalised ratio was being implemented. A lower daily dose of aspirin (< 100 mg) may be associated with a lower major bleeding risk than higher doses. AUTHORS' CONCLUSIONS Adding antiplatelet therapy, either dipyridamole or low-dose aspirin, to oral anticoagulation decreases the risk of systemic embolism or death among patients with prosthetic heart valves. The risk of major bleeding is increased with antiplatelet therapy. These results apply to patients with mechanical prosthetic valves or those with biological valves and indicators of high risk such as atrial fibrillation or prior thromboembolic events. The effectiveness and safety of low-dose aspirin (100 mg daily) appears to be similar to higher-dose aspirin and dipyridamole. In general, the quality of the included trials tended to be low, possibly reflecting the era when the majority of the trials were conducted (1970s and 1980s when trial methodology was less advanced).
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Kim TS, Na CY, Oh SS, Kim JH. Long-term mortality and morbidity after button Bentall operation. J Card Surg 2013; 28:280-4. [PMID: 23480627 DOI: 10.1111/jocs.12085] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND AND AIM OF THE STUDY The purpose of this study is to evaluate the long-term outcomes of the button Bentall procedure for the correction of aortic root disease. METHODS A total of 195 patients who underwent the button Bentall procedure between 1997 and 2010 were studied. The main pathology was annuloaortic ectasia. A mechanical valve was used in 163 patients (83.6%). The median duration of follow-up was 64 months (14133.0 patient-years). RESULTS There were five operative deaths (2.6%). Late overall mortality was 7.9%. The actuarial overall survival rate was 95.8 ± 1.5% at 5 years, 89.6 ± 3.4% at 10 years, and 75.9 ± 7.3% at 15 years. Multivariate logistic regression analysis identified preoperative poor mobility, cardiopulmonary bypass time, deep hypothermic circulatory arrest (DHCA) use, embolism, and bleeding event as significant independent risk factors for the late overall mortality. At 5, 10, and 15 years, actuarial composite valve graft-related event-free survival was 85.8 ± 2.8%, 75.5 ± 4.4%, and 69.3 ± 7.3%, respectively. Hypertension and concomitant coronary artery bypass graft (CABG) were independent predictors of composite valve graft-related events. Age, concomitant CABG, and DHCA use were associated with bleeding. CONCLUSIONS Valve-related morbidities, such as embolism and bleeding, determine the long-term overall mortality in aortic root replacement with button Bentall operation, similar to that in routine valve surgery.
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Affiliation(s)
- Tae Sik Kim
- Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Sejong Heart Institute, Bucheon, Republic of Korea
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Thiagarajan P, Jankowski JA. Tipping the Balance: Benefits and Risks of Aspirin in Chemoprevention of Colorectal Cancer. CURRENT COLORECTAL CANCER REPORTS 2013. [DOI: 10.1007/s11888-012-0151-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Hass B, Pooley J, Harrington AE, Clemens A, Feuring M. Treatment of venous thromboembolism - effects of different therapeutic strategies on bleeding and recurrence rates and considerations for future anticoagulant management. Thromb J 2012; 10:24. [PMID: 23276253 PMCID: PMC3554503 DOI: 10.1186/1477-9560-10-24] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 12/19/2012] [Indexed: 12/31/2022] Open
Abstract
Effective treatment of venous thromboembolism (VTE) strikes a balance between prevention of recurrence and bleeding complications. The current standard of care is heparin followed by a vitamin K antagonist such as warfarin. However, this option is not without its limitations, as the anticoagulant effect of warfarin is associated with high inter- and intra-patient variability and patients must be regularly monitored to ensure that anticoagulation is within the narrow target therapeutic range. Several novel oral anticoagulant agents are in the advanced stages of development for VTE treatment, some of which are given after an initial period of heparin treatment, in line with current practice, while others switch from high to low doses after the initial phase of treatment. In this review we assess the critical considerations for treating VTE in light of emerging clinical data for new oral agents and discuss the merits of novel treatment regimens for patients who have experienced an episode of deep vein thrombosis or pulmonary embolism.
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Affiliation(s)
- Bastian Hass
- Boehringer Ingelheim GmbH, Binger Strasse 173, 55216, Ingelheim am Rhein, Germany.
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Anticoagulation therapy with combined low dose aspirin and warfarin following mechanical heart valve replacement. Thromb Res 2011; 128:e91-4. [DOI: 10.1016/j.thromres.2011.07.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Revised: 06/29/2011] [Accepted: 07/05/2011] [Indexed: 11/23/2022]
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Torella M, Torella D, Chiodini P, Franciulli M, Romano G, De Santo L, De Feo M, Amarelli C, Sasso FC, Salvatore T, Ellison GM, Indolfi C, Cotrufo M, Nappi G. LOWERing the INtensity of oral anticoaGulant Therapy in patients with bileaflet mechanical aortic valve replacement: results from the "LOWERING-IT" Trial. Am Heart J 2010; 160:171-8. [PMID: 20598989 DOI: 10.1016/j.ahj.2010.05.005] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2010] [Accepted: 05/06/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Moderate anticoagulation after mechanical heart valve replacement has been proposed to reduce the risk of bleeding related to lifelong anticoagulation. However, the efficacy of such reduced antithrombotic regimens is still unknown. The present prospective open-label, single-center, randomized controlled trial aimed to evaluate the safety and feasibility of reduced oral anticoagulation after isolated mechanical aortic valve replacement. METHODS Low-risk patients undergoing bileaflet mechanical aortic valve replacement were randomized to a low International normalized ratio (INR) target (1.5-2.5; LOW-INR group) or to the standard currently recommended INR (2.0-3.0; CONVENTIONAL-INR group) through daily coumarine oral therapy. No aspirin was added. Median follow-up was 5.6 years. The primary outcome was assessment of noninferiority of the low over the standard anticoagulation regimen on thromboembolic events. Secondary end point was the superiority of the reduced INR target strategy on bleeding events. RESULTS We analyzed 396 patients (197 in the LOW-INR group and 199 in the CONVENTIONAL-INR group). The mean of INR was 1.94 +/- 0.21 and 2.61 +/- 0.25 in the LOW-INR and CONVENTIONAL-INR groups, respectively (P < .001). One versus three thromboembolic events occurred in the LOW-INR and CONVENTIONAL-INR, respectively, meeting the noninferiority criterion (P = .62). Total hemorrhagic events occurred in 6 patients in the LOW-INR group and in 16 patients in the CONVENTIONAL-INR group (P = .04). CONCLUSIONS LOWERING-IT trial established that the proposed LOW-INR target is safe and feasible in low-risk patients after bileaflet aortic mechanical valve replacement. It results in similar thrombotic events and in a significant reduction of bleeding occurrence when compared to the conventional anticoagulation regimen.
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Yinon Y, Siu SC, Warshafsky C, Maxwell C, McLeod A, Colman JM, Sermer M, Silversides CK. Use of low molecular weight heparin in pregnant women with mechanical heart valves. Am J Cardiol 2009; 104:1259-63. [PMID: 19840573 DOI: 10.1016/j.amjcard.2009.06.040] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2009] [Revised: 06/19/2009] [Accepted: 06/19/2009] [Indexed: 11/30/2022]
Abstract
There are a number of different anticoagulation options for pregnant women with mechanical heart valves. The purpose of this study was to examine maternal thromboembolic complications in women with mechanical valves treated with low-molecular weight heparin (LMWH) throughout pregnancy. This was a substudy of a larger prospective cohort study of pregnant women with heart disease followed from 1998 to 2008. All pregnant women with mechanical left-sided valves who were treated with LMWH throughout pregnancy were included. Maternal thromboembolic events were defined as valve thrombosis, need for valve replacement, or stroke during pregnancy or postpartum (up to 6 months). Twenty-three pregnancies (17 women) occurred in women treated with LMWH and low-dose aspirin: 15 in women with mechanical mitral valves, 9 in women with mechanical aortic valves, and 1 in a woman with both. There was 1 maternal thromboembolic event (4%), which resulted in maternal and fetal death. Five women (22%) developed other adverse cardiac events during pregnancy. Nine pregnancies (43%) had fetal or neonatal adverse events, 5 of which had favorable outcomes. Three pregnancies were complicated by postpartum hemorrhage. In conclusion, carefully monitored LMWH may be a suitable anticoagulation strategy in pregnant women with mechanical heart valves who are unwilling to use warfarin. However, this group of women remains at risk for maternal cardiac and fetal complications. The occurrence of valve thrombosis resulting in maternal death despite therapeutic anti-Xa levels highlights current limitations with anticoagulation in this population.
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Affiliation(s)
- Yoav Yinon
- Mount Sinai Hospital, University of Toronto, Canada
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Bouganim T, Shapira Y, Sagie A, Vaturi M, Battler A, Kornowski R, Lev EI. Platelet reactivity in patients with a history of obstructive prosthetic valve thrombosis. Am J Cardiol 2009; 103:1760-3. [PMID: 19539089 DOI: 10.1016/j.amjcard.2009.02.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2008] [Revised: 02/10/2009] [Accepted: 02/15/2009] [Indexed: 10/20/2022]
Abstract
One of the most serious complications of mechanical valves is obstructive prosthetic valve thrombosis (OPVT or "stuck valve"). Some patients develop OPVT despite an international normalized ratio (INR) in the therapeutic recommended range. We hypothesized that patients who develop OPVT have hyper-reactive platelets. We, therefore, examined platelet reactivity in patients who developed OPVT, despite a therapeutic or near-therapeutic INR, compared with a matched control group. We compared platelet reactivity between patients who had had an OPVT episode, despite a therapeutic or near-therapeutic INR (n = 18), and a matched group of patients with mechanical valves who did not develop this complication (n = 18) from 1996 to 2007. Platelet reactivity was evaluated by platelet aggregation in response to various agonists, platelet deposition under flow conditions in the Impact-R system, and plasma levels of platelet activation markers (soluble CD40 ligand and P-selectin). In the OPVT group, the average INR during the index episode was 3.1 +/- 1.5, and 44.6 +/- 40 months had elapsed from the index episode to the present study. Both groups were matched for gender, age +/-10 years, valve position and type, active smoking, and diabetes. Patients with an OPVT history had a greater aggregation in response to collagen (p = 0.05), greater platelet deposition in the Impact-R system (p = 0.01), and tended to have higher levels of soluble P-selection and soluble CD40 ligand (p = 0.07) than their control counterparts. In conclusion, patients with a history of OPVT appear to have increased platelet reactivity, which might contribute to an increased risk of thrombotic complications. These patients would, therefore, likely benefit from the addition of antiplatelet therapy to their standard anticoagulant treatment.
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English J, Smith W. Cardio-embolic stroke. HANDBOOK OF CLINICAL NEUROLOGY 2009; 93:719-749. [PMID: 18804677 DOI: 10.1016/s0072-9752(08)93036-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Joey English
- Department of Neurology, University of California, San Francisco, CA 94143, USA
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Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS, Nishimura RA, Carabello BA, Faxon DP, Freed MD, Lytle BW, O'Gara PT, O'Rourke RA, Shah PM. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2008; 52:e1-142. [PMID: 18848134 DOI: 10.1016/j.jacc.2008.05.007] [Citation(s) in RCA: 1058] [Impact Index Per Article: 66.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:e523-661. [PMID: 18820172 DOI: 10.1161/circulationaha.108.190748] [Citation(s) in RCA: 698] [Impact Index Per Article: 43.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Salem DN, O'Gara PT, Madias C, Pauker SG. Valvular and Structural Heart Disease. Chest 2008; 133:593S-629S. [DOI: 10.1378/chest.08-0724] [Citation(s) in RCA: 191] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Schulman S, Beyth RJ, Kearon C, Levine MN. Hemorrhagic Complications of Anticoagulant and Thrombolytic Treatment. Chest 2008; 133:257S-298S. [PMID: 18574268 DOI: 10.1378/chest.08-0674] [Citation(s) in RCA: 488] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Sam Schulman
- From the Thrombosis Service, McMaster Clinic, HHS-General Hospital, Hamilton, ON, Canada.
| | - Rebecca J Beyth
- Rehabilitation Outcomes Research Center NF/SG Veterans Health System, Gainesville, FL
| | - Clive Kearon
- McMaster University Clinic, Henderson General Hospital, Hamilton, ON, Canada
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Hermosillo AJ, Spinler SA. Aspirin, clopidogrel, and warfarin: is the combination appropriate and effective or inappropriate and too dangerous? Ann Pharmacother 2008; 42:790-805. [PMID: 18477734 DOI: 10.1345/aph.1k591] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To review the rationale, clinical practice guideline recommendations, and clinical trial data describing bleeding and clinical outcomes associated with the use of the combination of aspirin, a thienopyridine, and warfarin. DATA SOURCES An English-language literature search was conducted using MEDLINE (1966-March 2008) and the search terms aspirin, clopidogrel, ticlopidine, thienopyridine, warfarin, antiplatelet, anticoagulant, myocardial infarction, atrial fibrillation, and percutaneous coronary intervention (PCI). Additional references were identified by reviewing reference citations of articles retrieved. STUDY SELECTION AND DATA EXTRACTION Applicable data were extracted from published reports and studies that included either clinical outcomes or adverse events. DATA SYNTHESIS Clinical guidelines recommend the combination of antiplatelets and anticoagulants based largely on writing committee consensus. To date, only one randomized clinical trial has evaluated the safety and efficacy of adding warfarin to dual antiplatelet therapy (ie, triple antithrombotic therapy). Other published data are from case series, observational studies, and case-controlled studies primarily of patients undergoing PCI with intracoronary stent placement. Four of 12 studies reported no increased risk of major bleeding events. In the other 8 studies, a 3- to 6-fold increase in bleeding events was reported with triple antithrombotic therapy. Ischemic events were reported in only 6 of the studies. Only 2 studies observed an additional benefit in the reduction of ischemic events, and 1 study reported worsened ischemic outcomes with the triple antithrombotic regimen compared with dual antithrombotic therapy. CONCLUSIONS Available guidelines pertaining to the concomitant administration of aspirin, a thienopyridine, and warfarin are based on limited trial data and consensus judgment. Overall, selection of triple antithrombotic therapy for patients with vascular disease is considered a matter of clinical judgment for an individual patient based on the prescriber's perceived balance between the patient's risk for recurrent ischemic events, expected duration of treatment, and patient's risk for bleeding.
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Affiliation(s)
- A Janelle Hermosillo
- Department of Pharmacy Practice and Pharmacy Administration, Philadelphia College of Pharmacy, University of the Sciences in Philadelphia, Philadelphia, PA 19104, USA
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Uebing A, Gatzoulis MA, von Kaisenberg C, Kramer HH, Strauss A. Congenital heart disease in pregnancy. DEUTSCHES ARZTEBLATT INTERNATIONAL 2008; 105:347-54. [PMID: 19629245 DOI: 10.3238/arztebl.2008.0347] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2007] [Accepted: 01/15/2008] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Pregnancy, birth, and the puerperium are associated with significant physiological changes and adaptations in the cardiovascular system, which pose a significant risk to pregnant women with congenital heart disease (CHD). Thanks to advances in pediatric cardiac surgery and cardiology the majority of children with CHD survive to adulthood, and an increasing number eventually become pregnant. In fact, cardiac disease - mostly congenital - is now a leading cause of maternal death in western industrialized countries. METHODS Selective literature review. RESULTS AND DISCUSSION Optimal care of women with CHD before, during, and after pregnancy requires a multidisciplinary team including obstetricians, cardiologists, and anaesthetists. Successful pregnancy at a minimum risk is feasible for most women with CHD when appropriate counseling and optimal care are provided.
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Abstract
Mechanical heart valves pose a particular challenge in pregnancy, as the primary agent used to prevent valve thrombosis, coumadin (warfarin), is a known teratogen. Alternatives to coumadin, such as unfractionated heparin (UFH) and low-molecular weight heparin (LMWH) are safer for the fetus, particularly during the first trimester of pregnancy, but expose the mother to potential valve failure. This review will examine these controversies and the complex literature regarding management in pregnancy.
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Reimold SC, Forbess LW. Pharmacologic Options for Treating Cardiovascular Disease During Pregnancy. Cardiovasc Ther 2007. [DOI: 10.1016/b978-1-4160-3358-5.50047-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Kulik A, Rubens FD, Wells PS, Kearon C, Mesana TG, van Berkom J, Lam BK. Early postoperative anticoagulation after mechanical valve replacement: a systematic review. Ann Thorac Surg 2006; 81:770-81. [PMID: 16427905 DOI: 10.1016/j.athoracsur.2005.07.023] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2005] [Revised: 07/04/2005] [Accepted: 07/06/2005] [Indexed: 10/25/2022]
Abstract
The optimal approach to early postoperative anticoagulation after mechanical valve implantation remains controversial. This review article examines the pathogenesis of thrombus formation and the different strategies for early postoperative anticoagulation. The most commonly reported anticoagulation regimens had the after estimates of early postoperative thromboembolism and hemorrhage: oral anticoagulation alone (0.9%, 3.3%); oral anticoagulation with intravenous unfractionated heparin (1.1%, 7.2%); and oral anticoagulation with low molecular weight heparin (0.6%, 4.8%). Although intravenous heparin may be associated with a higher incidence of hemorrhage, a randomized trial is needed to provide the best evidence regarding early postoperative anticoagulation after mechanical valve implantation. Nearly four decades have passed since the first mechanical prosthetic valves were implanted. Frequent thromboembolic complications with the first mechanical valves led to recommendations of universal anticoagulation for these patients. Since then, several design changes and modifications have been made to improve the longevity, hemodynamics, and thrombogenicity of newer generation mechanical valves. With improved blood flow, less stasis, and less thrombogenic materials, lower rates of thromboembolism have been reported. Despite these advances however, thromboembolism and anticoagulant-related bleeding continue to account for 75% of all complications after mechanical valve replacement. Occurring most commonly within six months after implantation, these complications can adversely affect mortality and quality of life. Furthermore, the threat of their occurrence creates a psychological burden for each patient with a mechanical valve. The need for life-long anticoagulation in patients with mechanical valves is not in dispute, and the perioperative management of anticoagulation during non-cardiac surgery has been reviewed extensively. However, the approach to early postoperative anticoagulation after mechanical valve implantation is still a matter of debate. The optimal intensity and timing of anticoagulation to prevent early thromboembolism after valve replacement surgery without postoperative bleeding complications is unknown. Hence, many anticoagulation protocols have been proposed, but a lack of consensus remains. The objectives of this study were (1) to reexamine the pathogenesis of thrombus formation and the need for anticoagulation; (2) to critically review the literature on early postoperative anticoagulation strategies; and (3) provide an estimate of the incidence of bleeding and thromboembolism for each approach to early postoperative anticoagulation.
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Affiliation(s)
- Alexander Kulik
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa Hospital, Ottawa, Canada
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Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing Committee to Revise the 1998 guidelines for the management of patients with valvular heart disease) developed in collaboration with the Society of Cardiovascular Anesthesiologists endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. J Am Coll Cardiol 2006; 48:e1-148. [PMID: 16875962 DOI: 10.1016/j.jacc.2006.05.021] [Citation(s) in RCA: 1094] [Impact Index Per Article: 60.8] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Bonow RO, Carabello BA, Kanu C, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation 2006; 114:e84-231. [PMID: 16880336 DOI: 10.1161/circulationaha.106.176857] [Citation(s) in RCA: 1391] [Impact Index Per Article: 77.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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ACC/AHA 2006 Practice Guidelines for the Management of Patients With Valvular Heart Disease: Executive Summary. J Am Coll Cardiol 2006. [DOI: 10.1016/j.jacc.2006.05.030] [Citation(s) in RCA: 131] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Gage BF, Yan Y, Milligan PE, Waterman AD, Culverhouse R, Rich MW, Radford MJ. Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillation (NRAF). Am Heart J 2006; 151:713-9. [PMID: 16504638 DOI: 10.1016/j.ahj.2005.04.017] [Citation(s) in RCA: 691] [Impact Index Per Article: 38.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2004] [Accepted: 04/28/2005] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although warfarin and other anticoagulants can prevent ischemic events, they can cause hemorrhage. Quantifying the rate of hemorrhage is crucial for determining the risks and net benefits of prescribing antithrombotic therapy. Our objective was to find a bleeding classification scheme that could quantify the risk of hemorrhage in elderly patients with atrial fibrillation. METHODS We combined bleeding risk factors from existing classification schemes into a new scheme, HEMORR2HAGES, and validated all bleeding classification schemes. We scored HEMORR2HAGES by adding 2 points for a prior bleed and 1 point for each of the other risk factors: hepatic or renal disease, ethanol abuse, malignancy, older (age > 75 years), reduced platelet count or function, hypertension (uncontrolled), anemia, genetic factors, excessive fall risk, and stroke. We used data from quality improvement organizations representing 7 states to assemble a registry of 3791 Medicare beneficiaries with atrial fibrillation. RESULTS There were 162 hospital admissions with an International Classification of Diseases, Ninth Revision, Clinical Modification code for hemorrhage. With each additional point, the rate of bleeding per 100 patient-years of warfarin increased: 1.9 for 0, 2.5 for 1, 5.3 for 2, 8.4 for 3, 10.4 for 4, and 12.3 for > or =5 points. In patients prescribed warfarin, HEMORR2HAGES had greater predictive accuracy (c statistic 0.67) than other bleed prediction schemes (P < .001). CONCLUSIONS Adaptations of existing classification schemes, especially a new bleeding risk scheme, HEMORR2HAGES, can quantify the risk of hemorrhage and aid in the management of antithrombotic therapy.
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Affiliation(s)
- Brian F Gage
- Division of General Medical Sciences, Washington University School of Medicine, St. Louis, MO 63110, USA.
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Butchart EG, Gohlke-Bärwolf C, Antunes MJ, Tornos P, De Caterina R, Cormier B, Prendergast B, Iung B, Bjornstad H, Leport C, Hall RJC, Vahanian A. Recommendations for the management of patients after heart valve surgery. Eur Heart J 2005; 26:2463-71. [PMID: 16103039 DOI: 10.1093/eurheartj/ehi426] [Citation(s) in RCA: 193] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Approximately 50,000 valve replacement operations take place in Europe annually and almost as many valve repair procedures. Previous European guidelines on management of patients after valve surgery were last published in 1995 and were limited to recommendations about antithrombotic prophylaxis. American guidelines covering the broader topic of the investigation and treatment of patients with valve disease were published in 1998 but devoted relatively little space to post-surgical management. This document represents the consensus view of a committee drawn from three European Society of Cardiology (ESC) Working Groups (WG): the WG on Valvular Heart Disease, the WG on Thrombosis, and the WG on Rehabilitation and Exercise Physiology. In almost all areas of patient management after valve surgery, randomized trials and meta-analyses do not exist. Such randomized trials as do exist are very few in number, are narrowly focused with small numbers, have limited general applicability, and do not lend themselves to meta-analysis because of widely divergent methodologies and different patient characteristics. Recommendations are therefore almost entirely based on non-randomized studies and relevant basic science.
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Affiliation(s)
- Eric G Butchart
- Department of Cardiothoracic Surgery, University Hospital of Wales, Cardiff, UK.
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Hering D, Piper C, Horstkotte D. Drug Insight: an overview of current anticoagulation therapy after heart valve replacement. ACTA ACUST UNITED AC 2005; 2:415-22. [PMID: 16119704 DOI: 10.1038/ncpcardio0271] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Vitamin K antagonists, such as warfarin, are the gold standard approach for the long-term anticoagulant therapy of patients with mechanical heart valves. Management decisions are, however, based predominantly on expert consensus and on data from nonrandomized, follow-up studies, which have inherent limitations in their methods. Low-intensity anticoagulation therapy provides protection against thromboembolic complications in patients with most types of modern prosthetic heart valve. The addition of low-dose aspirin is safe if international normalized ratio values below 3.5 are maintained. A combined regimen should be considered in high-risk patients and those with coexistent coronary artery or cerebrovascular disease, and in patients who have suffered a thromboembolic event despite a therapeutic international normalized ratio. Thromboprophylaxis with unfractionated or low-molecular-weight heparins is restricted to specific situations, such as when a patient is intolerant to vitamin K antagonists, when surgical procedures require discontinuation of oral anticoagulation, or when the patient is pregnant. A lack of uniformity across practice guidelines make it difficult to reach treatment decisions. Each patient's preference, expressed after counseling about the risks and benefits of each treatment strategy, and an individual assessment of the patient's risk factors, should guide treatment decisions. At present, new anticoagulant agents such as factor Xa inhibitors do not represent a treatment option for heart valve recipients.
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Affiliation(s)
- Detlef Hering
- Department of Cardiology, Heart Center North Rhine-Westphalia, Ruhr University Bochum, Georgstrasse 11, 32545 Bad Oeynhausen, Germany.
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Abstract
A large number of prosthetic heart valves (PHV) are being implanted in patients with both congenital and acquired valvular disease. Many of the recipients of such valves are women of childbearing age who desire to have children. The main issues involved with pregnancy in a patient with PHV include the selection of PHV in women during their childbearing age, risks to both the mother and the fetus associated with pregnancy and the management of the patients with PHV during gestation.
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Affiliation(s)
- Uri Elkayam
- Heart Failure Program, Division of Cardiovascular Medicine, University of Southern California, Keck School of Medicine, Los Angeles, California 90033, USA.
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Abstract
BACKGROUND Low-dose aspirin is an important therapeutic option in the secondary prevention of myocardial infarction (MI) and ischemic stroke, especially in light of its unique cost-effectiveness and widespread availability. In addition, based on the results of a number of large studies, aspirin is also widely used in the primary prevention of MI. This review provides an update of the available data to offer greater clarity regarding the risks of aspirin with respect to hemorrhagic stroke, as well as insights regarding patient selection to minimize the risk of this complication. SUMMARY OF REVIEW In the secondary prevention of cardiovascular, cerebrovascular, and ischemic events, the evidence supports that the benefits of aspirin treatment significantly outweigh the risk of a major hemorrhage. The evidence from primary prevention of MI studies, including that from the recent Women's Health Study evaluation of aspirin use in healthy women, demonstrate that the increased risk for hemorrhagic stroke is small, is comparable to the secondary prevention studies, and fails to achieve statistical significance. A reasonable estimate of the risk of hemorrhagic stroke associated with the use of aspirin in primary prevention patients is 0.2 events per 1000 patient-years, which is comparable to estimates of the risk associated with the use of aspirin in secondary prevention patients. CONCLUSIONS When considering whether aspirin is appropriate, the absolute therapeutic cardiovascular benefits of aspirin must be balanced with the possible risks associated with its use, with the most serious being hemorrhagic stroke.
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Nouette K, Richebé P, Calderon J, Mouton C, Janvier G. [Perioperative anticoagulation management for prosthetic heart valves]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2005; 24:621-31. [PMID: 15908168 DOI: 10.1016/j.annfar.2005.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2004] [Accepted: 02/26/2005] [Indexed: 05/02/2023]
Abstract
OBJECTIVES The practices and the guidelines over the perioperative management of the anticoagulation of patients with cardiac valves prothesis are the object of no consensual attitude. The thrombotic risk over the time is well known. It depends of the type or the location on the valve, of their associations and the age of the patient. In the perioperative period, the antithrombotic treatment must be interrupted according to the surgical haemorrhagic risk. STUDY DESIGN Short review. RESULTS Only patients, without associated risk factor, carriers of bioprosthesis from more than 3 months, can be maintained only under antiplatelets agents. In others situations, the caution imposes a bridge of anticoagulants from 48 to 72 hours with unfractionated heparin (subcutaneous at home, intravenous at the hospital). Low molecular weight heparin has no commercial authorization in this indication. The resumption of the anticoagulation by unfractionated heparin in postoperative period must be the most premature possible after the decrease of the surgical bleeding. The relay by vitamin K antagonists has to be made over 48 to 72 hours. Within the framework of the urgency, the surgical haemorrhagic risk is weak for an INR <1.5. According to the urgency of the surgery, a treatment by vitamin K (if the delay is over 12 hours) or by prothrombinic complex allows to correct this INR. The identification of thrombotic complications requires a particular attention. In the postoperative period, as soon as there is suspicion of thrombosis, clinical manifestations must be consolidated by the practice of a transoesophageal echography, which only confirm the diagnosis.
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Affiliation(s)
- K Nouette
- Fédération d'anesthésie-réanimation chirurgicale, CHU de Bordeaux, groupe hospitalier Sud, 33604 Pessac cedex, France
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Tominaga R, Kurisu K, Ochiai Y, Tomita Y, Masuda M, Morita S, Yasui H. A 10-Year Experience With the Carbomedics Cardiac Prosthesis. Ann Thorac Surg 2005; 79:784-9. [PMID: 15734377 DOI: 10.1016/j.athoracsur.2004.08.067] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2004] [Indexed: 11/17/2022]
Abstract
BACKGROUND There are few reports on the long-term results of Carbomedics prosthetic heart valves. METHODS Five hundred five patients who underwent valve replacement with this prosthesis in the aortic or mitral position were chosen for this study. Patients' mean age was 57 years. There were 173 aortic (AVR), 253 mitral (MVR), and 79 double (DVR) valve implants. The mean follow-up was 5.1 years, and cumulative follow-up was 2,590 patient-years with an overall follow-up rate of 99.2%. RESULTS The early mortality rate for the total population was 2.8% (AVR 1.2%, MVR 3.6%, DVR 3.8%). Actuarial freedom from thromboembolism at 10 years was 81.8% +/- 5.1%, 85.7% +/- 3.2%, and 88.8% +/- 6.8% for AVR, MVR, and DVR, respectively. At 10 years, 92.7% of AVR, 85.4% of MVR, and 94.7% of DVR patients were free of valve-related death. Overall survival rate at 10 years was 77.6% +/- 4.6%, 71.8% +/- 4.2%, and 81.3% +/- 5.8% for AVR, MVR, and DVR, respectively. The linearized rate of thromboembolism was 1.45%/patient-year, 1.78%/patient-year, 0.67%/patient-year; of major bleeding events, 0.52%/patient-year, 0.85%/patient-year, 0.45%/patient-year; of valve thrombosis, 0%/patient-year, 0.25%/patient-year, 0%/patient-year; of prosthetic valve endocarditis, 0.1%/patient-year, 0.25%/patient-year, 0.22%/patient-year; and of all reoperations, 0.31%/patient-year, 0.93%/patient-year, 1.1%/patient-year for AVR, MVR, and DVR, respectively. CONCLUSIONS The Carbomedics prosthetic heart valves showed comparable or even better results than those of other mechanical valves with respect to morbidity and mortality. These results may justify the use of Carbomedics valves as one of the mechanical heart valves.
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Affiliation(s)
- Ryuji Tominaga
- Department of Cardiovascular Surgery, Kyushu University, Fukuoka, Japan.
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Shireman TI, Howard PA, Kresowik TF, Ellerbeck EF. Combined Anticoagulant–Antiplatelet Use and Major Bleeding Events in Elderly Atrial Fibrillation Patients. Stroke 2004; 35:2362-7. [PMID: 15331796 DOI: 10.1161/01.str.0000141933.75462.c2] [Citation(s) in RCA: 154] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Bleeding risks from combined antiplatelet-warfarin therapy have not been well-described in clinical practice. We examined antiplatelet therapy among warfarin users and the impact on major bleeding rates.
Methods—
Retrospective cohort analysis of persons discharged on warfarin after an atrial fibrillation admission using data from Medicare’s National Stroke Project. Data included Medicare claims, enrollment information, and medical record abstracted data. Logistic regression and Cox proportional hazards models were used to predict concurrent antiplatelet use and hospitalization with a major acute bleed within 90 days after discharge from the index AF admission.
Results—
10 093 warfarin patients met inclusion criteria with a mean age of 77 years; 19.4% received antiplatelet therapy. Antiplatelet use was less common among women, older persons, and persons with cancer, terminal diagnoses, dementia, and bleeding history. Persons with coronary disease were more likely to receive an antiplatelet agent. Antiplatelets increased major bleeding rates from 1.3% to 1.9% (
P
=0.052). In the multivariate analysis, factors associated with bleeding events included age (OR, 1.03; 95% CI, 1.002 to 1.05), anemia (OR, 2.52; 95% CI, 1.64 to 3.88), a history of bleeding (OR, 2.40; 95% CI, 1.71 to 3.38), and concurrent antiplatelet therapy (OR, 1.53; 95% CI, 1.05 to 2.22).
Conclusions—
Although concerns about increased bleeding risk with combined warfarin-antiplatelet therapy are not unfounded, the risk of bleeding is moderately increased. The decision to use concurrent antiplatelet therapy appears to be tempered by cardiac and bleeding risk factors.
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Affiliation(s)
- Theresa I Shireman
- Pharmacy Practice Department, University of Kansas School of Pharmacy, 1251 Wescoe Hall Drive, Lawrence, KS 66045, USA.
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Levine MN, Raskob G, Beyth RJ, Kearon C, Schulman S. Hemorrhagic Complications of Anticoagulant Treatment. Chest 2004; 126:287S-310S. [PMID: 15383476 DOI: 10.1378/chest.126.3_suppl.287s] [Citation(s) in RCA: 318] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
This chapter about hemorrhagic complications of anticoagulant treatment is part of the seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Bleeding is the major complication of anticoagulant therapy. The criteria for defining the severity of bleeding varies considerably between studies, accounting in part for the variation in the rates of bleeding reported. The major determinants of vitamin K antagonist-induced bleeding are the intensity of the anticoagulant effect, underlying patient characteristics, and the length of therapy. There is good evidence that vitamin K antagonist therapy, targeted international normalized ratio (INR) of 2.5 (range, 2.0 to 3.0), is associated with a lower risk of bleeding than therapy targeted at an INR > 3.0. The risk of bleeding associated with IV unfractionated heparin (UFH) in patients with acute venous thromboembolism (VTE) is < 3% in recent trials. This bleeding risk may increase with increasing heparin dosages and age (> 70 years). Low molecular weight heparin (LMWH) is associated with less major bleeding compared with UFH in acute VTE. UFH and LMWH are not associated with an increase in major bleeding in ischemic coronary syndromes, but are associated with an increase in major bleeding in ischemic stroke. Information on bleeding associated with the newer generation of antithrombotic agents has begun to emerge. In terms of treatment decision making for anticoagulant therapy, bleeding risk cannot be considered alone, ie, the potential decrease in thromboembolism must be balanced against the potential increased bleeding risk.
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Affiliation(s)
- Mark N Levine
- Henderson Research Centre, 711 Concession St, Hamilton, Ontario L8V 1C3
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Salem DN, Stein PD, Al-Ahmad A, Bussey HI, Horstkotte D, Miller N, Pauker SG. Antithrombotic Therapy in Valvular Heart Disease—Native and Prosthetic. Chest 2004; 126:457S-482S. [PMID: 15383481 DOI: 10.1378/chest.126.3_suppl.457s] [Citation(s) in RCA: 225] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
This chapter about antithrombotic therapy in native and prosthetic valvular heart disease is part of the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S-187S). Among the key recommendations in this chapter are the following: For patients with rheumatic mitral valve disease and atrial fibrillation (AF), or a history of previous systemic embolism, we recommend long-term oral anticoagulant (OAC) therapy (target international normalized ratio [INR], 2.5; range, 2.0 to 3.0) [Grade 1C+]. For patients with rheumatic mitral valve disease with AF or a history of systemic embolism who suffer systemic embolism while receiving OACs at a therapeutic INR, we recommend adding aspirin, 75 to 100 mg/d (Grade 1C). For those patients unable to take aspirin, we recommend adding dipyridamole, 400 mg/d, or clopidogrel (Grade 1C). In people with mitral valve prolapse (MVP) without history of systemic embolism, unexplained transient ischemic attacks (TIAs), or AF, we recommended against any antithrombotic therapy (Grade 1C). In patients with MVP and documented but unexplained TIAs, we recommend long-term aspirin therapy, 50 to 162 mg/d (Grade 1A). For all patients with mechanical prosthetic heart valves, we recommend vitamin K antagonists (Grade 1C+). For patients with a St. Jude Medical (St. Paul, MN) bileaflet valve in the aortic position, we recommend a target INR of 2.5 (range, 2.0 to 3.0) [Grade 1A]. For patients with tilting disk valves and bileaflet mechanical valves in the mitral position, we recommend a target INR of 3.0 (range, 2.5 to 3.5) [Grade 1C+]. For patients with caged ball or caged disk valves, we suggest a target INR of 3.0 (range, 2.5 to 3.5) in combination with aspirin, 75 to 100 mg/d (Grade 2A). For patients with bioprosthetic valves, we recommend vitamin K antagonists with a target INR of 2.5 (range, 2.0 to 3.0) for the first 3 months after valve insertion in the mitral position (Grade 1C+) and in the aortic position (Grade 2C). For patients with bioprosthetic valves who are in sinus rhythm and do not have AF, we recommend long-term (> 3 months) therapy with aspirin, 75 to 100 mg/d (Grade 1C+).
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Affiliation(s)
- Deeb N Salem
- Tufts New England Medical Center, 750 Washington St, Boston, MA 02111, USA.
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