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Khalid SI, Mirpuri P, Chilakapati S, Kwak A, Mitchell D, Adogwa O, Mehta AI. The Impact of Preoperative Antithrombotic Therapy on the Risks for Thrombo-ischemic Events and Bleeding among Patients Undergoing Elective Spine Surgery. Asian Spine J 2023; 17:1082-1088. [PMID: 38050357 PMCID: PMC10764144 DOI: 10.31616/asj.2023.0125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 07/09/2023] [Accepted: 07/10/2023] [Indexed: 12/06/2023] Open
Abstract
STUDY DESIGN Retrospective matched analysis. PURPOSE To evaluate the effect of antithrombotic drug therapy on the rates of thrombo-ischemic or bleeding events 90 days following elective spine surgery. OVERVIEW OF LITERATURE Thrombo-ischemic and bleeding complications in patients undergoing spine surgery are major causes of morbidity. Many patients who pursue elective spine surgery are concurrently receiving antithrombotic therapy for unrelated conditions; however, at this time, the effects of preoperative antithrombotic use on postoperative bleeding and thrombosis are unclear. METHODS Using an all-payer claims database, patients who underwent elective cervical and lumbar spine interventions between January 1, 2010, and June 30, 2018, were identified. Individuals were categorized into groups taking and not taking antithrombotics. A 1:1 analysis was constructed based on comorbidities found to be independently associated with bleeding or ischemic complications using logistic regression models. The primary outcomes were the rates of thrombo-ischemic events and bleeding complications. RESULTS A total of 660,866 patients were eligible for inclusion. Following the matching procedure, 56,476 patient records were analyzed, with 28,238 in each group. The antithrombotic agent group had significantly greater odds of developing any 90-day thromboischemic event after surgery: deep vein thrombosis (odds ratio [OR], 3.61; 95% confidence interval [CI], 3.06-4.25), pulmonary embolism (OR, 3.93; 95% CI, 3.34-4.62), myocardial infarction (OR, 6.20; 95% CI, 5.69-6.76), and ischemic stroke (OR, 3.76; 95% CI, 3.31-4.27). In addition, the antithrombotic agent group had an increased likelihood of experiencing hematoma (OR, 1.54; 95% CI, 1.35-1.76) and need for transfusion (OR, 2.61; 95% CI, 2.29-2.96). CONCLUSIONS Patients taking antithrombotic medications before elective surgery of the cervical and lumbar spine had increased risks of both ischemic and bleeding events. Spine surgeons should carefully consider these implications when appraising patients for surgery, given the lack of guidelines on perioperative management of antithrombotic agents.
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Affiliation(s)
- Syed I. Khalid
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL,
USA
| | - Pranav Mirpuri
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL,
USA
| | - Sai Chilakapati
- Department of Neurosurgery, University of Texas Southwestern, Dallas, TX,
USA
| | - Angelika Kwak
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL,
USA
| | - Devon Mitchell
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL,
USA
| | - Owoicho Adogwa
- Department of Neurosurgery, University of Cincinnati School of Medicine, Cincinnati, OH,
USA
| | - Ankit I. Mehta
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL,
USA
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Kietaibl S, Ahmed A, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, De Robertis E, Faraoni D, Filipescu DC, Fries D, Godier A, Haas T, Jacob M, Lancé MD, Llau JV, Meier J, Molnar Z, Mora L, Rahe-Meyer N, Samama CM, Scarlatescu E, Schlimp C, Wikkelsø AJ, Zacharowski K. Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022. Eur J Anaesthesiol 2023; 40:226-304. [PMID: 36855941 DOI: 10.1097/eja.0000000000001803] [Citation(s) in RCA: 71] [Impact Index Per Article: 71.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesiology & Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University Vienna, Austria (SK), Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS Trust (AAh), Department of Cardiovascular Sciences, University of Leicester, UK (AAh), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AAf), Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark (AAf), Department of Anaesthesiology & Critical Care, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble-Alpes University Hospital, Grenoble, France (PA), Department of Anaesthesiology & Intensive Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania (GB), Division of Anaesthesia, Analgesia, and Intensive Care - Department of Medicine and Surgery, University of Perugia, Italy (EDR), Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA (DFa), University of Medicine and Pharmacy Carol Davila, Department of Anaesthesiology & Intensive Care, Emergency Institute for Cardiovascular Disease, Bucharest, Romania (DCF), Department of Anaesthesia and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria (DFr), Department of Anaesthesiology & Critical Care, APHP, Université Paris Cité, Paris, France (AG), Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida, USA (TH), Department of Anaesthesiology, Intensive Care and Pain Medicine, St.-Elisabeth-Hospital Straubing, Straubing, Germany (MJ), Department of Anaesthesiology, Medical College East Africa, The Aga Khan University, Nairobi, Kenya (MDL), Department of Anaesthesiology & Post-Surgical Intensive Care, University Hospital Doctor Peset, Valencia, Spain (JVL), Department of Anaesthesiology & Intensive Care, Johannes Kepler University, Linz, Austria (JM), Department of Anesthesiology & Intensive Care, Semmelweis University, Budapest, Hungary (ZM), Department of Anaesthesiology & Post-Surgical Intensive Care, University Trauma Hospital Vall d'Hebron, Barcelona, Spain (LM), Department of Anaesthesiology & Intensive Care, Franziskus Hospital, Bielefeld, Germany (NRM), Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP. Centre - Université Paris Cité - Cochin Hospital, Paris, France (CMS), Department of Anaesthesiology and Intensive Care, Fundeni Clinical Institute, Bucharest and University of Medicine and Pharmacy Carol Davila, Bucharest, Romania (ES), Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Linz and Ludwig Boltzmann-Institute for Traumatology, The Research Centre in Co-operation with AUVA, Vienna, Austria (CS), Department of Anaesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark (AW) and Department of Anaesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany (KZ)
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Moon J, AlFarsi M, Marinescu D, AlQahtani M, Pang A, Ghitulescu G, Vasilevsky CA, Boutros M. Emergency colectomies in the NOAC era: a nationwide analysis demonstrating increased complications. Surg Endosc 2023; 37:660-668. [PMID: 36163564 DOI: 10.1007/s00464-022-09630-y] [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: 09/07/2021] [Accepted: 09/11/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND The use of Non-vitamin K antagonist oral anticoagulants (NOAC) has increased substantially since their introduction in 2010. The lack of readily available reversal agents poses a challenge in perioperative management. The aim of this study was to evaluate the impact of NOACs on the outcomes of emergency colectomies. METHODS All adult patients on long-term anticoagulation who underwent emergency colectomies were identified from the Nationwide Inpatient Sample (NIS) database from 2002 to 2018. Long-term anticoagulation was defined using ICD-9/10 codes. Two cohorts were compared: anticoagulated patients in the pre-NOAC era (2002-2010) and anticoagulated patients in the NOAC era (2010-2018). Outcomes of interest were postoperative surgical complications, mortality and need for transfusion. RESULTS Of 13,218 patients on long-term anticoagulation, 3,264 patients were treated in the pre-NOAC era and 9,954 in the NOAC era. Over the study period, there was a significant increase in the proportion of anticoagulated patients undergoing emergency colectomies (R2 = 0.91). On univariate analysis, anticoagulated patients in the NOAC era were medically more comorbid and had higher rates of postoperative surgical complications (73.3% vs 60.3%, p < 0.001) and mortality (8.2% vs. 6.7%, p = 0.006), but had lower rates of postoperative bleeding (3.5% vs. 4.4%, p = 0.002) and transfusions (38.1% vs. 45.4%, p < 0.001). On multivariable regression, after accounting for clinically significant covariates, anticoagulation in the NOAC era was associated with decreased rates of postoperative bleeding (OR 0.70, 95%CI 0.57-0.88) and transfusions (OR 0.71 95%CI 0.64-0.77) but remained an independent predictor of increased overall postoperative complications (OR 1.26, 95%CI 1.14-1.39). CONCLUSION Prevalence of long-term anticoagulation in patients undergoing emergency colectomies is increasing. Although associated with lower rates of postoperative bleeding and transfusions, anticoagulation in the NOAC era is associated with higher rates of overall postoperative complications. Evidence-based guidelines for perioperative management of patients on NOACs in the emergency colorectal surgery setting are needed.
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Affiliation(s)
- Jeongyoon Moon
- Department of Surgery, McGill University, Montreal, QC, Canada
| | - Maryam AlFarsi
- Department of Surgery, McGill University, Montreal, QC, Canada
| | | | | | - Allison Pang
- Department of Surgery, McGill University, Montreal, QC, Canada
| | | | | | - Marylise Boutros
- Department of Surgery, McGill University, Montreal, QC, Canada.
- Division of Colon and Rectal Surgery, Jewish General Hospital, McGill University, 3755 Cote Ste Catherine, Room G-308, Montreal, QC, H3T 1E2, Canada.
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Gibert A, Lanoiselée J, Janisset L, Pernod G, Ollier E, Delavenne X. Development of a Bayesian estimation tool to determine the optimal duration of apixaban discontinuation before a high‐bleeding risk procedure. Fundam Clin Pharmacol 2022; 36:898-907. [DOI: 10.1111/fcp.12770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 01/25/2022] [Accepted: 02/18/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Audrick Gibert
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase Université de Lyon Saint‐Etienne France
| | - Julien Lanoiselée
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase Université de Lyon Saint‐Etienne France
- Departement d'Anesthésie Réanimation CHU de Saint‐Etienne Saint‐Etienne France
| | - Luc Janisset
- Service des Urgences CHU de Saint‐Etienne Saint‐Etienne France
| | | | - Edouard Ollier
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase Université de Lyon Saint‐Etienne France
| | - Xavier Delavenne
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase Université de Lyon Saint‐Etienne France
- Laboratoire de Pharmacologie Toxicologie CHU de Saint‐Etienne Saint‐Etienne France
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GC. Guía ESC 2020 sobre el diagnóstico y tratamiento del síndrome coronario agudo sin elevación del segmento ST. Rev Esp Cardiol (Engl Ed) 2021. [DOI: 10.1016/j.recesp.2020.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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6
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GCM. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2021; 42:1289-1367. [PMID: 32860058 DOI: 10.1093/eurheartj/ehaa575] [Citation(s) in RCA: 2719] [Impact Index Per Article: 906.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Direct-acting Oral Anticoagulants in Dermatologic Surgery. ACTAS DERMO-SIFILIOGRAFICAS 2020. [DOI: 10.1016/j.adengl.2019.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Cabezas-Calderon V, Bassas Freixas P, García-Patos Briones V. Anticoagulantes orales directos en cirugía dermatológica. ACTAS DERMO-SIFILIOGRAFICAS 2020; 111:357-363. [DOI: 10.1016/j.ad.2019.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 10/02/2019] [Accepted: 10/03/2019] [Indexed: 12/13/2022] Open
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Ferrandis R, Llau JV, Sanz JF, Cassinello CM, González-Larrocha Ó, Matoses SM, Suárez V, Guilabert P, Torres LM, Fernández-Bañuls E, García-Cebrián C, Sierra P, Barquero M, Montón N, Martínez-Escribano C, Llácer M, Gómez-Luque A, Martín J, Hidalgo F, Yanes G, Rodríguez R, Castaño B, Duro E, Tapia B, Pérez A, Villanueva ÁM, Álvarez JC, Sabaté S. Periprocedural Direct Oral Anticoagulant Management: The RA-ACOD Prospective, Multicenter Real-World Registry. TH OPEN 2020; 4:e127-e137. [PMID: 32607466 PMCID: PMC7319799 DOI: 10.1055/s-0040-1712476] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 04/14/2020] [Indexed: 12/23/2022] Open
Abstract
Introduction There is scarce real-world experience regarding direct oral anticoagulants (DOACs) perioperative management. No study before has linked bridging therapy or DOAC-free time (pre-plus postoperative time without DOAC) with outcome. The aim of this study was to investigate real-world management and outcomes. Methods RA-ACOD is a prospective, observational, multicenter registry of adult patients on DOAC treatment requiring surgery. Primary outcomes were thrombotic and hemorrhagic complications. Follow-up was immediate postoperative (24-48 hours) and 30 days. Statistics were performed using a univariate and multivariate analysis. Data are presented as odds ratios (ORs [95% confidence interval]). Results From 26 Spanish hospitals, 901 patients were analyzed (53.5% major surgeries): 322 on apixaban, 304 on rivaroxaban, 267 on dabigatran, 8 on edoxaban. Fourteen (1.6%) patients suffered a thrombotic event, related to preoperative DOAC withdrawal (OR: 1.57 [1.03-2.4]) and DOAC-free time longer than 6 days (OR: 5.42 [1.18-26]). Minor bleeding events were described in 76 (8.4%) patients, with higher incidence for dabigatran (12.7%) versus other DOACs (6.6%). Major bleeding events occurred in 17 (1.9%) patients. Bridging therapy was used in 315 (35%) patients. It was associated with minor (OR: 2.57 [1.3-5.07]) and major (OR: 4.2 [1.4-12.3]) bleeding events, without decreasing thrombotic events. Conclusion This study offers real-world data on perioperative DOAC management and outcomes in a large prospective sample size to date with a high percentage of major surgery. Short-term preprocedural DOAC interruption depending on the drug, hemorrhagic risk, and renal function, without bridging therapy and a reduced DOAC-free time, seems the safest practice.
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Affiliation(s)
- Raquel Ferrandis
- Anaesthesiology and Critical Care, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Juan V. Llau
- Anaesthesiology and Critical Care, Hospital Universitario Doctor Peset, València, Spain
| | - Javier F. Sanz
- Anaesthesiology and Critical Care, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Salomé M. Matoses
- Anaesthesiology and Critical Care, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Vanessa Suárez
- Anaesthesiology and Critical Care, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain
| | - Patricia Guilabert
- Anaesthesiology and Critical Care, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Luís-Miguel Torres
- Anaesthesiology and Critical Care, Hospital Universitario Puerta del Mar, Cadiz, Spain
| | | | - Consuelo García-Cebrián
- Anaesthesiology and Critical Care, Hospital Universitari i Politècnic La Fe, València, Spain
| | - Pilar Sierra
- Anaesthesiology and Critical Care, Fundació Puigvert, Barcelona, Spain
| | - Marta Barquero
- Anaesthesiology and Critical Care, Hospital Parc Taulí, Sabadell, Spain
| | - Nuria Montón
- Anaesthesiology and Critical Care, Hospital Universitari i Politècnic La Fe, València, Spain
| | | | - Manuel Llácer
- Anaesthesiology and Critical Care, Hospital Costa del Sol, Marbella, Spain
| | - Aurelio Gómez-Luque
- Anaesthesiology and Critical Care, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Julia Martín
- Anaesthesiology and Critical Care, Hospital Universitario Doctor Peset, València, Spain
| | - Francisco Hidalgo
- Anaesthesiology and Critical Care, Clínica Universitaria de Navarra, Pamplona, Spain
| | - Gabriel Yanes
- Anaesthesiology and Critical Care, Hospital Virgen del Rocio, Sevilla, Spain
| | - Rubén Rodríguez
- Anaesthesiology and Critical Care, Hospital Universitario de Móstoles, Madrid, Spain
| | - Beatriz Castaño
- Anaesthesiology and Critical Care, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Elena Duro
- Anaesthesiology and Critical Care, Hospital Universitario de Getafe, Madrid, Spain
| | - Blanca Tapia
- Anaesthesiology and Critical Care, Hospital La Paz, Madrid, Spain
| | - Antoni Pérez
- Anaesthesiology and Critical Care, Hospital de Mataró, Mataró, Spain
| | - Ángeles M. Villanueva
- Anaesthesiology and Critical Care, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Juan-Carlos Álvarez
- Anaesthesiology and Critical Care, Hospital Universitario Parc de Salut Mar, Barcelona, Spain
| | - Sergi Sabaté
- Anaesthesiology and Critical Care, Fundació Puigvert, Barcelona, Spain
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Lamperti M, Khozenko A, Kumar A. Perioperative Management of Patients Receiving New Anticoagulants. Curr Pharm Des 2019; 25:2149-2157. [PMID: 31560280 DOI: 10.2174/1381612825666190709220449] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 06/25/2019] [Indexed: 01/01/2023]
Abstract
There is an increased use of oral anticoagulants for the prevention of venous and arterial thrombosis. Vitamin-K antagonists have been used for decades as the main oral anticoagulants but they have the draback a complex therapeutic management, slow onset of action and by a different oral intake caused by dietary vitamin K intake. New non-vitamin K antagonist oral anticoagulants (NOACs) have been developed to overcome the limitations of warfarin. Their management is easier as it requires a fixed daily dose without coagulation monitoring. Although their therapeutic profile is safe, proper attention should be paid in case of unexpected need for the reversal of their coagulation effect and in case a patient needs to have a scheduled surgery. For non-acute cardiac surgery, discontinuation of NOACs should start at least 48 hours prior surgery. Intracranial bleedings associated with NOACs are less dangerous comparing to those warfarin-induced. NOACs need to be stopped ≥24 hours in case of elective surgery for low bleeding-risk procedures and ≥48 hours for high bleeding-risk surgery in patients with normal renal function and 72 hours in case of reduced CrCl < 80. The therapy with NOACs should be resumed from 48 to 72 hours after the procedure depending on the perceived bleeding, type of surgery and thrombotic risks. There are some available NOAC reversal agents acting within 5 to 20 minutes. In case of lack of reversal agent, adequate diuresis, renal replacement therapy and activated charcoal in case of recent ingestion should be considered.
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Affiliation(s)
- Massimo Lamperti
- Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Andrey Khozenko
- Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Arun Kumar
- Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
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[Bridging anticoagulation in patients receiving vitamin K antagonists : Current status]. Internist (Berl) 2019; 59:744-752. [PMID: 29946874 DOI: 10.1007/s00108-018-0447-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Approximately 30% of patients receiving oral anticoagulation using vitamin K antagonists (VKA) require surgery within 2 years. In this context, a clinical decision on the need and the mode of a peri-interventional bridging with heparin is needed. While a few years ago, bridging was almost considered a standard of care, recent study results triggered a discussion on which patients will need bridging at all. Revisiting the currently available recommendations and study results the conclusion can be drawn that the indications for bridging with heparin must nowadays be taken more narrowly and considering the individual patient risk of bleeding and thromboembolism. Bridging with heparin is only needed in patients with a very high risk of thromboembolism. This overview aims to give guidance for a risk-adapted peri-interventional approach to management of patients with a need for long-term anticoagulation using VKA.
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12
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Abstract
A growing number of patients in Germany receive a long-term prophylactic anticoagulation with phenprocoumone or one of the novel direct oral anticoagulants (NOAC), such as dabigatran, rivaroxaban or apixaban. The most common indication for an oral anticoagulant therapy is atrial fibrillation (approximately 75%) where the anticoagulant therapy can reduce the risk for an embolic event, particularly stroke by 60%. Operations carried out during such a therapy can result in major bleeding complications. On the other hand, suspending anticoagulant therapy can lead to an increased risk of thromboembolisms. Thus, the preoperative assessment should address the bleeding risk of the planned operation, the individual risk of thromboembolism, as well as other factors, such as patient age and renal function. If the individual assessment shows a substantial risk of perioperative bleeding when anticoagulant treatment is continued and a substantial risk of thromboembolism if the treatment is suspended, then a perioperative bridging, for example with low molecular weight heparin, is necessary. Perioperative bridging also leads to an increased risk of perioperative bleeding. Thus, undifferentiated bridging for all patients with atrial fibrillation with anticoagulant treatment is not recommended. Instead, the indications for a perioperative bridging should be decided according to individual risk profiles.
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Rossini R, Tarantini G, Musumeci G, Masiero G, Barbato E, Calabrò P, Capodanno D, Leonardi S, Lettino M, Limbruno U, Menozzi A, Marchese UOA, Saia F, Valgimigli M, Ageno W, Falanga A, Corcione A, Locatelli A, Montorsi M, Piazza D, Stella A, Bozzani A, Parolari A, Carone R, Angiolillo DJ. A Multidisciplinary Approach on the Perioperative Antithrombotic Management of Patients With Coronary Stents Undergoing Surgery: Surgery After Stenting 2. JACC Cardiovasc Interv 2019. [PMID: 29519377 DOI: 10.1016/j.jcin.2017.10.051] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Perioperative management of antithrombotic therapy in patients treated with coronary stents undergoing surgery remains poorly defined. Importantly, surgery represents a common reason for premature treatment discontinuation, which is associated with an increased risk in mortality and major adverse cardiac events. However, maintaining antithrombotic therapy to minimize the incidence of perioperative ischemic complications may increase the risk of bleeding complications. Although guidelines provide some recommendations with respect to the perioperative management of antithrombotic therapy, these have been largely developed according to the thrombotic risk of the patient and a definition of the hemorrhagic risk specific to each surgical procedure, key to defining the trade-off between ischemia and bleeding, is not provided. These observations underscore the need for a multidisciplinary collaboration among cardiologists, anesthesiologists, hematologists and surgeons to reach this goal. The present document is an update on practical recommendations for standardizing management of antithrombotic therapy management in patients treated with coronary stents (Surgery After Stenting 2) in various types of surgery according to the predicted individual risk of thrombotic complications against the anticipated risk of surgical bleeding complications. Cardiologists defined the thrombotic risk using a "combined ischemic risk" approach, while surgeons classified surgeries according to their inherent hemorrhagic risk. Finally, a multidisciplinary agreement on the most appropriate antithrombotic treatment regimen in the perioperative phase was reached for each surgical procedure.
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Affiliation(s)
- Roberta Rossini
- Dipartimento Emergenze e Aree Critiche, Ospedale Santa Croce e Carle, Cuneo, Italy.
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Giuseppe Musumeci
- Dipartimento Emergenze e Aree Critiche, Ospedale Santa Croce e Carle, Cuneo, Italy
| | - Giulia Masiero
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Emanuele Barbato
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Paolo Calabrò
- Division of Cardiology, Department of Cardio-Thoracic Sciences, Università degli Studi della Campania "Luigi Vanvitelli," Naples, Italy
| | - Davide Capodanno
- Division of Cardiology, Cardio-Thoracic-Vascular Department, Azienda Ospedaliero Universitaria "Policlinico-Vittorio Emanuele, Catania, Italy; Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | - Sergio Leonardi
- Coronary Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Maddalena Lettino
- Cardiovascular Department, Humanitas Research Hospital, Rozzano, Italy
| | - Ugo Limbruno
- U.O.C. Cardiologia, Azienda USL Toscana Sudest, Grosseto, Italy
| | - Alberto Menozzi
- Unità Operativa di Cardiologia, Azienda Ospedaliero-Universitaria di Parma, Italy
| | - U O Alfredo Marchese
- U.O.C. Cardiologia Interventistica, Anthea Hospital, GVM Care & Research, Bari, Italy
| | - Francesco Saia
- Cardiology Unit, Cardio-Thoraco-Vascular Department, University Hospital of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Marco Valgimigli
- Swiss Cardiovascular Centre Bern, Bern University Hospital, Bern, Switzerland
| | - Walter Ageno
- Degenza Breve Internistica e Centro Trombosi ed Emostasi, Dipartimento di Medicina e Chirurgia, Università dell'Insubria, Varese, Italy
| | - Anna Falanga
- Department of Immunohematology and Transfusion Medicine, Thrombosis and Hemostasis Center, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Antonio Corcione
- Department of Anaesthesia and Critical Care, AORN Dei Colli, Naples, Italy
| | - Alessandro Locatelli
- Dipartimento Emergenze e Aree Critiche, Ospedale Santa Croce e Carle, Cuneo, Italy
| | - Marco Montorsi
- Dipartimento di Chirurgia Generale, Humanitas Research Hospital and University, Milano, Italy
| | - Diego Piazza
- Policlinico Vittorio Emanuele di Catania, Catania, Italy
| | - Andrea Stella
- Chirurgia Vascolare, Università di Bologna, Ospedale Sant'Orsola-Malpighi, Bologna, Italy
| | - Antonio Bozzani
- UOC Chirurgia Vascolare, Dipartimento di Scienze Chirurgiche, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Alessandro Parolari
- Dipartimento di Scienze Biomediche per la Salute, Policlinico San Donato IRCCS, University of Milano, Milan, Italy
| | - Roberto Carone
- Azienda Ospedaliera Universitaria Città della salute e della scienza, Torino, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida, College of Medicine-Jacksonville, Jacksonville, Florida
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14
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Lott A, Haglin J, Belayneh R, Konda SR, Leucht P, Egol KA. Surgical Delay Is Not Warranted for Patients With Hip Fractures Receiving Non-Warfarin Anticoagulants. Orthopedics 2019; 42:e331-e335. [PMID: 30913296 DOI: 10.3928/01477447-20190321-02] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 09/14/2018] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to evaluate whether patients with hip fractures receiving antiplatelet and direct oral anticoagulants treated within 48 hours of admission had worse surgical and clinical outcomes than those whose surgery was delayed more than 48 hours. Consecutive patients 55 years and older with an operatively treated hip fracture were analyzed. Patients receiving the following anticoagulants were included: antiplatelet drugs, factor Xa inhibitors, and direct thrombin inhibitors. Outcomes included surgical blood loss, procedure time, transfusion requirement, length of stay, complication rate, and need for intensive care unit or step-down unit level care. Patients who underwent surgery within 48 hours of presentation were compared with patients whose surgery was delayed more than 48 hours. Of 551 consecutive operative hip fracture patients, 78 (14.2%) were receiving the anticoagulant medications included in this study. Of these 78 patients, 58 had surgery within 48 hours and 20 had surgery after 48 hours. When comparing the early and delayed fixation cohorts, there was no difference in transfusion requirement, length of surgery, or blood loss. Type of anticoagulant made no difference in transfusion requirement, blood loss, or length of surgery. There was also no difference in the mean number of complications or in the need for intensive care unit or step-down unit level care. In this study, patients receiving antiplatelet therapy, factor Xa inhibitors, or direct thrombin inhibitors who underwent surgical fixation of their hip fracture within 48 hours of admission were at no higher risk for transfusion, increased surgical blood loss, longer operative time, or inpatient mortality. [Orthopedics. 2019; 42(3):e331-e335.].
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15
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Radoï L, Hajage D, Giboin C, Maman L, Monnet-Corti V, Descroix V, Mahé I. Perioperative management of oral anticoagulated patients undergoing an oral, implant, or periodontal procedure: a survey of practices of members of two dental scientific societies, the PRADICO study. Clin Oral Investig 2019; 23:4311-4323. [PMID: 30887189 DOI: 10.1007/s00784-019-02877-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 03/06/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Studies on the perioperative management of patients on direct oral anticoagulants (DOACs) receiving oral invasive procedures are sparse. Moreover, the recommendations of the scientific societies on DOACs are discordant, and the practices are highly variable. We conducted a survey of general and specialized dentists in France to compare their practices concerning the management of patients receiving vitamin K antagonists (VKAs) and DOACs. MATERIALS AND METHODS Members of two dental surgical societies were invited to participate in the survey. One hundred forty-one practitioners answered an online questionnaire focusing on the periprocedural management of oral anticoagulated patients (participation rate, 17.8%). RESULTS Practitioners at hospitals or mixed practices and specialists treated significantly more anticoagulated patients and more frequently performed procedures with high hemorrhagic risk than practitioners with private practice and general dentists. Greater than 90% of practitioners did not modify the treatment for patients on VKAs and controlled the International Normalized Ratio (INR) preoperatively. Regarding DOACs, 62.9% of practitioners did not change the treatment, 70.8% did not prescribe any biological tests, and 13.9% prescribed an INR. Practitioners at hospitals and mixed practices and specialists had better training and knowledge about DOACs. CONCLUSIONS This survey showed that anticoagulated patients were managed mostly by specialists in private or hospital care, notably when requiring oral procedures at high hemorrhagic risk. CLINICAL RELEVANCE A growing proportion of anticoagulated patients are being treated by dentists in primary care. Consequently, they need training, especially concerning DOACs. Additionally, consensus recommendations are necessary for better coordination of stakeholders and patient safety. Trial registration on ClinicalTrials.gov : NCT03150303.
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Affiliation(s)
- Loredana Radoï
- Faculté de chirurgie dentaire, Département de médecine orale et de chirurgie orale, Université Paris Descartes, Paris, France. .,Département de chirurgie orale, AP-HP, Hôpital Louis Mourier, Colombes, France.
| | - David Hajage
- Département Biostatistique Santé Publique et Information Médicale, Centre de Pharmacoépidémiologie (Cephepi), Sorbonne Université, CIC-1421, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| | - Caroline Giboin
- Département Biostatistique Santé Publique et Information Médicale, Centre de Pharmacoépidémiologie (Cephepi), Sorbonne Université, CIC-1421, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| | - Louis Maman
- Faculté de chirurgie dentaire, Département de médecine orale et de chirurgie orale, Université Paris Descartes, Paris, France.,Département de chirurgie orale, AP-HP, Hôpital Charles Foix, Ivry-sur-Seine, France
| | - Virginie Monnet-Corti
- Département de parodontologie, AP-HM, Hôpital de la Timone, Marseille, France.,Faculté de Chirurgie Dentaire, Département de parodontologie, Université Aix-Marseille, Marseille, France
| | - Vianney Descroix
- Département d'odontologie, AP-HP, Hôpitaux Universitaires Pitié-Salpêtrière-Charles Foix, Paris, France
| | - Isabelle Mahé
- Faculté de Pharmacie, Inserm UMR_S1140, Paris, France.,Université Paris Diderot, Paris, France.,Hôpital Louis Mourier, AP-HP, Colombes, France
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16
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Kai AM, Vadivelu N, Urman RD, Shukla S, Schonberger R, Banack T. Perioperative Considerations in the Management of Anticoagulation Therapy for Patients Undergoing Surgery. Curr Pain Headache Rep 2019; 23:13. [PMID: 30796535 DOI: 10.1007/s11916-019-0747-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW As ambulatory surgery has become increasingly more common, the appropriate management of anticoagulation therapy in patients undergoing invasive procedures has become progressively more relevant to healthcare professionals. The purpose of this literature review is to provide an overview of current common anaticoagulants and their pharmacological properties and to evaluate recent relevant literature and bridging therapy and provide recommendations on risk-guided therapy. RECENT FINDINGS With the development of new drugs and the advancing study and practice of anticoagulation use, clinicians must keep up-to-date on the optimal management of patients requiring anticoagulation. NOACs and warfarin continue to be the mainstays of treatment, with varying timelines regarding when to hold administration of the different agents within the perioperative period. There are numerous factors that are considered in patients with multiple comorbidities including the risk for stroke on long-term anticoagulation and risk for thromboembolism, particularly in the perioperative setting when certain medication regimens may be altered and/or briefly held. There is ongoing investigation whether certain NOACs have more efficacy or greater safety profiles, depending on the degree of surgical intervention.
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Affiliation(s)
- Alice M Kai
- Department of Internal Medicine, NYU-Winthrop Hospital, 222 Station Plaza North Suite 598, Mineola, NY, USA.
| | - Nalini Vadivelu
- Department of Anesthesiology, Yale University School of Medicine, TMP3 333, Cedar Street, New Haven, CT, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, USA
| | - Shikha Shukla
- Department of Anesthesiology, Yale University School of Medicine, TMP3 333, Cedar Street, New Haven, CT, USA
| | - Rob Schonberger
- Department of Anesthesiology, Yale University School of Medicine, TMP3 333, Cedar Street, New Haven, CT, USA
| | - Trevor Banack
- Department of Anesthesiology, Yale University School of Medicine, TMP3 333, Cedar Street, New Haven, CT, USA
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17
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Spahn DR, Beer JH, Borgeat A, Chassot PG, Kern C, Mach F, Nedeltchev K, Korte W. NOACs in Anesthesiology. Transfus Med Hemother 2019; 46:282-293. [PMID: 31700511 DOI: 10.1159/000491400] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 06/17/2018] [Indexed: 12/29/2022] Open
Abstract
Background Due to increasing use of new oral anticoagulants (NOACs), clinicians are faced more and more frequently with clinical issues related to these drugs. Objective The objective of this publication is to make practical suggestions for the perioperative management of NOACs as well as for their handling in overdoses and bleedings. Recommendations In elective surgery and creatinine clearance ≥ 50 ml/min, a NOAC should be discontinued 24-36 h before the intervention, and even earlier in case of reduced kidney function. In emergency interventions that cannot be delayed, the management is dependent on the NOAC plasma levels. With levels ≤ 30 ng/ml, surgery can be performed. With levels >30 ng/ml, reversal agents should be considered. In low bleeding risk surgery, NOACs can be re-started 24 h after the intervention, which is prolonged to 48-72 h after surgery with high bleeding risk. In case of NOAC overdose and minor bleedings, temporary discontinuation and supportive care are usually sufficient to control the situation. In severe or life-threatening bleedings, nonspecific and specific reversal agents should be considered.
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Affiliation(s)
- Donat R Spahn
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Jürg-Hans Beer
- Department of Internal Medicine, Cantonal Hospital of Baden, Baden, Switzerland
| | - Alain Borgeat
- Department of Anesthesiology, Balgrist University Hospital, Zurich, Switzerland
| | - Pierre-Guy Chassot
- Formerly Department of Anesthesiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Christian Kern
- Department of Anesthesiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - François Mach
- Department of Internal Medicine, University Hospitals of Geneva (HUG), Geneva, Switzerland
| | | | - Wolfgang Korte
- Center for Laboratory Medicine; Hemostasis and Hemophilia Center, St. Gallen, Switzerland
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18
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Coscarella M, Motte S, Dalati MF, Oliveira-E-Silva T, Entezari K, Roumeguere T. New oral anti-coagulation drugs and prostate biopsy: a call for guidelines. Ther Adv Urol 2018; 10:437-443. [PMID: 30574204 PMCID: PMC6295786 DOI: 10.1177/1756287218811037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Accepted: 10/11/2018] [Indexed: 01/14/2023] Open
Abstract
Background: Prostate biopsy is a rather frequent procedure, mostly performed in outpatient settings. Bleeding complications following this procedure require precise and delicate management of pre-, peri- and post-procedure anti-coagulation treatments. New oral anti-coagulation drugs (NOACs) are increasingly used. However, the management of such treatments is feared and not yet well known to urologists. A protocol for prostate biopsy management of NOACs seems mandatory. Materials and methods: A review of the literature, using Pubmed and Cochrane databases, together with analysis of several medical associations’ recommendations in urology, anaesthesiology, cardiology, oncology and drug safety agency, was performed. Results: There are no recommendations about NOAC management for prostate biopsy available from scientific societies. There is also a lack of specific urological studies. However, several panels of expert recommendations could be helpful in establishing standardized protocols adapted from surgery to prostate biopsy. With the growing use of NOACs, recommendations have shifted to continue anti-coagulant treatment without bridging NOACs for low bleeding risk procedures such as prostate biopsy, in carefully selected groups of patients. Conclusion: Extensive indications coupled with the ease of use of NOACs contribute significantly to the widespread replacement of traditional vitamin K antagonist. Knowing that heparin bridging leads to more bleeding, and in the pursuit of more autonomy and safety, urologists should be able to propose dedicated anti-coagulant management using NOACs adapted to carefully selected patients before the prostate biopsy procedure. Further studies and guidelines specific to the concept of non-bridging for anti-coagulant-requiring patients are mandatory for this routine procedure.
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Affiliation(s)
- Mathieu Coscarella
- Department of Urology, Erasme Hospital, University Clinics of Brussels, Route de Lennik 808, 1070 Brussels, Belgium Department of Urology, CHU St Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Serge Motte
- Department of Vascular Diseases, University Clinics of Brussels, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Mohamad-Fadi Dalati
- Department of Urology, CHU Saint Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Tania Oliveira-E-Silva
- Department of Urology, CHU Saint Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Kim Entezari
- Department of Urology, CHU Saint Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Thierry Roumeguere
- Department of Urology, University Clinics of Brussels, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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19
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Spyropoulos AC, Myrka A, Triller DM, Ragan S, York C, King JM, Lee TK. Uptake and Utilization of the Management of Anticoagulation in the Periprocedural Period App: Longitudinal Analysis. JMIR Mhealth Uhealth 2018; 6:e11090. [PMID: 30578235 PMCID: PMC6320435 DOI: 10.2196/11090] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 08/10/2018] [Accepted: 08/14/2018] [Indexed: 01/21/2023] Open
Abstract
Background Anticoagulants are major contributors to preventable adverse drug events, and their optimal management in the periprocedural period is particularly challenging. Traditional methods of disseminating clinical guidelines and tools cannot keep pace with the rapid expansion of available therapeutic agents, approved indications for use, and published medical evidence, so a mobile app, Management of Anticoagulation in the Periprocedural Period (MAPPP), was developed and disseminated to provide clinicians with guidance that reflects the most current medical evidence. Objective The objective of this study was to assess the global, national, and state-level acquisition of a mobile app since its initial release and characterize individual episodes of use based on drug selection, procedural bleeding risk, and patient thromboembolic risk. Methods Data were extracted from a mobile app usage tracker (Google Analytics) to characterize new users and completed episodes temporally (by calendar quarter) and geographically (globally, nationally, and in the targeted US state of New York) for the period between April 1, 2016 and September 30, 2017. Results The app was acquired by 2866 new users in the measurement period, and the users completed nearly 10,000 individual episodes of use. Acquisition and utilization spanned 51 countries globally, predominantly in the United States and particularly in New York State. Warfarin and rivaroxaban were the most frequently selected drugs, and completed episodes most frequently included the selection of high bleeding risk (4888/9963, 49.06%) and high thromboembolic risk categories (4500/9963, 45.17%). Conclusions The MAPPP app is a successful means of disseminating current guidance on periprocedural anticoagulant use, as indicated by broad global uptake and upward trends in utilization. Limitations in access to provider and patient-specific data preclude objective evaluation of the clinical impact of the app. An ongoing study incorporating app logic into electronic health record systems at participant health systems will provide a more definitive evaluation of the clinical impact of the app logic.
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Affiliation(s)
- Alex C Spyropoulos
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, United States
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20
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Ibrahim A, Walsh LG, Algaali M, Satti Z, Kiernan TJ, Yan BP. Insight into the perioperative management of direct oral anticoagulants: concerns and considerations. Expert Opin Pharmacother 2018; 20:465-472. [PMID: 30521411 DOI: 10.1080/14656566.2018.1551879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Direct oral anticoagulants (DOACs) have gained momentum in recent years in patients requiring anticoagulation for the prevention and management of venous thromboembolism and thromboembolic events caused by atrial fibrillation. The use of these agents involves potential bleeding complications, particularly during invasive procedures. With increasing use of DOACs, adequate knowledge regarding the perioperative management of patients on DOACs has become indispensable. AREAS COVERED This review covers the indications, mechanism of action, and pharmacokinetics of DOACs and their management in different perioperative settings based on various current guidelines and practices. The role of bridging therapy with heparin and the recently developed reversal agents are also discussed. EXPERT OPINION The perioperative management of DOACs is influenced by drug pharmacokinetics, potential comorbidities of the patient and perioperative thrombotic and bleeding risk. In low bleeding risk and minor procedures, continuing DOACs seems to be safe. Interrupting DOACs in high-risk procedures might be necessary and should be based on the elimination half-life of the drug and renal function of the patient. Further research is needed to better clarify the role of recently developed reversal agents in the perioperative setting and to identify specific laboratory tests to guide the perioperative management of DOACs.
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Affiliation(s)
- Abdalla Ibrahim
- a Cardiology Department , University Hospital Limerick , Limerick , Ireland
| | - Leon G Walsh
- b Department of Surgery , University Hospital Limerick , Limerick , Ireland
| | - Mohamed Algaali
- a Cardiology Department , University Hospital Limerick , Limerick , Ireland
| | - Zahir Satti
- a Cardiology Department , University Hospital Limerick , Limerick , Ireland
| | - Thomas J Kiernan
- c Division of Cardiology, Department of Medicine , University Hospital Limerick, Graduate Entry Medical School (GEMS), University of Limerick , Limerick , Ireland
| | - Bryan P Yan
- d Division of Cardiology, Department of Medicine and Therapeutics , The Chinese University of Hong Kong, Prince of Wales Hospital , Hong Kong , China
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21
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Atia R, Bonnel S, Vallos M, Laroche L, Borderie V, Bouheraoua N. [Spontaneous choroidal hemorrhage associated with novel oral anticoagulants: A report of two cases and literature review]. J Fr Ophtalmol 2018; 41:767-772. [PMID: 30213607 DOI: 10.1016/j.jfo.2018.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 01/14/2018] [Accepted: 01/15/2018] [Indexed: 11/16/2022]
Abstract
New direct oral anticoagulants (DOAC) have been approved for treatment and prevention of some thromboembolic diseases: acute and chronic phase of thromboembolic disease, deep venous thrombosis prophylaxis in orthopedic surgery and prevention of stroke in patients with atrial fibrillation. These molecules are an alternative to heparins and vitamin K antagonists. Among these, rivaroxaban (Xarelto®, Bayer Schering Pharma) is a direct factor Xa inhibitor, and dabigatran etexilate (Pradaxa®, Boehringer Ingelheim) is a direct free thrombin inhibitor. These molecules are almost the ideal anticoagulant: oral administration, few drug and food interactions, wide therapeutic target, and especially no lab monitoring. However, their use remains associated with hemorrhagic complications such as gastrointestinal, intracranial or urinary hemorrhages. We describe two clinical cases of spontaneous choroidal hemorrhage in patients treated with direct oral anticoagulants (rivaroxaban and dabigatran etexilate) for atrial fibrillation. These cases show that an ocular hemorrhagic risk exists with these drugs. Patients treated with DOAC should have the therapeutic dose adjusted based on creatinine clearance. Special monitoring should be performed in patients with age-related macular degeneration or with hypertension even though meta-analysis shows that the risk of intraocular bleeding is reduced by 22% compared with warfarin.
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Affiliation(s)
- R Atia
- Service d'ophtalmologie 5, centre national d'ophtalmologie des Quinze-Vingts, UPMC, Sorbonne université, 28, rue de Charenton, 75012 Paris, France
| | - S Bonnel
- Service d'ophtalmologie 5, centre national d'ophtalmologie des Quinze-Vingts, UPMC, Sorbonne université, 28, rue de Charenton, 75012 Paris, France
| | - M Vallos
- Service d'hématologie, hôpital de la pitié salpêtrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - L Laroche
- Service d'ophtalmologie 5, centre national d'ophtalmologie des Quinze-Vingts, UPMC, Sorbonne université, 28, rue de Charenton, 75012 Paris, France; INSERM UMR S 968, UPMC, institut de la Vision, Sorbonne université, 17 rue Moreau, 75012 Paris, France
| | - V Borderie
- Service d'ophtalmologie 5, centre national d'ophtalmologie des Quinze-Vingts, UPMC, Sorbonne université, 28, rue de Charenton, 75012 Paris, France; INSERM UMR S 968, UPMC, institut de la Vision, Sorbonne université, 17 rue Moreau, 75012 Paris, France
| | - N Bouheraoua
- Service d'ophtalmologie 5, centre national d'ophtalmologie des Quinze-Vingts, UPMC, Sorbonne université, 28, rue de Charenton, 75012 Paris, France; INSERM UMR S 968, UPMC, institut de la Vision, Sorbonne université, 17 rue Moreau, 75012 Paris, France.
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22
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Schellong SM, Riess H, Spannagl M, Omran H, Schwarzbach M, Langer F, Gogarten W, Bramlage P, Bauersachs RM. [Bridging anticoagulation in patients receiving vitamin K antagonists : Current status]. Anaesthesist 2018; 67:599-606. [PMID: 29926118 DOI: 10.1007/s00101-018-0463-0] [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: 12/11/2022]
Abstract
Approximately 30% of patients receiving oral anticoagulation using vitamin K antagonists (VKA) require surgery within 2 years. In this context, a clinical decision on the need and the mode of a peri-interventional bridging with heparin is needed. While a few years ago, bridging was almost considered a standard of care, recent study results triggered a discussion on which patients will need bridging at all. Revisiting the currently available recommendations and study results the conclusion can be drawn that the indications for bridging with heparin must nowadays be taken more narrowly and considering the individual patient risk of bleeding and thromboembolism. Bridging with heparin is only needed in patients with a very high risk of thromboembolism. This overview aims to give guidance for a risk-adapted peri-interventional approach to management of patients with a need for long-term anticoagulation using VKA.
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Affiliation(s)
- S M Schellong
- Medizinische Klinik 2, Krankenhaus Dresden-Friedrichstadt, Friedrichstr. 41, 01067, Dresden, Deutschland.
| | - H Riess
- Medizinische Klinik mit Schwerpunkt Hämatologie, Onkologie und Tumorimmunologie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - M Spannagl
- Hämostaseologie, Campus Innenstadt, Klinikum der Universität München, München, Deutschland
| | - H Omran
- St. Marien Hospital, Bonn, Deutschland
| | - M Schwarzbach
- Klinik für Allgemein‑, Viszeral‑, Gefäß- und Thoraxchirurgie, Klinikum Frankfurt Höchst, Frankfurt, Deutschland
| | - F Langer
- II. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - W Gogarten
- Klinik für Anästhesiologie, operative Intensivmedizin, Notfallmedizin und Schmerztherapie, Klinikum Bielefeld, Bielefeld, Deutschland
| | - P Bramlage
- Institut für Pharmakologie und Präventive Medizin, Cloppenburg, Deutschland
| | - R M Bauersachs
- Klinik für Gefäßmedizin - Angiologie, Klinikum Darmstadt GmbH, Darmstadt, Deutschland.,Centrum für Thrombose und Hämostase, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
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23
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Ye JB, Sul YH, Lee JY, Go SJ, Choi JH. Adaptation of New Oral Anticoagulants for Warfarin Anticoagulated Patient with Traumatic Ongoing Hemorrhage. JOURNAL OF ACUTE CARE SURGERY 2018. [DOI: 10.17479/jacs.2018.8.1.33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Jin Bong Ye
- Department of Trauma Surgery, Chungbuk National University Hospital, Cheongju, Korea
| | - Young Hoon Sul
- Department of Trauma Surgery, Chungbuk National University Hospital, Cheongju, Korea
| | - Jin Young Lee
- Department of Trauma Surgery, Chungbuk National University Hospital, Cheongju, Korea
| | - Seung Je Go
- Department of Trauma Surgery, Chungbuk National University Hospital, Cheongju, Korea
| | - Jung Hee Choi
- Department of Anesthesiology and Pain Medicine, Chungbuk National University Hospital, Cheongju, Korea
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Olivera P, Gabilondo M, Constans M, Tàssies D, Plensa E, Pons V, Las Heras G, Jiménez C, Campoy D, Bustins A, Oliver A, Marzo C, Canals T, Varela A, Sorigue M, Sánchez E, Ene G, Perea G, Vicente L, López M, Cerdá M, Johansson E, Aguinaco MR, Santos N, Mateo J, Reverter JC, Moya Á, Santamaría A. Tromboc@t Working Group recommendations for management in patients receiving direct oral anticoagulants. Med Clin (Barc) 2018; 151:210.e1-210.e13. [PMID: 29602444 DOI: 10.1016/j.medcli.2018.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 01/07/2018] [Accepted: 01/25/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND AND OBJECTIVES In recent years, direct oral anticoagulants (DOACs) have become an alternative to vitamin K antagonists (VKA) for the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (NVAF) as well as for prevention and treatment of deep venous thrombosis. Pivotal trials have demonstrated non-inferiority and potential superiority compared to warfarin, which increases the options of anticoagulant treatment. In our setting, the Anticoagulant Treatment Units (ATUs) and Primary Care Centres (PCCs) play an important role in the education, follow-up, adherence control and management in special situations of anticoagulated patients. These considerations have motivated us to elaborate the present consensus document that aims to establish clear recommendations that incorporate the findings of scientific research into clinical practice to improve the quality of care in the field of anticoagulation. MATERIAL AND METHODS A group of experts from the Catalan Thrombosis Group (TROMBOC@T) reviewed all published literature from 2009 to 2016, in order to provide recommendations based on clinical evidence. RESULTS As a result of the project, a set of practical recommendations have been established that will facilitate treatment, education, follow-up and management in special situations of anticoagulated patients with ACODs. CONCLUSIONS Progressive increase in the use of DOACs calls for measures to establish and homogenise clinical management guidelines for patients anticoagulated with DOACs in ATUs and PCCs.
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Affiliation(s)
- Pável Olivera
- Unidad de Trombosis y Hemostasia, Departamento de Hematología, Hospital Universitari Vall d' Hebron, Barcelona, España
| | - Miren Gabilondo
- Departamento de Hematología, Hospital Universitario Araba Txagorritxu, Vitoria, España
| | - Mireia Constans
- Unidad de Trombosis y Hemostasia, Departamento de Hematología, Hospital Universitari Vall d' Hebron, Barcelona, España
| | - Dolors Tàssies
- Unidad de Hemostasia y Trombosis, Departamento de Hemoterapia y Hemostasia (ICMHO), Hospital Clínic, Barcelona, España
| | - Esther Plensa
- Departamento de Hematología, Consorci Sanitari del Maresme, Mataró, España
| | - Verónica Pons
- Unidad de Trombosis y Hemostasia, Departamento de Hematología, Hospital Universitari Vall d' Hebron, Barcelona, España
| | - Germán Las Heras
- Departamento de Hematología, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, España
| | - Carmen Jiménez
- Departamento de Hematología, Hospital del Mar , Barcelona, España
| | - Desirée Campoy
- Departamento de Hematología, Hospital Universitari Sagrat Cor, Barcelona, España
| | - Anna Bustins
- Departamento de Hematología, Hospital Universitari Doctor Josep Trueta, Girona, España
| | - Artur Oliver
- Departamento de Hematología, Fundació Puigvert, Barcelona, España
| | - Cristina Marzo
- Departamento de Hematología, Hospital Universitari Arnau de Vilanova, Lleida, España
| | - Tania Canals
- Unidad de Trombosis y Hemostasia, Departamento de Hematología, Hospital Universitari Vall d' Hebron, Barcelona, España
| | - Anna Varela
- Unidad de Trombosis y Hemostasia, Departamento de Hematología, Hospital Universitari Vall d' Hebron, Barcelona, España
| | - Marc Sorigue
- Unidad de Trombosis y Hemostasia, Hospital Universitari Germans Trias i Pujol, Badalona, España
| | - Eva Sánchez
- Unidad de Trombosis y Hemostasia, Departamento de Hematología, Hospital Universitari Vall d' Hebron, Barcelona, España
| | - Gabriela Ene
- Departamento de Hematología, Hospital Sant Joan de Déu de Martorell , España
| | - Granada Perea
- Departemento de Hematología, Corporació Sanitaria Parc Taulí, Sabadell, España
| | - Laura Vicente
- Departamento de Hematología, Consorci Sanitari de Terrasa - Hospital de Terrasa, , España
| | - Meritxell López
- Departamento de Hematología, Hospital Universitario Mútua Terrassa, España
| | - María Cerdá
- Unidad de Trombosis y Hemostasia, Departamento de Hematología, Hospital Universitari Vall d' Hebron, Barcelona, España
| | - Erik Johansson
- Unidad de Trombosis y Hemostasia, Departamento de Hematología, Hospital Universitari Vall d' Hebron, Barcelona, España
| | - M Reyes Aguinaco
- Departamento de Hematología, Hospital Universitari Joan XXIII , Tarragona, España
| | - Nazly Santos
- Departamento de Hematología, Hospital Universitari Arnau de Vilanova, Lleida, España
| | - José Mateo
- Unidad de Trombosis y Hemostasia, Departamento de Hematología, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | | | - Ángel Moya
- Unidad de Arritmias, Departamento de Cardiología, Hospital Universitari Vall d' Hebron, Barcelona, España
| | - Amparo Santamaría
- Unidad de Trombosis y Hemostasia, Departamento de Hematología, Hospital Universitari Vall d' Hebron, Barcelona, España.
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Taranu R, Redclift C, Williams P, Diament M, Tate A, Maddox J, Wilson F, Eardley W. Use of Anticoagulants Remains a Significant Threat to Timely Hip Fracture Surgery. Geriatr Orthop Surg Rehabil 2018; 9:2151459318764150. [PMID: 29619276 PMCID: PMC5871052 DOI: 10.1177/2151459318764150] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 01/22/2018] [Indexed: 12/15/2022] Open
Abstract
Introduction: Hip fracture remains the biggest single source of morbidity and mortality in the elderly trauma population, and any intervention focused on quality improvement and system efficiency is beneficial for both patients and clinicians. Two of the variables contributory to improving care and efficiency are time to theater and length of stay, with the overall goal being to improve care as reflected within the achievement of best practice tariff. One of the biggest barriers to optimizing these variables is preinjury anticoagulation. Method: Building on our previous work with warfarin in this population, we utilized a regional hip fracture collaborative network collecting prospective data through the National Hip Fracture Database with custom fields pertaining to all agents, including novel oral anticoagulants. Results: In all, 1965 hip fracture patients median age 83 years (1639 not anticoagulated) were admitted to the 5 centers over 12 months. Median length of stay was 20.71 days; time to theater 23.09 hours, and the populations (anticoagulated vs control) were evenly matched for injury. Anticoagulated patients were delayed to theater (P ≤ .001), were inpatients for longer (P ≤ .001) and gained less best practice tariff (P ≤ .05). All variables per agent were noted and the impact of each assessed. Conclusions: Despite the widespread use of newer anticoagulants, popular due to unmonitored reversal and administration, patients stay longer in hospital and wait longer for surgery than nonanticoagulated patients of the same age and injury. Contemporary perioperative practices impact negatively on the ability to perform timely surgery on hip fracture patients. We propose a guideline specific to the management of anticoagulation in the hip fracture population to aid the optimum preparation of patients for theater, achievement of timely surgery, and potentially reduce length of stay.
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Affiliation(s)
- Razvan Taranu
- James Cook University Hospital, Middlesbrough, United Kingdom
| | | | - Patrick Williams
- ST5 Trauma and Orthopaedics, James Cook University Hospital, Middlesbrough, United Kingdom
| | - Marina Diament
- ST5 Trauma and Orthopaedics, James Cook University Hospital, Middlesbrough, United Kingdom
| | - Anne Tate
- James Cook University Hospital, Middlesbrough, United Kingdom
| | - Jamie Maddox
- James Cook University Hospital, Middlesbrough, United Kingdom
| | - Faye Wilson
- City Hospitals Sunderland NHS Foundation Trust, Sunderland, United Kingdom
| | - Will Eardley
- James Cook University Hospital, Middlesbrough, United Kingdom
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Maegele M, Grottke O, Schöchl H, Sakowitz OA, Spannagl M, Koscielny J. Direct Oral Anticoagulants in Emergency Trauma Admissions. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 113:575-82. [PMID: 27658470 DOI: 10.3238/arztebl.2016.0575] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 05/17/2016] [Accepted: 05/17/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND Direct (non-vitamin-K-dependent) oral anticoagulants (DOAC) are given as an alternative to vitamin K antagonists (VKA) to prevent stroke and embolic disease in patients with atrial fibrillation that is not due to pathology of the heart valves. Fatal hemorrhage is rarer when DOACs are given (nonvalvular atrial fibrillation: odds ratio [OR] 0.68; 95% confidence interval [95% CI: 0.48; 0.96], and venous thromboembolism: OR 0.54; [0.22; 1.32]). 48% of emergency trauma patients need an emergency operation or early surgery. Clotting disturbances elevate the mortality of such patients to 43%, compared to 17% in patients without a clotting disturbance. This underscores the impor tance of the proper, targeted treatment of trauma patients who are aking DOAC. METHODS This review is based on articles retrieved by a selective search in PubMed and on a summary of expert opinion and the recommendations of the relevant medical specialty societies. RESULTS Peak DOAC levels are reached 2-4 hours after the drug is taken. In patients with normal renal and hepatic function, no drug accumulation, and no drug interactions, the plasma level of DOAC 24 hours after administration is generally too low to cause any clinically relevant risk of bleeding. The risk of drug accumulation is higher in patients with renal dysfunction (creatinine clearance [CrCl] of 30 mL/min or less). Dabigatran levels can be estimated from the thrombin time, ecarin clotting time, and diluted thrombin time, while levels of factor Xa inhibitors can be estimated by means of calibrated chromogenic anti-factor Xa activity tests. Routine clotting studies do not reliably reflect the anticoagulant activity of DOAC. Surgery should be postponed, if possible, until at least 24-48 hours after the last dose of DOAC. For patients with mild, non-life threatening hemorrhage, it suffices to discontinue DOAC; for patients with severe hemorrhage, there are special treatment algorithms that should be followed. CONCLUSION DOACs in the setting of hemorrhage are a clinical challenge in the traumatological emergency room because of the inadequate validity of the relevant laboratory tests. An emergency antidote is now available only for dabigatran.
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Affiliation(s)
- Marc Maegele
- Department of Trauma and Orthopedic Sugery, Cologne-Merheim Medical Center (CMMC), Witten/Herdecke University, Cologne and Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Campus Cologne-Merheim, Cologne, Experimental Hemostaseology, Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Department of Anesthesiology and Intensive Care Medicine, AUVA Emergency Hospital, Salzburg (Austria), Department of Neurosurgery, Ludwigsburg Hospital, Ludwigsburg, Department of Anesthesiology, Ludwig Maximilian University of Munich, Munich, Institute for Transfusion Medicine, Charité University Medicine Berlin, Berlin
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Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications (Second Edition). Reg Anesth Pain Med 2017; 43:225-262. [DOI: 10.1097/aap.0000000000000700] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Katritsis GD, Katritsis DG. Management of Complications in Anticoagulated Patients with Atrial Fibrillation. Arrhythm Electrophysiol Rev 2017; 6:167-178. [PMID: 29326831 PMCID: PMC5739886 DOI: 10.15420/aer.2017.23.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 07/27/2017] [Indexed: 12/23/2022] Open
Abstract
Oral anticoagulation is mandatory for patients at high risk of thromboembolism, but the risk of bleeding should also be taken into account. Direct oral anticoagulants are now recommended for non-valvular AF as a potential alternative to warfarin. In this article we discuss methods to assess the anticoagulant effect of these agents, specific and general antidotes, and management of complications such as embolic and haemorrhagic stroke, and significant bleeding.
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Levi M. Reverse engineering for new oral anticoagulants: Non-specific reversal agents and the anticoagulant activity of dabigatran and rivaroxaban. Thromb Haemost 2017; 108:201-2. [DOI: 10.1160/th12-05-0330] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2012] [Accepted: 05/21/2012] [Indexed: 11/05/2022]
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Castillo J, Andrés JD, Gomar C, Gómez-Luque A, Hidalgo F, Llau JV, Sierra P, Torres LM, Ferrandis R. The perioperative management of new direct oral anticoagulants: a question without answers. Thromb Haemost 2017; 110:515-22. [DOI: 10.1160/th12-11-0868] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Accepted: 05/25/2013] [Indexed: 11/05/2022]
Abstract
SummaryNew direct oral anticoagulant agents (DOAC) are currently licensed for thromboprophylaxis after hip and knee arthroplasty and for longterm prevention of thromboembolic events in non-valvular atrial fibrillation as well as treatment and secondary prophylaxis of venous thromboembolism. Some other medical indications are emerging. Thus, anaesthesiologists are increasingly likely to encounter patients on these drugs who need elective or emergency surgery. Due to the lack of experience and data, the management of DOAC in the perioperative period is controversial. In this article, we review available information and recommendations regarding the periprocedural management of the currently most clinically developed DOAC, apixaban, dabigatran, and rivaroxaban. We discuss two trends of managing patients on DOAC for elective surgery. The first is stopping the DOAC 1–5 days before surgery (depending on the drug, patient and bleeding risk) without bridging. The second is stopping the DOAC 5 days preoperatively and bridging with low-molecular-weight heparin. The management of patients on DOAC needing emergency surgery is also reviewed. As no data exist for the use of haemostatic products for the reversal of the anticoagulant effect in these cases, rescue treatment recommendations are proposed.
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Eller T, Flieder T, Fox V, Gripp T, Dittrich M, Kuhn J, Alban S, Knabbe C, Birschmann I. Direct oral anticoagulants and heparins: laboratory values and pitfalls in 'bridging therapy'. Eur J Cardiothorac Surg 2017; 51:624-632. [PMID: 28043992 DOI: 10.1093/ejcts/ezw368] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 10/19/2016] [Indexed: 02/03/2023] Open
Abstract
Objectives The three direct oral anticoagulants (DOACs) dabigatran, apixaban and rivaroxaban are now widely used in clinical practice. For patients requiring perioperative interruption of DOACs, heparin bridging is still under discussion. Here we show, for the first time, the influence of concomitantly used DOACs and heparins on laboratory assays. Methods For spiking experiments, 10 healthy donors and nine patients treated with DOACs were investigated. The measurement of DOACs and heparins was performed with routine methods on the ACL TOP [HEMOCLOT ® direct thrombin inhibitor (CoaChrom Diagnostica, Austria), COAMATIC ® Heparin (Chromogenix, USA) calibrated with rivaroxaban, apixaban, unfractionated heparin (UFH) and low molecular weight heparin (LMWH), additionally PT reagent RecombiPlasTin 2G and aPTT reagent SynthASil (Instrumentation Laboratory, Germany)] and the DOACs were additionally quantified with liquid chromatography-mass spectrometry. A linear regression model has been used to estimate the effect of DOAC prestimulation. Results No influence of dabigatran could be demonstrated in the anti-Xa testing methods for LMWH, UFH, rivaroxaban or apixaban. All FXa-inhibiting drugs affected all the anti-Xa testing methods in their own specific ways. Compared with heparin alone, measurement of heparins in samples with a basic concentration of DOACs (200 ng/ml) displays a more dramatic increase. Samples of patients with therapeutic intake of DOACs spiked with UFH and LMWH showed the expected pharmacokinetic profiles, but increased pharmacodynamic effects. Conclusions Direct thrombin and FXa inhibitors exhibit distinct effects on assay results when used concomitantly with heparins. These interactions must be considered in the interpretation of assay results during bridging therapy.
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Affiliation(s)
- Thomas Eller
- Labor Krone GbR, Siemensstrasse, Bad Salzuflen, Germany
| | - Tobias Flieder
- Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Institut für Laboratoriums- und Transfusionsmedizin, Georgstrasse, Bad Oeynhausen, Germany
| | - Vanessa Fox
- Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Institut für Laboratoriums- und Transfusionsmedizin, Georgstrasse, Bad Oeynhausen, Germany
| | - Tatjana Gripp
- Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Institut für Laboratoriums- und Transfusionsmedizin, Georgstrasse, Bad Oeynhausen, Germany
| | - Marcus Dittrich
- Department of Bioinformatics, Biocenter, University of Würzburg, Am Hubland, Würzburg, Germany
| | - Joachim Kuhn
- Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Institut für Laboratoriums- und Transfusionsmedizin, Georgstrasse, Bad Oeynhausen, Germany
| | - Susanne Alban
- Pharmaceutical Institute, Christian-Albrechts University of Kiel, Gutenbergstr, Kiel, Germany
| | - Cornelius Knabbe
- Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Institut für Laboratoriums- und Transfusionsmedizin, Georgstrasse, Bad Oeynhausen, Germany
| | - Ingvild Birschmann
- Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Institut für Laboratoriums- und Transfusionsmedizin, Georgstrasse, Bad Oeynhausen, Germany
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Santamaría A. Bridge therapy in patients under anticoagulation: Is it still the question? Med Clin (Barc) 2017; 149:303-304. [PMID: 28743404 DOI: 10.1016/j.medcli.2017.06.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 06/21/2017] [Accepted: 06/21/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Amparo Santamaría
- Unidad de Hemostasis y Trombosis, Servicio de Hematología, Hospital Universitario Dexeus y Hospital Universitario de la Vall d'Hebron, Barcelona, España.
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Kanthabalan A, Dawson C. Guideline for stopping anticoagulants prior to urological procedures. JOURNAL OF CLINICAL UROLOGY 2017. [DOI: 10.1177/2051415817728612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There is a lack of clear evidence and guidelines on how to reverse anticoagulation prior to emergency and elective urological procedures. Our aim was to produce local hospital guidelines based on current evidence to simplify the perioperative process of stopping traditional and novel oral anticoagulants and antiplatelet therapy.
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Affiliation(s)
| | - Chris Dawson
- Department of Urology, Peterborough City Hospitals, UK
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Petit-Monéger A, Thiessard F, Jouhet V, Noize P, Berdaï D, Kret M, Sitta R, Salmi LR, Saillour-Glénisson F. Development and validation of hospital information system-generated indicators of the appropriateness of oral anticoagulant prescriptions in hospitalised adults: the PACHA study protocol. BMJ Open 2017; 7:e016488. [PMID: 28860229 PMCID: PMC5589008 DOI: 10.1136/bmjopen-2017-016488] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 06/19/2017] [Accepted: 06/21/2017] [Indexed: 01/16/2023] Open
Abstract
INTRODUCTION The appropriateness of oral anticoagulant prescriptions is a major challenge to improve quality and safety of care. As indicators of the appropriateness of oral anticoagulant prescriptions are lacking, the aim of the study is to develop and validate a panel of such indicators, in hospitalised adults, from the hospital information system of two university hospitals in France. METHODS AND ANALYSIS The study will be carried out in four steps: (1) a literature review to identify indicators of the appropriateness of oral anticoagulant prescriptions and their conditions of appropriateness; (2) a Delphi consensus method to assess the potential utility and operational implementation of the selected indicators; (3) techniques of medical data search to implement indicators from the hospital information system and; (4) a cross-sectional study to assess the ability of indicators to detect inappropriate oral anticoagulant prescriptions, performance of medical data search techniques for tracking or retrieving information and the ability of tools to be transferred into other institutions. The fourth step will include up to 80 patient hospital stays for each indicator, depending on the prevalence of inappropriate prescriptions estimated in interim analyses. ETHICS AND DISSEMINATION This work addresses the current lack of quality indicators of the appropriateness of oral anticoagulant prescriptions. We aim to develop and validate such indicators for integrating them into hospital clinical practice, as part of a structured approach to improve quality and safety of care. As each hospital information system is different, we will propose tools transferable to other healthcare institutions to allow an automated construction of these indicators. The PACHA study protocol was approved by institutional review boards and ethics committees (CPP Sud-Ouest et Outre Mer III-DC 2016/119; CPP Ile-de-France II-CDW_2016_0014). REGISTRATION DETAILS Clinical Trial.gov registration: NCT02898090.
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Affiliation(s)
- Aurélie Petit-Monéger
- CHU de Bordeaux, Pôle de santé publique, Service d'Information Médicale, Bordeaux, France
- University of Bordeaux, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
| | - Frantz Thiessard
- CHU de Bordeaux, Pôle de santé publique, Service d'Information Médicale, Bordeaux, France
- University of Bordeaux, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
| | - Vianney Jouhet
- CHU de Bordeaux, Pôle de santé publique, Service d'Information Médicale, Bordeaux, France
- University of Bordeaux, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
| | - Pernelle Noize
- University of Bordeaux, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
- CHU de Bordeaux, Pôle de santé publique, Service de Pharmacologie Médicale, Bordeaux, France
| | - Driss Berdaï
- CHU de Bordeaux, Pôle de santé publique, Service de Pharmacologie Médicale, Bordeaux, France
| | - Marion Kret
- CHU de Bordeaux, Pôle de santé publique, Service d'Information Médicale, Bordeaux, France
| | - Rémi Sitta
- CHU de Bordeaux, Pôle de santé publique, Service d'Information Médicale, Bordeaux, France
| | - Louis-Rachid Salmi
- CHU de Bordeaux, Pôle de santé publique, Service d'Information Médicale, Bordeaux, France
- University of Bordeaux, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
| | - Florence Saillour-Glénisson
- CHU de Bordeaux, Pôle de santé publique, Service d'Information Médicale, Bordeaux, France
- University of Bordeaux, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
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Sun MT, Wood MK, Chan W, Selva D, Sanders P, Casson RJ, Wong CX. Risk of Intraocular Bleeding With Novel Oral Anticoagulants Compared With Warfarin: A Systematic Review and Meta-analysis. JAMA Ophthalmol 2017; 135:864-870. [PMID: 28687831 PMCID: PMC5710315 DOI: 10.1001/jamaophthalmol.2017.2199] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 05/22/2017] [Indexed: 12/11/2022]
Abstract
Importance It is unclear if the risk of intraocular bleeding with novel oral anticoagulants differs compared with warfarin. Objective To characterize the risk of intraocular bleeding with novel oral anticoagulants compared with warfarin. Data Sources A systematic review and meta-analysis was undertaken in an academic medical setting. MEDLINE and ClinicalTrials.gov were searched for randomized clinical trials published up until August 2016. This search was supplemented by manual bibliography searches of identified trials and other review articles. Study Selection Studies were eligible for inclusion if they were phase 3 randomized clinical trials, enrolled patients with atrial fibrillation or venous thromboembolism, compared a novel oral anticoagulant (dabigatran, rivaroxaban, apixaban, or edoxaban) with warfarin, and recorded event data on intraocular bleeding. Data on intraocular bleeding were pooled using inverse-variance, weighted, fixed-effects meta-analysis. Data Extraction and Synthesis The PRISMA guidelines were used for abstracting data and assessing quality. Independent extraction was performed by 2 investigators. Main Outcomes and Measures Intraocular bleeding events and associated risk ratio for novel oral anticoagulants compared with warfarin. Results Twelve trials investigating 102 627 patients were included. Randomization to novel oral anticoagulants was associated with a 22% relative reduction in intraocular bleeding compared with warfarin (risk ratio, 0.78; 95% CI, 0.61-0.99). There was no significant heterogeneity observed (I2 = 4.8%, P = .40). Comparably lower risks of intraocular bleeding with novel oral anticoagulants were seen in subgroup analyses, with no significant difference according to the indication for anticoagulation (P for heterogeneity = .49) or the novel oral anticoagulant type (P for heterogeneity = .15). Summary estimates did not differ materially when random-effects meta-analytic techniques were used. Conclusions and Relevance These results suggest that novel oral anticoagulants reduce the risk of intraocular bleeding by approximately one-fifth compared with warfarin. Similar benefits were seen in both patients with atrial fibrillation and venous thromboembolism. Our data have particular relevance for patients at higher risk of spontaneous retinal and subretinal bleeding. These findings may also have important implications in the perioperative period, in which the use of novel oral anticoagulants may be superior. Future studies are required to better characterize the optimal management of patients with both ophthalmic disease and cardiovascular comorbidities requiring anticoagulation.
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Affiliation(s)
- Michelle T. Sun
- South Australian Institute of Ophthalmology, The University of Adelaide and Royal Adelaide Hospital, Adelaide
| | - Megan K. Wood
- South Australian Institute of Ophthalmology, The University of Adelaide and Royal Adelaide Hospital, Adelaide
| | - WengOnn Chan
- South Australian Institute of Ophthalmology, The University of Adelaide and Royal Adelaide Hospital, Adelaide
| | - Dinesh Selva
- South Australian Institute of Ophthalmology, The University of Adelaide and Royal Adelaide Hospital, Adelaide
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, The University of Adelaide and Royal Adelaide Hospital, Adelaide
| | - Robert J. Casson
- South Australian Institute of Ophthalmology, The University of Adelaide and Royal Adelaide Hospital, Adelaide
| | - Christopher X. Wong
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, The University of Adelaide and Royal Adelaide Hospital, Adelaide
- Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, England
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Godier A, Dincq AS, Martin AC, Radu A, Leblanc I, Antona M, Vasse M, Golmard JL, Mullier F, Gouin-Thibault I. Predictors of pre-procedural concentrations of direct oral anticoagulants: a prospective multicentre study. Eur Heart J 2017; 38:2431-2439. [DOI: 10.1093/eurheartj/ehx403] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 06/29/2017] [Indexed: 12/20/2022] Open
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Wamala H, Scott IA, Caney X. Perioperative management of new oral anticoagulants in patients undergoing elective surgery at a tertiary hospital. Intern Med J 2017; 47:1412-1421. [PMID: 28589690 DOI: 10.1111/imj.13513] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 03/10/2017] [Accepted: 06/01/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Increasing numbers of patients receiving new oral anticoagulants (NOAC) are undergoing elective surgery. The extent to which perioperative interruption of NOAC therapy and use of bridging heparin are concordant with best evidence is uncertain. AIMS To determine: (i) concordance of NOAC and bridging heparin use with guidelines; and (ii) associations between guideline concordance and patient characteristics, surgical factors and perioperative adverse events. METHODS Retrospective study of consecutive adult patients undergoing elective surgery at a tertiary hospital between 1 January 2014 and 30 June 2015 and were receiving NOAC for at least 3 months prior to surgery. Concordance of perioperative anticoagulation management with hospital guidelines was rated by two independent researchers according to explicit thrombosis and bleeding risk tables. RESULTS One hundred and fifty patients of mean (±SD) age 72.0 (±11.6) years were studied; 75% had atrial fibrillation as NOAC indication. Decision to interrupt anticoagulation in 142 patients was rated guideline-concordant in 59 (41.5%) based on low bleeding risk in all cases and high thrombotic risk in one-third. Concordant decisions were associated with past myocardial infarction (P = 0.009), chronic kidney disease (P = 0.05), use of dabigatran (P = 0.06) and major surgery (P < 0.001). Bridging heparin was prescribed in 51 (35.9%) patients and not prescribed in 91 (64.1%), with 64 (45.1%) decisions rated guideline-discordant comprising 27 decisions to prescribe and 37 not to prescribe. Guideline concordant bridging was associated with chronic kidney disease (P = 0.02); discordant bridging with use of dabigatran (P = 0.04), high thrombotic risk (P = 0.004), past ischaemic stroke (P = 0.07). At 30 days, only one adverse event (major bleed) was noted. CONCLUSION Considerable discordance exists between guideline recommendations and perioperative NOAC management. Assistive tools are required that better align decision-making with current best practice.
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Affiliation(s)
- Henry Wamala
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Ian A Scott
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Xenia Caney
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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Abstract
Novel anticoagulants (NAGs) have emerged as the preferred alternatives to vitamin K antagonists. In patients being considered for regional anesthesia, these drugs present a layer of complexity in the preprocedure evaluation. There are no established tests to monitor anticoagulant activity and our experience is short with these drugs. These authors believe it is important to review the relevant hematology, orthopedics, and anesthesiology literature to provide a valuable reference for the clinician who is met with these challenges. In addition to discussing NAGs, we also review the existing American Society of Regional Anesthesia guidelines for heparin, low-molecular-weight heparin, and antiplatelet agents.
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Affiliation(s)
- Mudit Kaushal
- Department of Anesthesiology, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA
| | - Ryan E Rubin
- Department of Anesthesiology, Louisiana State University School of Medicine, 1542 Tulane Avenue, Room 658, New Orleans, LA 70112, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University School of Medicine, 1542 Tulane Avenue, Room 658, New Orleans, LA 70112, USA
| | - Karina Gritsenko
- Department of Anesthesiology, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA.
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Dubois V, Dincq AS, Douxfils J, Ickx B, Samama CM, Dogné JM, Gourdin M, Chatelain B, Mullier F, Lessire S. Perioperative management of patients on direct oral anticoagulants. Thromb J 2017; 15:14. [PMID: 28515674 PMCID: PMC5433145 DOI: 10.1186/s12959-017-0137-1] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 05/04/2017] [Indexed: 12/31/2022] Open
Abstract
Direct oral anticoagulants (DOACs) have been licensed worldwide for several years for various indications. Each year, 10-15% of patients on oral anticoagulants will undergo an invasive procedure and expert groups have issued several guidelines on perioperative management in such situations. The perioperative guidelines have undergone numerous updates as clinical experience of emergency management has increased and perioperative studies including measurement of residual anticoagulant levels have been published. The high inter-patient variability of DOAC plasma levels has challenged the traditional recommendation that perioperative DOAC interruption should be based only on the elimination half-life of DOACs, especially before invasive procedures carrying a high risk of bleeding. Furthermore, recent publications have highlighted the potential danger of heparin bridging use when DOACs are stopped before an invasive procedure. As antidotes are progressively becoming available to manage severe bleeding or urgent procedures in patients on DOACs, accurate laboratory tests have become the standard to guide their administration and their actions need to be well understood by clinicians. This review aims to provide a systematic approach to managing patients on DOACs, based on recent updates of various perioperative guidance, and highlighting the advantages and limits of recommendations based on pharmacokinetic properties and laboratory tests.
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Affiliation(s)
- Virginie Dubois
- Université catholique de Louvain, CHU UCL Namur, Department of Anesthesiology, Yvoir, Belgium
| | - Anne-Sophie Dincq
- Université catholique de Louvain, CHU UCL Namur, Department of Anesthesiology, Yvoir, Belgium
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
| | - Jonathan Douxfils
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Université de Namur, Department of Pharmacy, Faculty of Medecine, Namur, Belgium
| | - Brigitte Ickx
- Université Libre de Bruxelles, Erasme University Hospital,Department of Anesthesiology, Brussels, Belgium
| | - Charles-Marc Samama
- Université Paris Descartes, Cochin University Hospital,Department of Anesthesiology and Intensive Care, Paris, France
| | - Jean-Michel Dogné
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Université de Namur, Department of Pharmacy, Faculty of Medecine, Namur, Belgium
| | - Maximilien Gourdin
- Université catholique de Louvain, CHU UCL Namur, Department of Anesthesiology, Yvoir, Belgium
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
| | - Bernard Chatelain
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Université catholique de Louvain, CHU UCL Namur, Hematology Laboratory, Yvoir, Belgium
| | - François Mullier
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Université catholique de Louvain, CHU UCL Namur, Hematology Laboratory, Yvoir, Belgium
| | - Sarah Lessire
- Université catholique de Louvain, CHU UCL Namur, Department of Anesthesiology, Yvoir, Belgium
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
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Koscielny J, Rosenthal C, von Heymann C. Nicht-Vitamin-K-abhängige orale Antikoagulanzien. Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0289-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Parida S, Thangaswamy CR. Cardiac tachyarrhythmias and anaesthesia: General principles and focus on atrial fibrillation. Indian J Anaesth 2017; 61:712-720. [PMID: 28970629 PMCID: PMC5613596 DOI: 10.4103/ija.ija_383_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Cardiac tachyarrhythmias are encountered commonly during the perioperative period and need to be promptly identified and appropriately managed by the anaesthesiologist. This review intends to highlight important aspects of these tachyarrhythmias and explore a temporal relationship between common medications employed in the perioperative period and their causation. Mechanisms of initiation of tachyarrhythmias, drugs that can trigger those, as well as their diagnosis and management, are also parts of the current review. Cardiac tachyarrhythmias may not always require treatment, and sometimes, aggressive management can trigger more serious types of arrhythmias. A thorough understanding of these tachyarrhythmias and their pathogenesis enables adopting a more objective approach, eschewing risks of inappropriate or unnecessary management strategies. We performed a MEDLINE search using combinations of MeSH terms such as ‘cardiac’, ‘arrhythmias’, ‘anaesthesia’, ‘perioperative’, ‘tachyarrhythmias’ and ‘anaesthetic implications’. We reviewed the relevant publications with regard to cardiac tachyarrhythmias occurring in the perioperative period.
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Affiliation(s)
- Satyen Parida
- Department of Anesthesiology and Critical Care, JIPMER, Puducherry, India
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Salerno DM, Tsapepas D, Papachristos A, Chang JH, Martin S, Hardy MA, McKeen J. Direct oral anticoagulant considerations in solid organ transplantation: A review. Clin Transplant 2016; 31. [PMID: 27859621 DOI: 10.1111/ctr.12873] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2016] [Indexed: 12/17/2022]
Abstract
For more than 60 years, warfarin was the only oral anticoagulation agent available for use in the United States. In many recent clinical trials, several direct oral anticoagulants (DOACs) demonstrated similar efficacy with an equal or superior safety profile, with some other notable benefits. The DOACs have lower inter- and intrapatient variability, much shorter half-lives, and less known drug-drug and drug-food interactions as compared to warfarin. Despite these demonstrated benefits, the use of DOACs has not gained uniform acceptance because of lack of supportive data in special patient populations, including recipients of solid organ transplants maintained on immunosuppression. This review describes the properties of several novel DOACs including their pharmacology and mechanisms of action as they relate to use among solid organ transplant recipients. We have particularly focused on (i) dosing in patients with impaired renal and hepatic function; (ii) considerations for drug-drug interactions with immunosuppressive medications; and (iii) management of the anticoagulated patients at the time of unplanned surgery. The risks and benefits of the use of DOACs in solid organ transplant recipients should be carefully evaluated prior to the introduction of these agents in this highly distinct patient population.
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Affiliation(s)
- David M Salerno
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Demetra Tsapepas
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, NY, USA.,Department of Surgery, Division of Abdominal Transplantation, Columbia University Medical Center, New York, NY, USA
| | | | - Jae-Hyung Chang
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY, USA
| | - Spencer Martin
- Department of Pharmacy, Hartford Hospital, Hartford, CT, USA
| | - Mark A Hardy
- Department of Surgery, Division of Abdominal Transplantation, Columbia University Medical Center, New York, NY, USA
| | - Jaclyn McKeen
- Department of Pharmacy, Hackensack University Medical Center, Hackensack, NJ, USA
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Curto A, Albaladejo A. Implications of apixaban for dental treatments. J Clin Exp Dent 2016; 8:e611-e614. [PMID: 27957279 PMCID: PMC5149100 DOI: 10.4317/jced.53004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 03/12/2016] [Indexed: 11/05/2022] Open
Abstract
Background Anticoagulation therapy is used in several conditions to prevent or treat thromboembolism. Recently, new oral anticoagulants have been introduced as alternatives to warfarin and acenocoumarol. In Europe, the European Medicines Agency has approved dabigatran, rivaroxaban and apixaban. Their advantages include: predictable pharmacokinetics, drug interactions and limited food, rapid onset of action and short half-life. However, they lack a specific reversal agent. Material and Methods A literature search was conducted through November 2015 for publications in the ISI Web of Knowledge, PubMed, Scopus and Cochrane Library using the keywords “apixaban”, “rivaroxaban”, “dabigatran”, “new oral anticoagulants”, “dental treatment” and “dental implications”. We included studies published in English and Spanish over the last 10 years. Results Apixaban has been recently introduced in the daily medical practices for the control of thromboembolism. The number of patients taking apixaban is increasing. Management of patients on anticoagulation therapy requires that dentists can accurately assess the patient prior to dental treatments. It is important for dentists to have a sound understanding of the mechanisms of action and management guidelines for patients taking new oral anticoagulants. Conclusions The dentist should consider carefully the management of patients on apixaban. This paper sets out a clinical guidance of dental practitioners treating these patients. There is a need for further clinical studies in order to establish more evidence-based guidelines for dental patients requiring apixaban. Key words:Apixaban, new oral anticoagulants, dental treatment.
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Affiliation(s)
- Adrian Curto
- Department of Surgery, Faculty of Medicine, University of Salamanca, Salamanca, Spain
| | - Alberto Albaladejo
- Department of Surgery, Faculty of Medicine, University of Salamanca, Salamanca, Spain
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45
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Yorkgitis BK, Zhang J, Rappold JF. Non-Vitamin K Antagonist Oral Anticoagulants: The Clinician's New Challenge. J Osteopath Med 2016; 115:612-21. [PMID: 26414714 DOI: 10.7556/jaoa.2015.122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Millions of US patients are prescribed oral anticoagulants. Traditionally, oral anticoagulation was achieved with vitamin K antagonists (VKAs). In recent years, non-VKA oral anticoagulants (NOACs) have emerged that provide an effective and convenient alternative to VKAs. These agents possess very different pharmacologic properties from what the medical community has grown accustom to with the VKAs. Thus, a new knowledge base is required for NOACs. One particular challenge with the NOACs is the lack of specific reversal agent, resulting in difficulties correcting the coagulopathy induced by these drugs when needed. A review of the current literature is presented to assist clinicians in gaining knowledge of the NOACs to care for patients.
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Abstract
Patients taking direct oral anticoagulants (DOACs) who then need an emergency invasive procedure require specialized management strategies. Appropriate patient evaluation includes assessment of the current anticoagulation state, including timing of the last dose. DOACs require particular coagulation assays to measure anticoagulation levels accurately, although standard coagulation screening tests may provide qualitative guidance. Specialty societies have endorsed general recommendations for patient management to promote hemostasis in anticoagulated patients requiring surgery or other invasive procedures. These include general stopping rules (such as ≥24 hours for low-risk procedures and ≥48 hours for high-risk surgery with normal renal function) for elective procedures. Bridging therapy when oral anticoagulant treatment is interrupted has recently been questioned, depending on the clinical scenario. Novel agents for the reversal of DOAC-induced anticoagulation have recently been developed. Idarucizumab, a humanized monoclonal antibody fragment that selectively binds dabigatran, was recently approved for clinical use in patients with life-threatening or uncontrolled bleeding, and for patients requiring emergency interventions. Idarucizumab can streamline the pre- and periprocedural anticoagulation management of dabigatran-treated patients, as it provides fast, complete, and sustainable reversibility. Andexanet alfa is an inactive, decoy factor Xa (FXa) molecule that binds FXa inhibitors, and ciraparantag is a synthetic molecule designed to bind fractionated and unfractionated heparins, and each of the currently approved DOACs. As clinical development of the additional anti-FXa-specific anticoagulant reversal agents proceeds, the respective role of each in the management of emergency bleeding events and invasive procedures will be better defined, and it is hoped they will make important contributions to patient care.
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Discontinuation and management of direct-acting anticoagulants for emergency procedures. Am J Emerg Med 2016; 34:14-18. [DOI: 10.1016/j.ajem.2016.09.048] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Albaladejo P, Bonhomme F, Blais N, Collet JP, Faraoni D, Fontana P, Godier A, Llau J, Longrois D, Marret E, Mismetti P, Rosencher N, Roullet S, Samama CM, Schved JF, Sié P, Steib A, Susen S. Management of direct oral anticoagulants in patients undergoing elective surgeries and invasive procedures: Updated guidelines from the French Working Group on Perioperative Hemostasis (GIHP) - September 2015. Anaesth Crit Care Pain Med 2016; 36:73-76. [PMID: 27659969 DOI: 10.1016/j.accpm.2016.09.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 09/09/2016] [Indexed: 11/16/2022]
Abstract
Since 2011, data on patients exposed to direct oral anticoagulants (DOAs) while undergoing invasive procedures have accumulated. At the same time, an increased hemorrhagic risk during perioperative bridging anticoagulation without thrombotic risk reduction has been demonstrated. This has led the GIHP to update their guidelines published in 2011. For scheduled procedures at low bleeding risk, it is suggested that patients interrupt DOAs the night before irrespective of type of drug and to resume therapy six hours or more after the end of the invasive procedure. For invasive procedures at high bleeding risk, it is suggested to interrupt rivaroxaban, apixaban and edoxaban three days before. Dabigatran should be interrupted according to the renal function, four days and five days if creatinine clearance is higher than 50mL/min and between 30 and 50mL/min, respectively. For invasive procedures at very high bleeding risk such as intracranial neurosurgery or neuraxial anesthesia, longer interruption times are suggested. Finally, bridging with parenteral anticoagulation and measurement of DOA concentrations can no longer routinely be used.
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Affiliation(s)
- Pierre Albaladejo
- Department of Anesthesiology and Intensive Care Medicine, Grenoble University Hospital, ThEMAS, TIMC, UMR, CNRS 5525, Université Grenoble-Alpes, 38043 Grenoble, France.
| | - Fanny Bonhomme
- Division of Anesthesiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Normand Blais
- Department de Medicine - University of Montréal, CHUM - Hôpital Notre-Dame, Montréal, Quebec, Canada
| | - Jean-Philippe Collet
- Univ Paris 06 (UPMC), ACTION Study Group, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (APHP), Paris, France
| | - David Faraoni
- Department of Anesthesiology, Peri-operative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, USA
| | - Pierre Fontana
- Division of Angiology and Haemostasis, University Hospitals of Geneva, Geneva, Switzerland
| | - Anne Godier
- Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
| | - Juan Llau
- Department of Anesthesiology and Critical Care. Hospital Clínic Universitari, Valencia, Spain
| | - Dan Longrois
- Département d'Anesthésie-Réanimation, Hôpital Bichat-Claude Bernard, University Paris Diderot, Sorbonne Paris Cité, U1148 INSERM, Paris, France
| | - Emmanuel Marret
- Department of Anesthesiology, American Hospital of Paris & Institut Hospitalier Franco-Britannique
| | - Patrick Mismetti
- Service de Médecine Vasculaire et Thérapeutique, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | - Nadia Rosencher
- Department of Anaesthesia and Intensive Care Medicine, Cochin and Hôtel-Dieu University Hospitals, Paris Descartes University, Paris, France
| | - Stéphanie Roullet
- Department of Anaesthesia and Intensive Care Medicine, Cochin and Hôtel-Dieu University Hospitals, Paris Descartes University, Paris, France
| | - Charles-Marc Samama
- Service d'Anesthésie Réanimation 1, Hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
| | | | - Pierre Sié
- Department of Hematology, Toulouse University Hospital, Toulouse, France
| | - Annick Steib
- Department of Anesthesiology and Intensive Care, University Hospital, Strasbourg, France
| | - Sophie Susen
- Department of Hematology and Transfusion, Lille University Hospital, Institut Pasteur de Lille, EGID, INSERM UMR 1011, University of Lille 2, Lille, France
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Risk stratification, perioperative and periprocedural management of the patient receiving anticoagulant therapy. J Clin Anesth 2016; 34:586-99. [PMID: 27687455 DOI: 10.1016/j.jclinane.2016.06.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 06/02/2016] [Accepted: 06/07/2016] [Indexed: 01/10/2023]
Abstract
As a result of the aging US population and the subsequent increase in the prevalence of coronary disease and atrial fibrillation, therapeutic use of anticoagulants has increased. Perioperative and periprocedural management of anticoagulated patients has become routine for anesthesiologists, who frequently mediate communication between the prescribing physician and the surgeon and assess the risks of both thromboembolic complications and hemorrhage. Data from randomized clinical trials on perioperative management of antithrombotic therapy are lacking. Therefore, clinical judgment is typically needed regarding decisions to continue, discontinue, bridge, or resume anticoagulation and regarding the time points when these events should occur in the perioperative period. In this review, we will discuss the most commonly used anticoagulants used in outpatient settings and discuss their management in the perioperative period. Special considerations for regional anesthesia and interventional pain procedures will also be reviewed.
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Charbonneau H, Pathak A, Albenque JP, Misrai V. Greenlight™ photovaporization of the prostate in patients under rivaroxaban: Lesson learned after the first cases. Prog Urol 2016; 26:273-5. [PMID: 26970929 DOI: 10.1016/j.purol.2016.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Accepted: 02/06/2016] [Indexed: 11/16/2022]
Affiliation(s)
- H Charbonneau
- EA 4564 "Modélisation de l'agression tissulaire et nociceptive", université Paul-Sabatier, 31000 Toulouse, France; Pôle anesthésie-réanimation, CHU Purpan, place du Dr-Baylac, 31059 Toulouse cedex 9, France.
| | - A Pathak
- Department of cardiovascular medicine, clinique Pasteur, 31300 Toulouse, France
| | - J-P Albenque
- Department of cardiovascular medicine, clinique Pasteur, 31300 Toulouse, France
| | - V Misrai
- Department of urology, clinique Pasteur, 31300 Toulouse, France
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