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Douketis JD, Spyropoulos AC. Perioperative Management of Anticoagulant and Antiplatelet Therapy. NEJM EVIDENCE 2023; 2:EVIDra2200322. [PMID: 38320132 DOI: 10.1056/evidra2200322] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Anticoagulant and Antiplatelet Drug ManagementManagement of patients on an anticoagulant or antiplatelet drug who require surgery or an invasive procedure is a common clinical problem. Douketis and Spyropoulos provide an evidence-based but practical approach to managing anticoagulants and antiplatelet drugs in the perioperative setting.
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Affiliation(s)
- James D Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton and McMaster University, Hamilton, ON, Canada
| | - Alex C Spyropoulos
- Department of Medicine, Anticoagulation and Clinical Thrombosis Service, Northwell Health at Lenox Hill Hospital, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Institute of Health Systems Science at The Feinstein Institutes for Medical Research, Manhasset, New York
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Douketis JD, Spyropoulos AC, Murad MH, Arcelus JI, Dager WE, Dunn AS, Fargo RA, Levy JH, Samama CM, Shah SH, Sherwood MW, Tafur AJ, Tang LV, Moores LK. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest 2022; 162:e207-e243. [PMID: 35964704 DOI: 10.1016/j.chest.2022.07.025] [Citation(s) in RCA: 78] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/10/2022] [Accepted: 07/11/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug. METHODS Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines. RESULTS A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures. CONCLUSIONS Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.
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Affiliation(s)
- James D Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton and McMaster University, Hamilton, ON, Canada.
| | - Alex C Spyropoulos
- Department of Medicine, Northwell Health at Lenox Hill Hospital, New York, NY; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Institute of Health Systems Science at The Feinstein Institutes for Medical Research, Manhasset, NY
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | - Juan I Arcelus
- Department of Surgery, Facultad de Medicina, University of Granada, Granada, Spain
| | - William E Dager
- Department of Pharmacy, University of California-Davis, Sacramento, CA
| | - Andrew S Dunn
- Division of Hospital Medicine, Department of Medicine, Mt. Sinai Health System, New York, NY
| | - Ramiz A Fargo
- Department of Internal Medicine, Loma Linda University Medical Center, Loma Linda, CA; Department of Internal Medicine, Riverside University Health System Medical Center, Moreno Valley, CA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, NC
| | - C Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP, Centre-Université Paris-Cité-Cochin Hospital, Paris, France
| | - Sahrish H Shah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | | | - Alfonso J Tafur
- Department of Medicine, Cardiovascular, NorthShore University HealthSystem, Evanston, IL
| | - Liang V Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong, University of Science and Technology, Wuhan, China
| | - Lisa K Moores
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
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Budi HS, Elsayed Ramadan D, Anitasari S, Widya Pangestika E. Estimation of Platelet Count and Bleeding Time of Mice Treated with Musa paradisiaca var. sapientum (L.) Kuntze Extract. J Exp Pharmacol 2022; 14:301-308. [PMID: 36321066 PMCID: PMC9618238 DOI: 10.2147/jep.s358105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 10/11/2022] [Indexed: 11/06/2022] Open
Abstract
Objective The aim of this study was to estimate the platelet count and bleeding time on peripheral blood smear of mice tail wound using Musa paradisiaca var. sapientum (L.) Kuntze (ambonese banana stem extract). Design Randomized post-test-only control group design. Materials and Methods Twenty-four male mice (Mus Musculus) were randomly divided into 4 groups. A negative control group was treated with carboxymethyl cellulose (CMC), a positive control group (K+) treated aspirin 100 mg/kg body weight, group P1 treated with aspirin 100 mg/kg body weight and tranexamic acid 50 mg/kg body weight, and group P2 treated with 30% of ambonese banana stem extract (ABSE). The mean and standard deviation data of platelet counts and bleeding time were analyzed by one-way ANOVA statistical software. Results and Discussion Tranexamic acid had no significant effect on platelets count compared to CMC group (p = 0.871), but administration of aspirin resulted in low platelets count significantly (p = 0.003). The platelet counts of ABSE and CMC groups were not significant different (p = 0.937). Aspirin has significantly shown prolonged bleeding time than CMC, tranexamic acid, and ABSE groups. However, there was no difference between the tranexamic acid and ABSE groups (p=0.934). The bleeding time of tranexamic acid and ABSE groups was similar, although the platelet count in the ABSE group was lower than in the CMC group. Conclusion This study proved that ambonese banana stem extract has a potency to shorten the bleeding time in mice tail wound without interfering to platelet count.
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Affiliation(s)
- Hendrik Setia Budi
- Department of Oral Biology, Dental Pharmacology, Faculty of Dental Medicine, Universitas Airlangga, Surabaya, Indonesia,Correspondence: Hendrik Setia Budi, Department of Oral Biology, Dental Pharmacology, Faculty of Dental Medicine, Universitas Airlangga, Surabaya, Indonesia, Tel/Fax +62315020255, Email
| | - Doaa Elsayed Ramadan
- Doctoral Program, Faculty of Dental Medicine, Universitas Airlangga, Surabaya, Indonesia,Directorate of Damietta Health Affairs, Ministry of Health and Population, Cairo, Egypt
| | - Silvia Anitasari
- Department of Dental Material and Devices, Dentistry Program, Faculty of Medicine, Universitas Mulawarman, Samarinda, Indonesia,School of Dentistry, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
| | - Elza Widya Pangestika
- Undergraduate Program, Faculty of Dental Medicine, Universitas Airlangga, Surabaya, Indonesia
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Montalvá E, Rodríguez-Perálvarez M, Blasi A, Bonanad S, Gavín O, Hierro L, Lladó L, Llop E, Pozo-Laderas JC, Colmenero J. Consensus Statement on Hemostatic Management, Anticoagulation, and Antiplatelet Therapy in Liver Transplantation. Transplantation 2022; 106:1123-1131. [PMID: 34999660 PMCID: PMC9128618 DOI: 10.1097/tp.0000000000004014] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Anticoagulation and antiplatelet therapies are increasingly used in liver transplant (LT) candidates and recipients due to cardiovascular comorbidities, portal vein thrombosis, or to manage posttransplant complications. The implementation of the new direct-acting oral anticoagulants and the recently developed antiplatelet drugs is a great challenge for transplant teams worldwide, as their activity must be monitored and their complications managed, in the absence of robust scientific evidence. In this changing and clinically heterogeneous scenario, the Spanish Society of Liver Transplantation and the Spanish Society of Thrombosis and Haemostasis aimed to achieve consensus regarding the indications, drugs, dosing, and timing of anticoagulation and antiplatelet therapies initiated from the inclusion of the patient on the waiting list to post-LT surveillance. A multidisciplinary group of experts composed by transplant hepatologists, surgeons, hematologists, transplant-specialized anesthesiologists, and intensivists performed a comprehensive review of the literature and identified 21 clinically relevant questions using the patient-intervention-comparison-outcome format. A preliminary list of recommendations was drafted and further validated using a modified Delphi approach by a panel of 24 transplant delegates, each representing a LT institution in Spain. The present consensus statement contains the key recommendations together with the core supporting scientific evidence, which will provide guidance for improved and more homogeneous clinical decision making.
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Affiliation(s)
- Eva Montalvá
- Department of HPB Surgery and Transplantation, La Fe University Hospital and University of Valencia, Instituto de Investigación Sanitaria de La Fe, Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Manuel Rodríguez-Perálvarez
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Department of Hepatology and Liver Transplantation, Reina Sofía University Hospital, IMIBIC, University of Córdoba, Córdoba, Spain
| | - Annabel Blasi
- Department of Anesthesiology, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Santiago Bonanad
- Unidad de Hemostasia y Trombosis, Servicio de Hematología, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Olga Gavín
- Departamento de Hematología y Hemoterapia, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Loreto Hierro
- Department of Liver Transplantation, Hospital Universitario La Paz, Madrid, Spain
| | - Laura Lladó
- Liver Transplant Unit, Department of Surgery, Bellvitge University Hospital, IDIBELL, University of Barcelona, Barcelona, Spain
| | - Elba Llop
- Department of Hepatology and Liver Transplantation, Reina Sofía University Hospital, IMIBIC, University of Córdoba, Córdoba, Spain
- Servicio de Aparato Digestivo, Instituto de Investigación Puerta de Hierro-Segovia Arana (IDIPHISA), Madrid, Spain
| | | | - Jordi Colmenero
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Department of Hepatology and Liver Transplantation, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
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Natale P, Palmer SC, Saglimbene VM, Ruospo M, Razavian M, Craig JC, Jardine MJ, Webster AC, Strippoli GF. Antiplatelet agents for chronic kidney disease. Cochrane Database Syst Rev 2022; 2:CD008834. [PMID: 35224730 PMCID: PMC8883339 DOI: 10.1002/14651858.cd008834.pub4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Antiplatelet agents are widely used to prevent cardiovascular events. The risks and benefits of antiplatelet agents may be different in people with chronic kidney disease (CKD) for whom occlusive atherosclerotic events are less prevalent, and bleeding hazards might be increased. This is an update of a review first published in 2013. OBJECTIVES To evaluate the benefits and harms of antiplatelet agents in people with any form of CKD, including those with CKD not receiving renal replacement therapy, patients receiving any form of dialysis, and kidney transplant recipients. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 13 July 2021 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We selected randomised controlled trials of any antiplatelet agents versus placebo or no treatment, or direct head-to-head antiplatelet agent studies in people with CKD. Studies were included if they enrolled participants with CKD, or included people in broader at-risk populations in which data for subgroups with CKD could be disaggregated. DATA COLLECTION AND ANALYSIS Four authors independently extracted data from primary study reports and any available supplementary information for study population, interventions, outcomes, and risks of bias. Risk ratios (RR) and 95% confidence intervals (CI) were calculated from numbers of events and numbers of participants at risk which were extracted from each included study. The reported RRs were extracted where crude event rates were not provided. Data were pooled using the random-effects model. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS We included 113 studies, enrolling 51,959 participants; 90 studies (40,597 CKD participants) compared an antiplatelet agent with placebo or no treatment, and 29 studies (11,805 CKD participants) directly compared one antiplatelet agent with another. Fifty-six new studies were added to this 2021 update. Seven studies originally excluded from the 2013 review were included, although they had a follow-up lower than two months. Random sequence generation and allocation concealment were at low risk of bias in 16 and 22 studies, respectively. Sixty-four studies reported low-risk methods for blinding of participants and investigators; outcome assessment was blinded in 41 studies. Forty-one studies were at low risk of attrition bias, 50 studies were at low risk of selective reporting bias, and 57 studies were at low risk of other potential sources of bias. Compared to placebo or no treatment, antiplatelet agents probably reduces myocardial infarction (18 studies, 15,289 participants: RR 0.88, 95% CI 0.79 to 0.99, I² = 0%; moderate certainty). Antiplatelet agents has uncertain effects on fatal or nonfatal stroke (12 studies, 10.382 participants: RR 1.01, 95% CI 0.64 to 1.59, I² = 37%; very low certainty) and may have little or no effect on death from any cause (35 studies, 18,241 participants: RR 0.94, 95 % CI 0.84 to 1.06, I² = 14%; low certainty). Antiplatelet therapy probably increases major bleeding in people with CKD and those treated with haemodialysis (HD) (29 studies, 16,194 participants: RR 1.35, 95% CI 1.10 to 1.65, I² = 12%; moderate certainty). In addition, antiplatelet therapy may increase minor bleeding in people with CKD and those treated with HD (21 studies, 13,218 participants: RR 1.55, 95% CI 1.27 to 1.90, I² = 58%; low certainty). Antiplatelet treatment may reduce early dialysis vascular access thrombosis (8 studies, 1525 participants) RR 0.52, 95% CI 0.38 to 0.70; low certainty). Antiplatelet agents may reduce doubling of serum creatinine in CKD (3 studies, 217 participants: RR 0.39, 95% CI 0.17 to 0.86, I² = 8%; low certainty). The treatment effects of antiplatelet agents on stroke, cardiovascular death, kidney failure, kidney transplant graft loss, transplant rejection, creatinine clearance, proteinuria, dialysis access failure, loss of primary unassisted patency, failure to attain suitability for dialysis, need of intervention and cardiovascular hospitalisation were uncertain. Limited data were available for direct head-to-head comparisons of antiplatelet drugs, including prasugrel, ticagrelor, different doses of clopidogrel, abciximab, defibrotide, sarpogrelate and beraprost. AUTHORS' CONCLUSIONS Antiplatelet agents probably reduced myocardial infarction and increased major bleeding, but do not appear to reduce all-cause and cardiovascular death among people with CKD and those treated with dialysis. The treatment effects of antiplatelet agents compared with each other are uncertain.
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Affiliation(s)
- Patrizia Natale
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Valeria M Saglimbene
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Marinella Ruospo
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Mona Razavian
- Renal and Metabolic Division, The George Institute for Global Health, Newtown, Australia
| | - Jonathan C Craig
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | | | - Angela C Webster
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Transplant and Renal Research, Westmead Millennium Institute, The University of Sydney at Westmead, Westmead, Australia
| | - Giovanni Fm Strippoli
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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Nemeh F, Buchbinder R, Hawley CM, Nelson MR, Waterkeyn JG, Reid CM. Activities supporting the growth of Clinical Trial Networks in Australia. Trials 2022; 23:81. [PMID: 35090533 PMCID: PMC8795956 DOI: 10.1186/s13063-021-05974-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 12/21/2021] [Indexed: 01/20/2023] Open
Abstract
Clinical Trial Networks in which trialists work collaboratively enable multi-site, large-scale, high-quality clinical trials to be efficiently run. Although the benefits of Clinical Trial Networks are largely known, establishing a Clinical Trial Network can be complex. There are many factors for clinicians and researchers to consider, and there is currently a paucity of information on how to form a Clinical Trial Network. This article provides a suggested roadmap on how to establish a Clinical Trial Network. The Australian Clinical Trials Alliance (ACTA) is the peak body for Clinical Trial Networks, Coordinating Centres and Registries in Australia, and has produced several resources to support the effective and efficient running of clinical trials. This guide has come about through discussions with members of the ACTA Clinical Trial Network Sector Expansion Reference Group consisting of clinical trialists, clinicians, researchers, and consumers.
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Affiliation(s)
- Fiona Nemeh
- Australian Clinical Trials Alliance, Melbourne, Victoria, Australia
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Prahran, Victoria, Australia.,Monash Department of Clinical Epidemiology, Cabrini Institute, Malvern, Victoria, Australia
| | - Carmel M Hawley
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia.,Australasian Kidney Trials Network, Faculty of Medicine, University of Queensland, Brisbane, Australia.,Translational Research Institute, Brisbane, Australia
| | - Mark R Nelson
- Australian Clinical Trials Alliance, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Prahran, Victoria, Australia.,Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | | | - Christopher M Reid
- Australian Clinical Trials Alliance, Melbourne, Victoria, Australia. .,School of Public Health and Preventive Medicine, Monash University, Prahran, Victoria, Australia. .,School of Public Health, Curtin University, Bentley, Western Australia, Australia.
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Sandler N, Ho H, Draxler DF, Bain CR, Smith JA, Hauser CJ, Gruen RL, Myles PS, Medcalf RL. Characterisation of Plasma Mitochondrial DNA, MMP-9 and Neutrophil Elastase in Patients Undergoing Coronary Artery Bypass Grafting: Effects of Tranexamic Acid and Postoperative Pneumonia. Heart Lung Circ 2021; 31:439-446. [PMID: 34627673 DOI: 10.1016/j.hlc.2021.08.008] [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: 05/16/2018] [Revised: 06/03/2021] [Accepted: 08/04/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Postoperative pneumonia is a major cause of morbidity and mortality following cardiac surgery. The inflammatory response to cardiac surgery has been widely studied, but specific mechanisms for postoperative pneumonia have not been determined. Tranexamic acid is renowned for its effect on bleeding but can also modulate inflammatory processes. Cardiac surgery is known to release mitochondrial DAMPs (mtDAMPs) and is linked to postoperative inflammation and atrial fibrillation. We speculated that mtDAMPs might be related to postoperative pneumonia and that this might be modulated by tranexamic acid. METHODS Forty-one (41) patients from the Aspirin and Tranexamic Acid for Coronary Artery Surgery (ATACAS) trial were studied. Levels of mitochondrial DNA, matrix metallopeptidase 9 (MMP-9) and neutrophil elastase (NE) were determined in plasma preoperatively, at 24 and 72 hours post-surgery and correlated with clinical outcome. RESULTS mtDNA was significantly elevated postoperatively in the placebo and tranexamic acid (TXA) groups. Neutrophil elastase increased immediately postoperatively and at 24 hours. MMP-9 was elevated in the placebo group early postoperatively and in the TXA group at the immediate postoperative time point and after 24 hours. Six (6) of the 41 (14.6%) patients subsequently developed pneumonia. mtDNA levels were significantly increased at the early postoperative period and the 24-hour time point in patients with pneumonia. CONCLUSIONS Cardiac surgery releases mtDNA, increases MMP-9 and NE and this was not influenced by TXA. Inflammation postoperatively might be linked to pneumonia since mtDNA was further elevated in these patients. Due to the low number of individuals developing pneumonia, further studies are warranted to clearly identify whether TXA impacts on the inflammatory response in postoperative pneumonia.
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Affiliation(s)
- Nicola Sandler
- Australian Centre for Blood Disease, Central Clinical School, Monash University, Melbourne, Vic, Australia.
| | - Heidi Ho
- Australian Centre for Blood Disease, Central Clinical School, Monash University, Melbourne, Vic, Australia
| | - Dominik F Draxler
- Australian Centre for Blood Disease, Central Clinical School, Monash University, Melbourne, Vic, Australia
| | - Christopher R Bain
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Vic, Australia
| | - Julian A Smith
- Department of Surgery, (School of Clinical Sciences at Monash Health), Monash University, Melbourne, Vic, Australia
| | - Carl J Hauser
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Russell L Gruen
- College of Health and Medicine, The Australian National University Canberra, ACT, Australia
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Vic, Australia
| | - Robert L Medcalf
- Australian Centre for Blood Disease, Central Clinical School, Monash University, Melbourne, Vic, Australia.
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Fischer K, Bodalbhai F, Awudi E, Surani S. Reversing Bleeding Associated With Antiplatelet Use: The Role of Tranexamic Acid. Cureus 2020; 12:e10290. [PMID: 33047080 PMCID: PMC7540200 DOI: 10.7759/cureus.10290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Dual antiplatelet therapy (DAPT) is the mainstay of therapy in patients that have been diagnosed with coronary artery disease. DAPT has known risk factors such as an increased risk of bleeding, and, currently, no specific medication is indicated to reverse bleeding associated with antiplatelet use. One medication that may help reduce blood loss is tranexamic acid (TXA). A retrospective review of the literature regarding TXA in the setting of antiplatelet associated bleeding through a systematic search strategy was conducted. This review of the literature followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines and included seven studies. Multiple studies demonstrated the impact on platelet function resulting from administering TXA through lower volumes of blood loss, lower transfusion requirements, and lower incidence of reoperations. TXA is not widely recommended to reverse antiplatelet medications; however, it is widely available, has a positive track record for use in various types of bleeding, and is relatively inexpensive and safe. Large-scale randomized trials are warranted to make a strong recommendation for TXA in reversing bleeding associated with antiplatelet therapy.
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Affiliation(s)
- Kyle Fischer
- Pharmacy, Texas A&M Irma Lerma Rangel College of Pharmacy, Kingsville, USA
| | - Fatema Bodalbhai
- Pharmacy, Texas A&M Irma Lerma Rangel College of Pharmacy, College Station, USA
| | - Elizabeth Awudi
- Pharmacy, Corpus Christi Medical Center, Corpus Christi, USA
| | - Salim Surani
- Internal Medicine, Corpus Christi Medical Center, Corpus Christi, USA.,Internal Medicine, University of North Texas, Dallas, USA
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Derzon JH, Clarke N, Alford A, Gross I, Shander A, Thurer R. Reducing red blood cell transfusion in orthopedic and cardiac surgeries with Antifibrinolytics: A laboratory medicine best practice systematic review and meta-analysis. Clin Biochem 2019; 71:1-13. [DOI: 10.1016/j.clinbiochem.2019.06.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 06/02/2019] [Accepted: 06/28/2019] [Indexed: 12/15/2022]
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Konishi Y, Evered LA, Scott DA, Silbert BS. Postoperative cognitive dysfunction after sevoflurane or propofol general anaesthesia in combination with spinal anaesthesia for hip arthroplasty. Anaesth Intensive Care 2019; 46:596-600. [PMID: 30447669 DOI: 10.1177/0310057x1804600610] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
It is unknown if the type of general anaesthetic used for maintenance of anaesthesia affects the incidence of postoperative cognitive dysfunction (POCD). The aim of this study was to compare the incidence of POCD in patients administered either sevoflurane or propofol for maintenance of anaesthesia during total hip replacement surgery. Following administration of a spinal anaesthetic, patients received either sevoflurane (n=121) or propofol (n=171) at the discretion of the anaesthetist for maintenance of general anaesthesia to maintain the processed electroencephalogram (bispectral index, BIS) under 60. POCD was assessed postoperatively at day 7, three months, and 12 months using a neurocognitive test battery. There was no statistically significant difference between the incidence of POCD at any timepoint with sevoflurane compared to propofol. The mean BIS was significantly lower in the sevoflurane group than in the propofol group (mean BIS 44.3 [standard deviation, SD 7.5] in the sevoflurane group versus 53.7 [SD 8.1] in the propofol group, <i>P</i>=0.0001). However, there was no statistically significant association between intraoperative BIS level and the incidence of POCD at any timepoint. Our results suggest that the incidence of POCD is not strongly influenced by the type of anaesthesia used in elderly patients.
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Affiliation(s)
- Y Konishi
- Fellow, Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, Victoria; Teikyo University School of Medicine, Tokyo, Japan
| | - L A Evered
- Associate Professor, Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital; Perioperative and Pain Medicine Unit, Melbourne Medical School, University of Melbourne; Melbourne, Victoria
| | - D A Scott
- Professor, Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital; Perioperative and Pain Medicine Unit, Melbourne Medical School, University of Melbourne, Melbourne, Victoria
| | - B S Silbert
- Associate Professor, Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital; Perioperative and Pain Medicine Unit, Melbourne Medical School, University of Melbourne, Melbourne, Victoria
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Myles PS, Smith JA, Kasza J, Silbert B, Jayarajah M, Painter T, Cooper DJ, Marasco S, McNeil J, Bussières JS, McGuinness S, Byrne K, Chan MT, Landoni G, Wallace S, Forbes A, Myles P, Smith J, Cooper DJ, Silbert B, McNeil J, Marasco S, Esmore D, Krum H, Tonkin A, Buxton B, Heritier S, Merry A, Liew D, McNeil J, Forbes A, Cooper D, Wallace S, Meehan A, Myles P, Wallace S, Galagher W, Farrington C, Ditoro A, Wutzlhofer L, Story D, Peyton P, Baulch S, Sidiropoulos S, Potgieter D, Baker R, Pesudovs B, O'Loughlin J Wells E, Coutts P, Bolsin S, Osborne C, Ives K, Smith J, Hulley A, Christie-Taylor G, Painter T, Lang S, Mackay H, Cokis C, March S, Bannon P, Wong C, Turner L, Scott D, Silbert B, Said S, Corcoran P, Painter T, de Prinse L, Bussières J, Gagné N, Lamy A, Semelhago L, Chan M, Underwood M, Choi G, Fung B, Landoni G, Lembo R, Monaco F, Simeone F, Marianello D, Alvaro G, De Vuono G, van Dijk D, Dieleman J, Numan S, McGuinness S, Parke R, Raudkivi P, Gilder E, Byrne K, Dunning J, Termaat J, Mans G, Jayarajah M, Alderton J, Waugh D, Platt M, Pai A, Sevillano A, Lal A, Sinclair C, Kunst G, Knighton A, Cubas G, Saravanan P, Millner R, Vasudevan V, Patteril M, Lopez E, Basu R, Lu J. Tranexamic acid in coronary artery surgery: One-year results of the Aspirin and Tranexamic Acid for Coronary Artery Surgery (ATACAS) trial. J Thorac Cardiovasc Surg 2019; 157:644-652.e9. [DOI: 10.1016/j.jtcvs.2018.09.113] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 09/13/2018] [Accepted: 09/27/2018] [Indexed: 11/30/2022]
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Myles PS, Smith JA, Kasza J, Silbert B, Jayarajah M, Painter T, Cooper DJ, Marasco S, McNeil J, Bussières JS, McGuinness S, Chan MTV, Wallace S, Forbes A. Aspirin in coronary artery surgery: 1-year results of the Aspirin and Tranexamic Acid for Coronary Artery Surgery trial. J Thorac Cardiovasc Surg 2018; 157:633-640. [PMID: 30401528 DOI: 10.1016/j.jtcvs.2018.08.114] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 07/07/2018] [Accepted: 08/21/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Aspirin may reduce the risk of vascular graft thrombosis after cardiovascular surgery. We previously reported the 30-day results of a trial evaluating aspirin use before coronary artery surgery. Here we report the 1-year outcomes evaluating late thrombotic events and disability-free survival. METHODS Using a factorial design, we randomly assigned patients undergoing coronary artery surgery to receive aspirin or placebo and tranexamic acid or placebo. The results of the aspirin comparison are reported here. The primary 1-year outcome was death or severe disability, the latter defined as living with a modified Katz activities of daily living score < 8. Secondary outcomes included a composite of myocardial infarction, stroke and death from any cause through to 1 year after surgery. RESULTS Patients were randomly assigned to aspirin (1059 patients) or placebo (1068 patients). The rate of death or severe disability was 4.1% in the aspirin group and 3.5% in the placebo group (relative risk, 1.17; 95% confidence interval, 0.76-1.81; P = .48). There was no significant difference in the rates of myocardial infarction (P = .11), stroke (P = .086), or death (P = .24), or a composite of these cardiovascular end points (P = .68). With the exception of those with a low European System for Cardiac Operative Risk Evaluation score (P = .03), there were no interaction effects on these outcomes with tranexamic acid (all tests of interaction P > .10). CONCLUSIONS In patients undergoing coronary artery surgery, preoperative aspirin did not reduce death or severe disability, or thrombotic events through to 1 year after surgery.
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Affiliation(s)
- Paul S Myles
- Alfred Hospital, Melbourne, Australia; Monash University, Melbourne, Australia.
| | - Julian A Smith
- Monash University, Melbourne, Australia; Monash Medical Centre, Clayton, Australia
| | | | | | | | - Thomas Painter
- Royal Adelaide Hospital and Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - D James Cooper
- Alfred Hospital, Melbourne, Australia; Monash University, Melbourne, Australia
| | - Silvana Marasco
- Alfred Hospital, Melbourne, Australia; Monash University, Melbourne, Australia
| | | | - Jean S Bussières
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Quebec, Canada
| | | | | | - Sophie Wallace
- Alfred Hospital, Melbourne, Australia; Monash University, Melbourne, Australia
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Withanawasam TI, Wright S. Advances in transfusion medicine RCPath, November 2016. Transfus Med 2017; 27:401-407. [PMID: 29282811 DOI: 10.1111/tme.12500] [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: 12/04/2017] [Revised: 11/22/2017] [Accepted: 12/04/2017] [Indexed: 01/08/2023]
Affiliation(s)
- T I Withanawasam
- National Health Service Blood and Transplant, Bristol, UK.,National Blood Transfusion Service, Colombo, Sri Lanka
| | - S Wright
- National Health Service Blood and Transplant, Bristol, UK
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Spence J, Long S, Tidy A, Raymer K, Devereaux PJ, Lamy A, Whitlock R, Syed S. Tranexamic Acid Administration During On-Pump Cardiac Surgery. Anesth Analg 2017; 125:1863-1870. [DOI: 10.1213/ane.0000000000002422] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Association between CK-MB Area Under the Curve and Tranexamic Acid Utilization in Patients Undergoing Coronary Artery Bypass Surgery. J Thromb Thrombolysis 2017; 43:446-453. [PMID: 28194628 DOI: 10.1007/s11239-017-1480-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Myonecrosis after coronary artery bypass graft (CABG) surgery is associated with excess mortality. Tranexamic acid (TA), an anti-fibrinolytic agent, has been shown to reduce peri-operative blood loss without increasing the risk of myocardial infarction (MI); however, no large study has examined the association between TA treatment and post-CABG myonecrosis. In the MC-1 to Eliminate Necrosis and Damage in Coronary Artery Bypass Graft Surgery II trial, inverse probability weighting of the propensity to receive TA was used to test for differences among the 656 patients receiving and 770 patients not receiving TA. The primary outcome was creatine kinase MB (CK-MB) area under the curve (AUC) through 24 h. The secondary outcome was 30-day cardiovascular death or MI. Patients who received TA were more frequently female, had a previous MI, heart failure, low molecular weight heparin therapy, on-pump CABG, valvular surgery, and saphenous vein or radial grafts. The median 24-h CK-MB AUC was higher in TA-treated patients [301.9 (IQR 196.7-495.6) vs 253.5 (153.4-432.5) ng h/mL, p < 0.001]. No differences in the 30-day incidence of cardiovascular death or MI were observed (8.7 vs 8.3%, adjusted OR 0.99; 95% CI 0.67-1.45, p = 0.948). In patients undergoing CABG, TA use was associated with a higher risk of myonecrosis; however, no differences were observed in death or MI. Future larger studies should be directed at examining the pathophysiology of TA myonecrosis, and its association with subsequent clinical outcomes.
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Landoni G, Pisano A, Lomivorotov V, Alvaro G, Hajjar L, Paternoster G, Nigro Neto C, Latronico N, Fominskiy E, Pasin L, Finco G, Lobreglio R, Azzolini ML, Buscaglia G, Castella A, Comis M, Conte A, Conte M, Corradi F, Dal Checco E, De Vuono G, Ganzaroli M, Garofalo E, Gazivoda G, Lembo R, Marianello D, Baiardo Redaelli M, Monaco F, Tarzia V, Mucchetti M, Belletti A, Mura P, Musu M, Pala G, Paltenghi M, Pasyuga V, Piras D, Riefolo C, Roasio A, Ruggeri L, Santini F, Székely A, Verniero L, Vezzani A, Zangrillo A, Bellomo R. Randomized Evidence for Reduction of Perioperative Mortality: An Updated Consensus Process. J Cardiothorac Vasc Anesth 2017; 31:719-730. [DOI: 10.1053/j.jvca.2016.07.017] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Indexed: 11/11/2022]
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Myles PS, Smith JA, Forbes A, Silbert B, Jayarajah M, Painter T, Cooper DJ, Marasco S, McNeil J, Bussières JS, McGuinness S, Byrne K, Chan MTV, Landoni G, Wallace S. Tranexamic Acid in Patients Undergoing Coronary-Artery Surgery. N Engl J Med 2017; 376:136-148. [PMID: 27774838 DOI: 10.1056/nejmoa1606424] [Citation(s) in RCA: 384] [Impact Index Per Article: 54.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Tranexamic acid reduces the risk of bleeding among patients undergoing cardiac surgery, but it is unclear whether this leads to improved outcomes. Furthermore, there are concerns that tranexamic acid may have prothrombotic and proconvulsant effects. METHODS In a trial with a 2-by-2 factorial design, we randomly assigned patients who were scheduled to undergo coronary-artery surgery and were at risk for perioperative complications to receive aspirin or placebo and tranexamic acid or placebo. The results of the tranexamic acid comparison are reported here. The primary outcome was a composite of death and thrombotic complications (nonfatal myocardial infarction, stroke, pulmonary embolism, renal failure, or bowel infarction) within 30 days after surgery. RESULTS Of the 4662 patients who were enrolled and provided consent, 4631 underwent surgery and had available outcomes data; 2311 were assigned to the tranexamic acid group and 2320 to the placebo group. A primary outcome event occurred in 386 patients (16.7%) in the tranexamic acid group and in 420 patients (18.1%) in the placebo group (relative risk, 0.92; 95% confidence interval, 0.81 to 1.05; P=0.22). The total number of units of blood products that were transfused during hospitalization was 4331 in the tranexamic acid group and 7994 in the placebo group (P<0.001). Major hemorrhage or cardiac tamponade leading to reoperation occurred in 1.4% of the patients in the tranexamic acid group and in 2.8% of the patients in the placebo group (P=0.001), and seizures occurred in 0.7% and 0.1%, respectively (P=0.002 by Fisher's exact test). CONCLUSIONS Among patients undergoing coronary-artery surgery, tranexamic acid was associated with a lower risk of bleeding than was placebo, without a higher risk of death or thrombotic complications within 30 days after surgery. Tranexamic acid was associated with a higher risk of postoperative seizures. (Funded by the Australian National Health and Medical Research Council and others; ATACAS Australia New Zealand Clinical Trials Registry number, ACTRN12605000557639 .).
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Affiliation(s)
- Paul S Myles
- From the Alfred Hospital (P.S.M., D.J.C., S. Marasco, S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S. Marasco, J.M., S.W.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; South West Cardiac Centre, Derriford Hospital, Plymouth, United Kingdom (M.J.); Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada (J.S.B.); Auckland City Hospital, Auckland (S. McGuinness), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele and Vita-Salute San Raffaele University, Milan (G.L.)
| | - Julian A Smith
- From the Alfred Hospital (P.S.M., D.J.C., S. Marasco, S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S. Marasco, J.M., S.W.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; South West Cardiac Centre, Derriford Hospital, Plymouth, United Kingdom (M.J.); Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada (J.S.B.); Auckland City Hospital, Auckland (S. McGuinness), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele and Vita-Salute San Raffaele University, Milan (G.L.)
| | - Andrew Forbes
- From the Alfred Hospital (P.S.M., D.J.C., S. Marasco, S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S. Marasco, J.M., S.W.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; South West Cardiac Centre, Derriford Hospital, Plymouth, United Kingdom (M.J.); Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada (J.S.B.); Auckland City Hospital, Auckland (S. McGuinness), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele and Vita-Salute San Raffaele University, Milan (G.L.)
| | - Brendan Silbert
- From the Alfred Hospital (P.S.M., D.J.C., S. Marasco, S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S. Marasco, J.M., S.W.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; South West Cardiac Centre, Derriford Hospital, Plymouth, United Kingdom (M.J.); Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada (J.S.B.); Auckland City Hospital, Auckland (S. McGuinness), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele and Vita-Salute San Raffaele University, Milan (G.L.)
| | - Mohandas Jayarajah
- From the Alfred Hospital (P.S.M., D.J.C., S. Marasco, S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S. Marasco, J.M., S.W.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; South West Cardiac Centre, Derriford Hospital, Plymouth, United Kingdom (M.J.); Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada (J.S.B.); Auckland City Hospital, Auckland (S. McGuinness), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele and Vita-Salute San Raffaele University, Milan (G.L.)
| | - Thomas Painter
- From the Alfred Hospital (P.S.M., D.J.C., S. Marasco, S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S. Marasco, J.M., S.W.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; South West Cardiac Centre, Derriford Hospital, Plymouth, United Kingdom (M.J.); Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada (J.S.B.); Auckland City Hospital, Auckland (S. McGuinness), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele and Vita-Salute San Raffaele University, Milan (G.L.)
| | - D James Cooper
- From the Alfred Hospital (P.S.M., D.J.C., S. Marasco, S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S. Marasco, J.M., S.W.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; South West Cardiac Centre, Derriford Hospital, Plymouth, United Kingdom (M.J.); Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada (J.S.B.); Auckland City Hospital, Auckland (S. McGuinness), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele and Vita-Salute San Raffaele University, Milan (G.L.)
| | - Silvana Marasco
- From the Alfred Hospital (P.S.M., D.J.C., S. Marasco, S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S. Marasco, J.M., S.W.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; South West Cardiac Centre, Derriford Hospital, Plymouth, United Kingdom (M.J.); Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada (J.S.B.); Auckland City Hospital, Auckland (S. McGuinness), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele and Vita-Salute San Raffaele University, Milan (G.L.)
| | - John McNeil
- From the Alfred Hospital (P.S.M., D.J.C., S. Marasco, S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S. Marasco, J.M., S.W.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; South West Cardiac Centre, Derriford Hospital, Plymouth, United Kingdom (M.J.); Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada (J.S.B.); Auckland City Hospital, Auckland (S. McGuinness), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele and Vita-Salute San Raffaele University, Milan (G.L.)
| | - Jean S Bussières
- From the Alfred Hospital (P.S.M., D.J.C., S. Marasco, S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S. Marasco, J.M., S.W.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; South West Cardiac Centre, Derriford Hospital, Plymouth, United Kingdom (M.J.); Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada (J.S.B.); Auckland City Hospital, Auckland (S. McGuinness), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele and Vita-Salute San Raffaele University, Milan (G.L.)
| | - Shay McGuinness
- From the Alfred Hospital (P.S.M., D.J.C., S. Marasco, S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S. Marasco, J.M., S.W.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; South West Cardiac Centre, Derriford Hospital, Plymouth, United Kingdom (M.J.); Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada (J.S.B.); Auckland City Hospital, Auckland (S. McGuinness), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele and Vita-Salute San Raffaele University, Milan (G.L.)
| | - Kelly Byrne
- From the Alfred Hospital (P.S.M., D.J.C., S. Marasco, S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S. Marasco, J.M., S.W.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; South West Cardiac Centre, Derriford Hospital, Plymouth, United Kingdom (M.J.); Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada (J.S.B.); Auckland City Hospital, Auckland (S. McGuinness), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele and Vita-Salute San Raffaele University, Milan (G.L.)
| | - Matthew T V Chan
- From the Alfred Hospital (P.S.M., D.J.C., S. Marasco, S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S. Marasco, J.M., S.W.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; South West Cardiac Centre, Derriford Hospital, Plymouth, United Kingdom (M.J.); Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada (J.S.B.); Auckland City Hospital, Auckland (S. McGuinness), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele and Vita-Salute San Raffaele University, Milan (G.L.)
| | - Giovanni Landoni
- From the Alfred Hospital (P.S.M., D.J.C., S. Marasco, S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S. Marasco, J.M., S.W.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; South West Cardiac Centre, Derriford Hospital, Plymouth, United Kingdom (M.J.); Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada (J.S.B.); Auckland City Hospital, Auckland (S. McGuinness), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele and Vita-Salute San Raffaele University, Milan (G.L.)
| | - Sophie Wallace
- From the Alfred Hospital (P.S.M., D.J.C., S. Marasco, S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S. Marasco, J.M., S.W.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; South West Cardiac Centre, Derriford Hospital, Plymouth, United Kingdom (M.J.); Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada (J.S.B.); Auckland City Hospital, Auckland (S. McGuinness), and Waikato Hospital, Hamilton (K.B.) - both in New Zealand; the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); and Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele and Vita-Salute San Raffaele University, Milan (G.L.)
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Silvetti S, Crivellari M, Castiglioni A, Landoni G, Zangrillo A, Alfieri O, Koster A, Faraoni D, Bolliger D, Tanaka KA. CASE 12—2016 Ascending Aorta Dissection in a Jehovah’s Witness Patient on Warfarin. J Cardiothorac Vasc Anesth 2016; 30:1709-1715. [DOI: 10.1053/j.jvca.2016.02.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Indexed: 01/01/2023]
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Mazzone AL, Baker RA, Gleadle JM. Mending a broken heart but breaking the kidney. Nephrology (Carlton) 2016; 21:812-20. [DOI: 10.1111/nep.12799] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 04/05/2016] [Accepted: 04/09/2016] [Indexed: 12/21/2022]
Affiliation(s)
- Annette L Mazzone
- Department of Cardiac Surgery Research and Perfusion, Cardiac and Thoracic Surgical Unit; Flinders Medical Centre; Adelaide South Australia Australia
- School of Medicine; Flinders University; Adelaide South Australia Australia
| | - Robert A Baker
- Department of Cardiac Surgery Research and Perfusion, Cardiac and Thoracic Surgical Unit; Flinders Medical Centre; Adelaide South Australia Australia
- School of Medicine; Flinders University; Adelaide South Australia Australia
| | - Jonathan M Gleadle
- School of Medicine; Flinders University; Adelaide South Australia Australia
- Department of Renal Medicine; Flinders Medical Centre; Adelaide South Australia Australia
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Myles PS, Smith JA, Forbes A, Silbert B, Jayarajah M, Painter T, Cooper DJ, Marasco S, McNeil J, Bussières JS, Wallace S. Stopping vs. Continuing Aspirin before Coronary Artery Surgery. N Engl J Med 2016; 374:728-37. [PMID: 26933848 DOI: 10.1056/nejmoa1507688] [Citation(s) in RCA: 112] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Most patients with coronary artery disease receive aspirin for primary or secondary prevention of myocardial infarction, stroke, and death. Aspirin poses a risk of bleeding in patients undergoing surgery, but it is unclear whether aspirin should be stopped before coronary artery surgery. METHODS We used a 2-by-2 factorial trial design to randomly assign patients who were scheduled to undergo coronary artery surgery and were at risk for perioperative complications to receive aspirin or placebo and tranexamic acid or placebo. The results of the aspirin trial are reported here. Patients were randomly assigned to receive 100 mg of aspirin or matched placebo preoperatively. The primary outcome was a composite of death and thrombotic complications (nonfatal myocardial infarction, stroke, pulmonary embolism, renal failure, or bowel infarction) within 30 days after surgery. RESULTS Among 5784 eligible patients, 2100 were enrolled; 1047 were randomly assigned to receive aspirin and 1053 to receive placebo. A primary outcome event occurred in 202 patients in the aspirin group (19.3%) and in 215 patients in the placebo group (20.4%) (relative risk, 0.94; 95% confidence interval, 0.80 to 1.12; P=0.55). Major hemorrhage leading to reoperation occurred in 1.8% of patients in the aspirin group and in 2.1% of patients in the placebo group (P=0.75), and cardiac tamponade occurred at rates of 1.1% and 0.4%, respectively (P=0.08). CONCLUSIONS Among patients undergoing coronary artery surgery, the administration of preoperative aspirin resulted in neither a lower risk of death or thrombotic complications nor a higher risk of bleeding than that with placebo. (Funded by the Australian National Health and Medical Research Council and others; Australia New Zealand Clinical Trials Registry number, ACTRN12605000557639.).
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Affiliation(s)
- Paul S Myles
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
| | - Julian A Smith
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
| | - Andrew Forbes
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
| | - Brendan Silbert
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
| | - Mohandas Jayarajah
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
| | - Thomas Painter
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
| | - D James Cooper
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
| | - Silvana Marasco
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
| | - John McNeil
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
| | - Jean S Bussières
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
| | - Sophie Wallace
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
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Gerstein NS, Brierley JK, Culling MD. Left ventricle thrombus after tranexamic acid for spine surgery in an HIV-positive patient. Spine J 2016; 16:e77-82. [PMID: 26523960 DOI: 10.1016/j.spinee.2015.10.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 09/02/2015] [Accepted: 10/22/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Our case highlights the underappreciated thrombotic risks of tranexamic acid (TXA) use in non-cardiac surgery and emphasizes the need to elucidate these risks with appropriate clinical trials. PURPOSE The use of TXA in non-cardiac surgery has significantly expanded in the past 5 years, especially after the 2010 publication of the CRASH-2 Trial. We submit a case with the intent to highlight the thrombotic risk of TXA use during non-cardiac surgery and discuss the need for careful risk stratification before the use of TXA in this context. STUDY DESIGN A 66-year-old man with long-standing HIV infection, hypertension, and no history of coronary artery disease (CAD) presented for revision spinal fusion surgery with the use of TXA is presented. METHODS To limit perioperative blood loss, the case patient received TXA intraoperatively. His operative course was uneventful. RESULTS During the first 12 hours postoperatively the patient was noted to have persistent tachycardia and ST-elevation on electrocardiogram. Echocardiography showed a new apical wall motion abnormality and a left ventricle thrombus; cardiac catheterization confirmed two-vessel CAD, treated with a bare-metal stent and anticoagulation. CONCLUSIONS The thrombotic risks of TXA use in non-cardiac surgery have yet to be adequately studied in clinical trials. Hence, TXA use in this context is still an area of uncertainty, and its thrombogenic risks have yet to be studied as a primary outcome in any large prospective trial to date. Patients with any hypercoagulable risk factors, including HIV infection or any prior thrombotic history in which TXA use is being considered, should prompt a discussion among the perioperative physicians involved.
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Affiliation(s)
- Neal Stuart Gerstein
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine, MSC 10 6000, 2211 Lomas Blvd NE, Albuquerque, New Mexico 87106, USA.
| | - Janet Kathryn Brierley
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine, MSC 10 6000, 2211 Lomas Blvd NE, Albuquerque, New Mexico 87106, USA
| | - Matthew Douglas Culling
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine, MSC 10 6000, 2211 Lomas Blvd NE, Albuquerque, New Mexico 87106, USA
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Gerstein NS, Kelly SP, Brierley JK. Yet Another Tranexamic Acid-Related Thrombotic Complication. J Cardiothorac Vasc Anesth 2015; 30:e21-2. [PMID: 26993525 DOI: 10.1053/j.jvca.2015.11.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Neal S Gerstein
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine Albuquerque, New Mexico
| | - Sean P Kelly
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine Albuquerque, New Mexico
| | - Janet K Brierley
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine Albuquerque, New Mexico
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Tranexamic acid precipitating onset of acute myocardial infarction. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/jppr.1050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Myles PS, Thompson G, Fedorow C, Farrington C, Sheridan N. Evaluation of differences in patient and physician perception of benefit and risks of aspirin and antifibrinolytic therapy in cardiac surgery. Anaesth Intensive Care 2014; 42:592-8. [PMID: 25233172 DOI: 10.1177/0310057x1404200508] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
It is unclear whether physicians and patients have similar concerns and preferences when considering benefit and risks of aspirin and antifibrinolytic therapy for cardiac surgery. We surveyed both groups to ascertain their perceptions and preferences for treatment in this setting. Both preoperative and postoperative cardiac surgical patients and the physician craft groups caring for them (cardiology, surgery, anaesthesia/critical care), were provided with estimates of benefits and risks of aspirin and antifibrinolytic therapy. All study participants were asked to stipulate the minimal absolute risk reduction required for them to agree to such therapy. When compared with the cardiac surgical patients they treat, physicians required a smaller thrombotic risk reduction with aspirin whilst accepting its known increased risk of bleeding. This was significantly different in a high-risk stroke setting (incidence 5%) where the required relative risk reduction with aspirin use for physicians was 20% versus patients 40% (P <0.001); and for myocardial infarction, physicians 20% versus patients 36% (P=0.051). For antifibrinolytic therapy, the tolerated increased relative risk of stroke for physicians was 20% versus patients 10% (P=0.004), and for myocardial infarction, physicians 16.7% versus patients 4.2% (P <0.001). The three physician craft groups had comparable tolerances of thrombotic risk. Patient and physician preferences for perioperative aspirin and antifibrinolytic therapy sometimes differ based on risk benefit analysis.
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Affiliation(s)
- P S Myles
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Victoria
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Myles PS. Antifibrinolytics, aspirin and cardiac surgery: evidence, guidelines and implications for current research. Anaesth Intensive Care 2014; 42:293-7. [PMID: 24847551 DOI: 10.1177/0310057x1404200303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Kunst G. From coronary steal to myocardial, renal, and cerebral protection: more questions than answers in anaesthetic preconditioning? Br J Anaesth 2014; 112:958-60. [PMID: 24574506 DOI: 10.1093/bja/aeu007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- G Kunst
- King's College Hospital NHS Foundation Trust, Department of Anaesthetics, Denmark Hill, London SE59RS, UK
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Ramakrishna H, Reidy C, Riha H, Sophocles A, Lane BJ, Patel PA, Andritsos M, Ghadimi K, Augoustides JGT. The year in cardiothoracic and vascular anesthesia: selected highlights from 2012. J Cardiothorac Vasc Anesth 2013; 27:86-91. [PMID: 23312777 DOI: 10.1053/j.jvca.2012.10.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Indexed: 11/11/2022]
Abstract
Cardiothoracic and vascular critical care has emerged as a subspecialty due to procedural breakthroughs, an aging population, and a multidisciplinary collaboration. This subspecialty now has a dedicated professional society, recently published guidelines, and plans for standardized certification. This paradigm shift represents a major collaboration opportunity for our specialty. The rise of evidence-based perioperative practice has produced a culture of large trials in our specialty to search for solutions to the challenging outcome questions. Besides the growth in the development of evidence, the consensus conference format and postpublication peer review have both emerged as effective processes for identifying the most relevant high-quality evidence. The quest for best perioperative practice has highlighted the importance of teamwork at all phases of care with respect to transitions in care, blood component transfusion, and research misconduct. The emergence of ultrasound as a standard for central vascular access also has been emphasized in recent multisociety guidelines. There also has been a paradigm shift in the management of patients with coronary artery disease. Recent guidelines have emphasized the roles of the cardiac anesthesiologist and the interventional cardiologist as part of the heart team approach. Major recent trials in comparative effectiveness have challenged the advantages of percutaneous coronary intervention, off-pump coronary artery bypass surgery, and intra-aortic balloon counterpulsation. The year 2012 has witnessed the emergence of new paradigms of care in our specialty with the emphasis on teamwork, safety, and quality. These processes will further improve perioperative outcome.
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Faraoni D, Savan V, Levy JH, Theusinger OM. Goal-directed coagulation management in the perioperative period of cardiac surgery. J Cardiothorac Vasc Anesth 2013; 27:1347-54. [PMID: 24103717 DOI: 10.1053/j.jvca.2013.08.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2013] [Indexed: 01/15/2023]
Affiliation(s)
- David Faraoni
- Department of Anesthesiology, Queen Fabiola Children's University Hospital (QFCUH), Free University of Brussels, Brussels, Belgium.
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Gupta PN, Mullamalla UR, Sabin P, Vellappan P. Acute MI in a young hypertensive woman: could it be due to tranexamic acid? BMJ Case Rep 2013; 2013:bcr-2013-009979. [PMID: 23715846 DOI: 10.1136/bcr-2013-009979] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The case report illustrates an acute myocardial infarction (MI) in a 41-year-old hypertensive woman possibly because of an intake of a combination of tranexamic acid and mefenamic acid for dysmenorrhoea and menorrhagia. There are multiple case reports of MI occurring in the setting of the use of antifibrinolytic agents including tranexamic acid. The present case serves as a warning that, even in patients with an apparently low risk for arterial thrombosis, these drugs may be implicated as a precipitant of MI.
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Affiliation(s)
- Prabha Nini Gupta
- Department of Cardiology, Medical College Hospital, Trivandrum, Kerala, India.
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Ker K, Edwards P, Perel P, Shakur H, Roberts I. Effect of tranexamic acid on surgical bleeding: systematic review and cumulative meta-analysis. BMJ 2012; 344:e3054. [PMID: 22611164 PMCID: PMC3356857 DOI: 10.1136/bmj.e3054] [Citation(s) in RCA: 579] [Impact Index Per Article: 48.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/26/2012] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess the effect of tranexamic acid on blood transfusion, thromboembolic events, and mortality in surgical patients. DESIGN Systematic review and meta-analysis. DATA SOURCES Cochrane central register of controlled trials, Medline, and Embase, from inception to September 2011, the World Health Organization International Clinical Trials Registry Platform, and the reference lists of relevant articles. STUDY SELECTION Randomised controlled trials comparing tranexamic acid with no tranexamic acid or placebo in surgical patients. Outcome measures of interest were the number of patients receiving a blood transfusion; the number of patients with a thromboembolic event (myocardial infarction, stroke, deep vein thrombosis, and pulmonary embolism); and the number of deaths. Trials were included irrespective of language or publication status. RESULTS 129 trials, totalling 10,488 patients, carried out between 1972 and 2011 were included. Tranexamic acid reduced the probability of receiving a blood transfusion by a third (risk ratio 0.62, 95% confidence interval 0.58 to 0.65; P<0.001). This effect remained when the analysis was restricted to trials using adequate allocation concealment (0.68, 0.62 to 0.74; P<0.001). The effect of tranexamic acid on myocardial infarction (0.68, 0.43 to 1.09; P = 0.11), stroke (1.14, 0.65 to 2.00; P = 0.65), deep vein thrombosis (0.86, 0.53 to 1.39; P = 0.54), and pulmonary embolism (0.61, 0.25 to 1.47; P=0.27) was uncertain. Fewer deaths occurred in the tranexamic acid group (0.61, 0.38 to 0.98; P = 0.04), although when the analysis was restricted to trials using adequate concealment there was considerable uncertainty (0.67, 0.33 to 1.34; P = 0.25). Cumulative meta-analysis showed that reliable evidence that tranexamic acid reduces the need for transfusion has been available for over 10 years. CONCLUSIONS Strong evidence that tranexamic acid reduces blood transfusion in surgery has been available for many years. Further trials on the effect of tranexamic acid on blood transfusion are unlikely to add useful new information. However, the effect of tranexamic acid on thromboembolic events and mortality remains uncertain. Surgical patients should be made aware of this evidence so that they can make an informed choice.
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Affiliation(s)
- Katharine Ker
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
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Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, Dunn AS, Kunz R. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e326S-e350S. [PMID: 22315266 DOI: 10.1378/chest.11-2298] [Citation(s) in RCA: 1034] [Impact Index Per Article: 86.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND This guideline addresses the management of patients who are receiving anticoagulant or antiplatelet therapy and require an elective surgery or procedure. METHODS The methods herein follow those discussed in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines article of this supplement. RESULTS In patients requiring vitamin K antagonist (VKA) interruption before surgery, we recommend stopping VKAs 5 days before surgery instead of a shorter time before surgery (Grade 1B). In patients with a mechanical heart valve, atrial fibrillation, or VTE at high risk for thromboembolism, we suggest bridging anticoagulation instead of no bridging during VKA interruption (Grade 2C); in patients at low risk, we suggest no bridging instead of bridging (Grade 2C). In patients who require a dental procedure, we suggest continuing VKAs with an oral prohemostatic agent or stopping VKAs 2 to 3 days before the procedure instead of alternative strategies (Grade 2C). In moderate- to high-risk patients who are receiving acetylsalicylic acid (ASA) and require noncardiac surgery, we suggest continuing ASA around the time of surgery instead of stopping ASA 7 to 10 days before surgery (Grade 2C). In patients with a coronary stent who require surgery, we recommend deferring surgery > 6 weeks after bare-metal stent placement and > 6 months after drug-eluting stent placement instead of undertaking surgery within these time periods (Grade 1C); in patients requiring surgery within 6 weeks of bare-metal stent placement or within 6 months of drug-eluting stent placement, we suggest continuing antiplatelet therapy perioperatively instead of stopping therapy 7 to 10 days before surgery (Grade 2C). CONCLUSIONS Perioperative antithrombotic management is based on risk assessment for thromboembolism and bleeding, and recommended approaches aim to simplify patient management and minimize adverse clinical outcomes.
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Affiliation(s)
- James D Douketis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | | | - Michael Mayr
- Medical Outpatient Department, University Hospital Basel, Basel, Switzerland
| | - Amir K Jaffer
- Division of Hospital Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Mark H Eckman
- Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati Medical Center, Cincinnati, OH
| | - Andrew S Dunn
- Department of Medicine, Mount Sinai School of Medicine, New York, NY
| | - Regina Kunz
- Academy of Swiss Insurance Medicine, Department of Medicine, University Hospital Basel, Basel, Switzerland.
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Cardiac dysfunction in the CABG patient. Curr Opin Pharmacol 2012; 12:166-71. [DOI: 10.1016/j.coph.2012.01.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Revised: 01/09/2012] [Accepted: 01/21/2012] [Indexed: 12/15/2022]
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Renal dysfunction and CABG. Curr Opin Pharmacol 2012; 12:181-8. [DOI: 10.1016/j.coph.2012.02.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Revised: 01/30/2012] [Accepted: 02/23/2012] [Indexed: 12/27/2022]
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Ferraris VA, Brown JR, Despotis GJ, Hammon JW, Reece TB, Saha SP, Song HK, Clough ER, Shore-Lesserson LJ, Goodnough LT, Mazer CD, Shander A, Stafford-Smith M, Waters J, Baker RA, Dickinson TA, FitzGerald DJ, Likosky DS, Shann KG. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg 2011; 91:944-82. [PMID: 21353044 DOI: 10.1016/j.athoracsur.2010.11.078] [Citation(s) in RCA: 859] [Impact Index Per Article: 66.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2010] [Revised: 11/20/2010] [Accepted: 11/29/2010] [Indexed: 12/16/2022]
Abstract
BACKGROUND Practice guidelines reflect published literature. Because of the ever changing literature base, it is necessary to update and revise guideline recommendations from time to time. The Society of Thoracic Surgeons recommends review and possible update of previously published guidelines at least every three years. This summary is an update of the blood conservation guideline published in 2007. METHODS The search methods used in the current version differ compared to the previously published guideline. Literature searches were conducted using standardized MeSH terms from the National Library of Medicine PUBMED database list of search terms. The following terms comprised the standard baseline search terms for all topics and were connected with the logical 'OR' connector--Extracorporeal circulation (MeSH number E04.292), cardiovascular surgical procedures (MeSH number E04.100), and vascular diseases (MeSH number C14.907). Use of these broad search terms allowed specific topics to be added to the search with the logical 'AND' connector. RESULTS In this 2011 guideline update, areas of major revision include: 1) management of dual anti-platelet therapy before operation, 2) use of drugs that augment red blood cell volume or limit blood loss, 3) use of blood derivatives including fresh frozen plasma, Factor XIII, leukoreduced red blood cells, platelet plasmapheresis, recombinant Factor VII, antithrombin III, and Factor IX concentrates, 4) changes in management of blood salvage, 5) use of minimally invasive procedures to limit perioperative bleeding and blood transfusion, 6) recommendations for blood conservation related to extracorporeal membrane oxygenation and cardiopulmonary perfusion, 7) use of topical hemostatic agents, and 8) new insights into the value of team interventions in blood management. CONCLUSIONS Much has changed since the previously published 2007 STS blood management guidelines and this document contains new and revised recommendations.
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Henry DA, Carless PA, Moxey AJ, O'Connell D, Stokes BJ, Fergusson DA, Ker K. Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev 2011; 2011:CD001886. [PMID: 21412876 PMCID: PMC4234031 DOI: 10.1002/14651858.cd001886.pub4] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Concerns regarding the safety of transfused blood have led to the development of a range of interventions to minimise blood loss during major surgery. Anti-fibrinolytic drugs are widely used, particularly in cardiac surgery, and previous reviews have found them to be effective in reducing blood loss, the need for transfusion, and the need for re-operation due to continued or recurrent bleeding. In the last few years questions have been raised regarding the comparative performance of the drugs. The safety of the most popular agent, aprotinin, has been challenged, and it was withdrawn from world markets in May 2008 because of concerns that it increased the risk of cardiovascular complications and death. OBJECTIVES To assess the comparative effects of the anti-fibrinolytic drugs aprotinin, tranexamic acid (TXA), and epsilon aminocaproic acid (EACA) on blood loss during surgery, the need for red blood cell (RBC) transfusion, and adverse events, particularly vascular occlusion, renal dysfunction, and death. SEARCH STRATEGY We searched: the Cochrane Injuries Group's Specialised Register (July 2010), Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 3), MEDLINE (Ovid SP) 1950 to July 2010, EMBASE (Ovid SP) 1980 to July 2010. References in identified trials and review articles were checked and trial authors were contacted to identify any additional studies. The searches were last updated in July 2010. SELECTION CRITERIA Randomised controlled trials (RCTs) of anti-fibrinolytic drugs in adults scheduled for non-urgent surgery. Eligible trials compared anti-fibrinolytic drugs with placebo (or no treatment), or with each other. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. This version of the review includes a sensitivity analysis excluding trials authored by Prof. Joachim Boldt. MAIN RESULTS This review summarises data from 252 RCTs that recruited over 25,000 participants. Data from the head-to-head trials suggest an advantage of aprotinin over the lysine analogues TXA and EACA in terms of reducing perioperative blood loss, but the differences were small. Compared to control, aprotinin reduced the probability of requiring RBC transfusion by a relative 34% (relative risk [RR] 0.66, 95% confidence interval [CI] 0.60 to 0.72). The RR for RBC transfusion with TXA was 0.61 (95% CI 0.53 to 0.70) and was 0.81 (95% CI 0.67 to 0.99) with EACA. When the pooled estimates from the head-to-head trials of the two lysine analogues were combined and compared to aprotinin alone, aprotinin appeared more effective in reducing the need for RBC transfusion (RR 0.90; 95% CI 0.81 to 0.99).Aprotinin reduced the need for re-operation due to bleeding by a relative 54% (RR 0.46, 95% CI 0.34 to 0.62). This translates into an absolute risk reduction of 2% and a number needed-to-treat (NNT) of 50 (95% CI 33 to 100). A similar trend was seen with EACA (RR 0.32, 95% CI 0.11 to 0.99) but not TXA (RR 0.80, 95% CI 0.55 to 1.17). The blood transfusion data were heterogeneous and funnel plots indicate that trials of aprotinin and the lysine analogues may be subject to publication bias.When compared with no treatment aprotinin did not increase the risk of myocardial infarction (RR 0.87, 95% CI 0.69 to 1.11), stroke (RR 0.82, 95% CI 0.44 to 1.52), renal dysfunction (RR 1.10, 95% CI 0.79 to 1.54) or overall mortality (RR 0.81, 95% CI 0.63 to 1.06). Similar trends were seen with the lysine analogues, but data were sparse. These data conflict with the results of recently published non-randomised studies, which found increased risk of cardiovascular complications and death with aprotinin. There are concerns about the adequacy of reporting of uncommon events in the small clinical trials included in this review.When aprotinin was compared directly with either, or both, of the two lysine analogues it resulted in a significant increase in the risk of death (RR 1.39, 95% CI 1.02, 1.89), and a non-significant increase in the risk of myocardial infarction (RR 1.11 95% CI 0.82, 1.50). Most of the data contributing to this added risk came from a single study - the BART trial (2008). AUTHORS' CONCLUSIONS Anti-fibrinolytic drugs provide worthwhile reductions in blood loss and the receipt of allogeneic red cell transfusion. Aprotinin appears to be slightly more effective than the lysine analogues in reducing blood loss and the receipt of blood transfusion. However, head to head comparisons show a lower risk of death with lysine analogues when compared with aprotinin. The lysine analogues are effective in reducing blood loss during and after surgery, and appear to be free of serious adverse effects.
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Affiliation(s)
- David A Henry
- Institute of Clinical Evaluative Sciences2075 Bayview AvenueG1 06TorontoOntarioCanadaM4N 3M5
| | - Paul A Carless
- Faculty of Health, University of NewcastleDiscipline of Clinical PharmacologyLevel 5, Clinical Sciences Building, Newcastle Mater HospitalEdith Street, WaratahNewcastleNew South WalesAustralia2298
| | - Annette J Moxey
- Faculty of Health, University of NewcastleResearch Centre for Gender, Health & AgeingLevel 2, David Maddison BuildingCnr King & Watt StreetsNewcastleNew South WalesAustralia2300
| | - Dianne O'Connell
- Cancer CouncilCancer Epidemiology Research UnitPO Box 572Kings CrossSydneyNSWAustralia1340
| | - Barrie J Stokes
- Faculty of Health, University of NewcastleDiscipline of Clinical PharmacologyLevel 5, Clinical Sciences Building, Newcastle Mater HospitalEdith Street, WaratahNewcastleNew South WalesAustralia2298
| | - Dean A Fergusson
- University of Ottawa Centre for Transfusion ResearchOttawa Health Research Institute501 Smyth RoadOttawaOntarioCanadaK1H 8L6
| | - Katharine Ker
- London School of Hygiene & Tropical MedicineCochrane Injuries GroupRoom 135Keppel StreetLondonUKWC1E 7HT
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Dixon B, Nixon I, Kenny J, Newcomb AE, Rosalion A, Opeskin K, Stamaratis G, Silbert BS, Said S, Santamaria JD, Campbell DJ. Aprotinin, but not tranexamic acid, is associated with increased pulmonary microvascular fibrin deposition after cardiac surgery. Thromb Res 2011; 127:272-4. [DOI: 10.1016/j.thromres.2010.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Revised: 11/15/2010] [Accepted: 11/15/2010] [Indexed: 10/18/2022]
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Raghunathan K, Connelly NR, Kanter GJ. ε-Aminocaproic Acid and Clinical Value in Cardiac Anesthesia. J Cardiothorac Vasc Anesth 2011; 25:16-9. [DOI: 10.1053/j.jvca.2010.07.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Indexed: 01/09/2023]
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Henry DA, Carless PA, Moxey AJ, O'Connell D, Stokes BJ, Fergusson DA, Ker K. Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev 2011:CD001886. [PMID: 21249650 DOI: 10.1002/14651858.cd001886.pub3] [Citation(s) in RCA: 192] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Concerns regarding the safety of transfused blood have led to the development of a range of interventions to minimise blood loss during major surgery. Anti-fibrinolytic drugs are widely used, particularly in cardiac surgery, and previous reviews have found them to be effective in reducing blood loss, the need for transfusion, and the need for re-operation due to continued or recurrent bleeding. In the last few years questions have been raised regarding the comparative performance of the drugs. The safety of the most popular agent, aprotinin, has been challenged, and it was withdrawn from world markets in May 2008 because of concerns that it increased the risk of cardiovascular complications and death. OBJECTIVES To assess the comparative effects of the anti-fibrinolytic drugs aprotinin, tranexamic acid (TXA), and epsilon aminocaproic acid (EACA) on blood loss during surgery, the need for red blood cell (RBC) transfusion, and adverse events, particularly vascular occlusion, renal dysfunction, and death. SEARCH STRATEGY We searched: the Cochrane Injuries Group's Specialised Register (July 2010), Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 3), MEDLINE (Ovid SP) 1950 to July 2010, EMBASE (Ovid SP) 1980 to July 2010. References in identified trials and review articles were checked and trial authors were contacted to identify any additional studies. The searches were last updated in July 2010. SELECTION CRITERIA Randomised controlled trials (RCTs) of anti-fibrinolytic drugs in adults scheduled for non-urgent surgery. Eligible trials compared anti-fibrinolytic drugs with placebo (or no treatment), or with each other. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. MAIN RESULTS This review summarises data from 252 RCTs that recruited over 25,000 participants. Data from the head-to-head trials suggest an advantage of aprotinin over the lysine analogues TXA and EACA in terms of reducing perioperative blood loss, but the differences were small. Compared to control, aprotinin reduced the probability of requiring RBC transfusion by a relative 34% (relative risk [RR] 0.66, 95% confidence interval [CI] 0.60 to 0.72). The RR for RBC transfusion with TXA was 0.61 (95% CI 0.53 to 0.70) and was 0.81 (95% CI 0.67 to 0.99) with EACA. When the pooled estimates from the head-to-head trials of the two lysine analogues were combined and compared to aprotinin alone, aprotinin appeared more effective in reducing the need for RBC transfusion (RR 0.90; 95% CI 0.81 to 0.99).Aprotinin reduced the need for re-operation due to bleeding by a relative 54% (RR 0.46, 95% CI 0.34 to 0.62). This translates into an absolute risk reduction of 2% and a number needed-to-treat (NNT) of 50 (95% CI 33 to 100). A similar trend was seen with EACA (RR 0.32, 95% CI 0.11 to 0.99) but not TXA (RR 0.80, 95% CI 0.55 to 1.17). The blood transfusion data were heterogeneous and funnel plots indicate that trials of aprotinin and the lysine analogues may be subject to publication bias.When compared with no treatment aprotinin did not increase the risk of myocardial infarction (RR 0.87, 95% CI 0.69 to 1.11), stroke (RR 0.82, 95% CI 0.44 to 1.52), renal dysfunction (RR 1.10, 95% CI 0.79 to 1.54) or overall mortality (RR 0.81, 95% CI 0.63 to 1.06). Similar trends were seen with the lysine analogues, but data were sparse. These data conflict with the results of recently published non-randomised studies, which found increased risk of cardiovascular complications and death with aprotinin. There are concerns about the adequacy of reporting of uncommon events in the small clinical trials included in this review.When aprotinin was compared directly with either, or both, of the two lysine analogues it resulted in a significant increase in the risk of death (RR 1.39, 95% CI 1.02, 1.89), and a non-significant increase in the risk of myocardial infarction (RR 1.11 95% CI 0.82, 1.50). Most of the data contributing to this added risk came from a single study - the BART trial (2008). AUTHORS' CONCLUSIONS Anti-fibrinolytic drugs provide worthwhile reductions in blood loss and the receipt of allogeneic red cell transfusion. Aprotinin appears to be slightly more effective than the lysine analogues in reducing blood loss and the receipt of blood transfusion. However, head to head comparisons show a lower risk of death with lysine analogues when compared with aprotinin. The lysine analogues are effective in reducing blood loss during and after surgery, and appear to be free of serious adverse effects.
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Affiliation(s)
- David A Henry
- Institute of Clinical Evaluative Sciences, 2075 Bayview Avenue, G1 06, Toronto, Ontario, Canada, M4N 3M5
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Hardy JF, Van der Linden P, Fergusson D. If we have bandwagons, magic bullets, and theoretical constructs, why do we need randomized clinical trials in transfusion medicine and perioperative hemostasis? Can J Anaesth 2010; 58:240-2, 242-5. [DOI: 10.1007/s12630-010-9444-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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Adler Ma SC, Brindle W, Burton G, Gallacher S, Hong FC, Manelius I, Smith A, Ho W, Alston RP, Bhattacharya K. Tranexamic acid is associated with less blood transfusion in off-pump coronary artery bypass graft surgery: a systematic review and meta-analysis. J Cardiothorac Vasc Anesth 2010; 25:26-35. [PMID: 21115366 DOI: 10.1053/j.jvca.2010.08.012] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2010] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Tranexamic acid reduces blood loss and transfusion in on-pump coronary artery bypass graft (CABG) surgery. Compared with on-pump, off-pump surgery is associated with less blood loss and transfusion. Therefore, tranexamic acid may be less effective for off-pump surgery, and its safety profile may be different in this setting. The aim of this study was to determine the efficacy and safety of tranexamic acid for off-pump CABG surgery. DESIGN Systematic review and meta-analysis. SETTING University of Edinburgh. INTERVENTIONS The administration of tranexamic acid. METHODS A systematic review of randomized controlled trials administering tranexamic acid to patients undergoing off-pump CABG surgery. A meta-analysis of 24-hour blood loss, postoperative allogeneic transfusion, and thromboembolic events. MEASUREMENTS AND MAIN RESULTS Eight trials were identified. The lack of appropriate data limited the meta-analysis on blood loss. Tranexamic acid significantly reduced the overall risk of allogeneic blood component transfusion (risk ratio = 0.47; 95% confidence intervals, 0.33-0.66; p < 0.0001) and packed red blood cell transfusions (risk ratio = 0.51; 95% CI, 0.36-0.71; p = 0.0001). No association was found between tranexamic acid and myocardial infarction, stroke, or pulmonary embolism. Population sizes of meta-analyses ranged from 466 to 544. CONCLUSIONS Tranexamic acid reduces blood transfusion after off-pump surgery. Although no association with adverse events was found, the population sample size was too small to detect rare but clinically significant adverse events. A well-designed randomized controlled trial with an appropriate sample size is required to confirm tranexamic acid effectiveness and safety in off-pump CABG surgery.
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Affiliation(s)
- S C Adler Ma
- University of Edinburgh, College of Medicine and Veterinary Medicine, Edinburgh, United Kingdom.
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Augoustides JGT. The year in cardiothoracic and vascular anesthesia: selected highlights from 2008. J Cardiothorac Vasc Anesth 2009; 23:1-7. [PMID: 19159841 DOI: 10.1053/j.jvca.2008.11.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2008] [Indexed: 11/11/2022]
Abstract
The 2008 highlights in cardiovascular and thoracic anesthesia include the ultimate departure of aprotinin from clinical practice. However, a new antihypertensive drug, clevidipine, was approved for perioperative control of hypertension. There were also advances in pharmacologic myocardial conditioning with agents such as cyclosporine, sodium nitroprusside, and levosimendan. Furthermore, ischemic preconditioning appears ready for testing in large clinical trials designed to improve ischemic outcomes after cardiac surgery. With regard to transfusion, a landmark study suggests that transfused red blood cells stored for >2 weeks may significantly worsen major outcome after cardiac surgery. Furthermore, a second study suggests that relative rather than absolute hemoglobin reduction significantly determines adverse outcomes after cardiac surgery. These studies may greatly affect future transfusion guidelines. Left-sided valve replacement has been revolutionized by transcatheter technology, which progressed significantly in 2008. Important advances in percutaneous coronary intervention included drug-eluting bioabsorbable stents and further insights into the clinical consequences of platelet resistance. These 2008 themes represent a sampling of the total highlights for the year. Many of the advances not covered have been reviewed and discussed in the literature review sections of the Journal in 2008.
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Affiliation(s)
- John G T Augoustides
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA 19104-4283, USA.
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Tosetto A, Balduini CL, Cattaneo M, De Candia E, Mariani G, Molinari AC, Rossi E, Siragusa S. Management of bleeding and of invasive procedures in patients with platelet disorders and/or thrombocytopenia: Guidelines of the Italian Society for Haemostasis and Thrombosis (SISET). Thromb Res 2009; 124:e13-8. [PMID: 19631969 DOI: 10.1016/j.thromres.2009.06.009] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2009] [Revised: 06/11/2009] [Accepted: 06/14/2009] [Indexed: 10/20/2022]
Abstract
The optimal management of bleeding or its prophylaxis in patients with disorders of platelet count or function is controversial. The bleeding diathesis of these patients is usually mild to moderate: therefore, transfusion of platelet concentrates may be inappropriate, as potential adverse effects might outweigh its benefit. The availability of several anti-hemorrhagic drugs further compounds this problem, mainly because the efficacy/suitability of the various treatment options in different clinical manifestations is not well defined. In these guidelines, promoted by the Italian Society for Studies on Haemostasis and Thrombosis (Società Italiana per lo Studio dell'Emostasi e della Trombosi [SISET]), we aim at offering the best available evidence to help the physicians involved in the management of patients with disorders of platelet count or function. Literature review and appraisal of available evidence are discussed for different clinical settings and for different available treatments, including platelet concentrates (PC), recombinant activated factor VII, desmopressin, antifibrinolytics, aprotinin and local hemostatic agents.
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Affiliation(s)
- A Tosetto
- Clinica Medica III, Università di Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia.
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The Effect of Epsilon-Aminocaproic Acid and Aprotinin on Fibrinolysis and Blood Loss in Patients Undergoing Primary, Isolated Coronary Artery Bypass Surgery: A Randomized, Double-Blind, Placebo-Controlled, Noninferiority Trial. Anesth Analg 2009; 109:15-24. [DOI: 10.1213/ane.0b013e3181a40b5d] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Porte RJ, Mallette SV, Burroughs AK. Aprotinin and lysine analogues in high-risk cardiac surgery. N Engl J Med 2008; 359:1181; author reply 1181-2. [PMID: 18784112 DOI: 10.1056/nejmc081370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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