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Di Biase L, Lakkireddy DJ, Marazzato J, Velasco A, Diaz JC, Navara R, Chrispin J, Rajagopalan B, Natale A, Mohanty S, Zhang X, Della Rocca D, Dalal A, Park K, Wiley J, Batchelor W, Cheung JW, Dangas G, Mehran R, Romero J. Antithrombotic Therapy for Patients Undergoing Cardiac Electrophysiological and Interventional Procedures: JACC State-of-the-Art Review. J Am Coll Cardiol 2024; 83:82-108. [PMID: 38171713 DOI: 10.1016/j.jacc.2023.09.831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 08/24/2023] [Accepted: 09/21/2023] [Indexed: 01/05/2024]
Abstract
Electrophysiological and interventional procedures have been increasingly used to reduce morbidity and mortality in patients experiencing cardiovascular diseases. Although antithrombotic therapies are critical to reduce the risk of stroke or other thromboembolic events, they can nonetheless increase the bleeding hazard. This is even more true in an aging population undergoing cardiac procedures in which the combination of oral anticoagulants and antiplatelet therapies would further increase the hemorrhagic risk. Hence, the timing, dose, and combination of antithrombotic therapies should be carefully chosen in each case. However, the maze of society guidelines and consensus documents published so far have progressively led to a hazier scenario in this setting. Aim of this review is to provide-in a single document-a quick, evidenced-based practical summary of the antithrombotic approaches used in different cardiac electrophysiology and interventional procedures to guide the busy clinician and the cardiac proceduralist in their everyday practice.
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Affiliation(s)
- Luigi Di Biase
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA.
| | | | - Jacopo Marazzato
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Alejandro Velasco
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Juan Carlos Diaz
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Rachita Navara
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Jonathan Chrispin
- Clinical Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, Austin, Texas, USA
| | | | - Xiaodong Zhang
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Aarti Dalal
- Division of Cardiology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Ki Park
- Department of Cardiovascular Medicine, University of Florida, Gainesville, Florida, USA
| | - Jose Wiley
- Division of Cardiology, Mount Sinai Medical Center, New York, New York, USA
| | - Wayne Batchelor
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Jim W Cheung
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA
| | - George Dangas
- Division of Cardiology, Mount Sinai Medical Center, New York, New York, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jorge Romero
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
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2
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2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Translation of the document prepared by the Czech Society of Cardiology. COR ET VASA 2022. [DOI: 10.33678/cor.2022.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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3
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Vondran M, von Aspern K, Garbade J, Lässing J, Kiefer P, Rastan AJ, Borger MA, Schroeter T. Is Implantable Cardioverter Defibrillator surgery in patients with an implanted left ventricular assist device safe under uninterrupted oral anticoagulation? Artif Organs 2022; 46:1564-1572. [PMID: 35192216 DOI: 10.1111/aor.14217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 12/27/2021] [Accepted: 02/03/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Implantable Cardioverter-Defibrillator (ICD) surgery in patients with implanted left ventricular assist devices (LVAD) is associated with an increased risk of bleeding complications because of the need to ensure that these patients are adequately anticoagulated. Our study aimed to evaluate the safety of our new strategy of uninterrupted oral anticoagulation compared to heparin-bridging during the surgical interval. METHODS Between 01/2009 and 01/2020, 116 patients with LVAD underwent ICD surgery. Since 01/2015, 60 patients were operated under continued sufficient oral anticoagulation with a vitamin k antagonist (VKA group). Fifty-six patients underwent a heparin-bridging regimen (heparin group). Demographics, perioperative data, complications, and mortality were analyzed. RESULTS Bleeding complications attributable to the surgical intervention occurred more often (19.6% vs. 10.0%, p=0.142) and at a higher rate of re-exploratory surgery (14.3 % vs. 5.0%, p=0.088) in the heparin group without reaching statistical significance. Moreover, the heparin group patients' postoperative total length of stay was 10 days longer. (17.8 ± 23.8 days vs. 8.3 ± 9.5 days, p=0.007). There were no procedure-related deaths, no thromboembolic events, and no LVAD-related thrombosis. CONCLUSION Our strategy of uninterrupted oral anticoagulation is safe and results in a reduction by more than half the number of days in hospital without an increase in adverse events.
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Affiliation(s)
- Maximilian Vondran
- University Department for Cardiac Surgery, Leipzig, Germany.,Department of Cardiac and Thoracic Vascular Surgery, Philipps-University Hospital Marburg, Marburg, Germany
| | | | - Jens Garbade
- University Department for Cardiac Surgery, Leipzig, Germany
| | - Johannes Lässing
- University Department for Cardiac Surgery, Leipzig, Germany.,Institute of Sports Medicine & Prevention, University of Leipzig Faculty of Medicine, Leipzig, Germany
| | - Philipp Kiefer
- University Department for Cardiac Surgery, Leipzig, Germany
| | - Ardawan Julian Rastan
- Department of Cardiac and Thoracic Vascular Surgery, Philipps-University Hospital Marburg, Marburg, Germany
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Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, Barrabés JA, Boriani G, Braunschweig F, Brignole M, Burri H, Coats AJ, Deharo JC, Delgado V, Diller GP, Israel CW, Keren A, Knops RE, Kotecha D, Leclercq C, Merkely B, Starck C, Thylén I, Tolosana JM. Grupo de trabajo sobre estimulación cardiaca y terapia de resincronización cardiaca de la Sociedad Europea de Cardiología (ESC). Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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5
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Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, Barrabés JA, Boriani G, Braunschweig F, Brignole M, Burri H, Coats AJS, Deharo JC, Delgado V, Diller GP, Israel CW, Keren A, Knops RE, Kotecha D, Leclercq C, Merkely B, Starck C, Thylén I, Tolosana JM, Leyva F, Linde C, Abdelhamid M, Aboyans V, Arbelo E, Asteggiano R, Barón-Esquivias G, Bauersachs J, Biffi M, Birgersdotter-Green U, Bongiorni MG, Borger MA, Čelutkienė J, Cikes M, Daubert JC, Drossart I, Ellenbogen K, Elliott PM, Fabritz L, Falk V, Fauchier L, Fernández-Avilés F, Foldager D, Gadler F, De Vinuesa PGG, Gorenek B, Guerra JM, Hermann Haugaa K, Hendriks J, Kahan T, Katus HA, Konradi A, Koskinas KC, Law H, Lewis BS, Linker NJ, Løchen ML, Lumens J, Mascherbauer J, Mullens W, Nagy KV, Prescott E, Raatikainen P, Rakisheva A, Reichlin T, Ricci RP, Shlyakhto E, Sitges M, Sousa-Uva M, Sutton R, Suwalski P, Svendsen JH, Touyz RM, Van Gelder IC, Vernooy K, Waltenberger J, Whinnett Z, Witte KK. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Europace 2022; 24:71-164. [PMID: 34455427 DOI: 10.1093/europace/euab232] [Citation(s) in RCA: 140] [Impact Index Per Article: 70.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Lind A, Ahsan M, Kaya E, Wakili R, Rassaf T, Jánosi RA. Early Pacemaker Implantation after Transcatheter Aortic Valve Replacement: Impact of PlasmaBlade™ for Prevention of Device-Associated Bleeding Complications. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:1331. [PMID: 34946276 PMCID: PMC8707306 DOI: 10.3390/medicina57121331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 12/01/2021] [Accepted: 12/02/2021] [Indexed: 12/03/2022]
Abstract
Background and Objectives: Permanent pacemaker implantation (PPI) is frequently required following transcatheter aortic valve replacement (TAVR). Dual antiplatelet therapy (DAPT) or oral anticoagulation therapy (OAK) is often necessary in these patients since they are at higher risk of thromboembolic events due to TAVR implantation, high incidence of coronary artery diseases (CAD) with the necessity of coronary intervention, and high rate of atrial fibrillation with the need of stroke prevention. We sought to evaluate the safety, efficiency, and clinical outcomes of early PPI following TAVR using the PlasmaBlade™ (Medtronic Inc., Minneapolis, MN, USA) pulsed electron avalanche knife (PEAK) for bleeding control in patients under DAPT or OAK. Materials and Methods: This retrospective single-center study included patients who underwent PPI after transfemoral TAVR (TF) at our center between December 2015 and May 2020. All PPI were performed using the PlasmaBlade™ Device. Results: The overall PPI rate was 14.1% (83 of 587 patients; 82.5 ± 4.6 years; 45.8% male). The PPI procedures were used to treat high-grade atrioventricular block (81.9%), severe sinus node dysfunction (13.3%), and alternating bundle branch block (4.8%). At the time of the procedure, 35 (42.2%) patients received DAPT, and 48 (57.8%) patients received OAK (50% with vitamin K antagonist (VKA) and 50% with novel oral anticoagulants (NOAK)). One device-pocket hematoma treated conservatively occurred in a patient (1.2%) receiving NOAK. Two re-operations were necessary in patients due to immediate lead dislocation (2.4%). Conclusions: The results of this study illustrate that the use of PlasmaBlade™ for PPI in patients after a TAVR who require antithrombotic treatment is feasible and might result into lower rates of severe bleeding complications compared to rates reported in the literature. Use of the PlasmaBlade device may be considered in this specific group of patients because of their high risk of bleeding.
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Affiliation(s)
- Alexander Lind
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University of Duisburg-Essen, 45147 Essen, Germany; (M.A.); (E.K.); (R.W.); (T.R.); (R.A.J.)
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7
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Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, Barrabés JA, Boriani G, Braunschweig F, Brignole M, Burri H, Coats AJS, Deharo JC, Delgado V, Diller GP, Israel CW, Keren A, Knops RE, Kotecha D, Leclercq C, Merkely B, Starck C, Thylén I, Tolosana JM. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Eur Heart J 2021; 42:3427-3520. [PMID: 34455430 DOI: 10.1093/eurheartj/ehab364] [Citation(s) in RCA: 865] [Impact Index Per Article: 288.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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8
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Islam F, Sabbe M, Heeren P, Milisen K. Consistency of decision support software-integrated telephone triage and associated factors: a systematic review. BMC Med Inform Decis Mak 2021; 21:107. [PMID: 33743697 PMCID: PMC7981379 DOI: 10.1186/s12911-021-01472-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 03/14/2021] [Indexed: 11/12/2022] Open
Abstract
Background In the recent decades, the use of computerized decision support software (CDSS)-integrated telephone triage (TT) has become an important tool for managing rising healthcare demands and overcrowding in the emergency department. Though these services have generally been shown to be effective, large gaps in the literature exist with regards to the overall quality of these systems. In the current systematic review, we aim to document the consistency of decisions that are generated in CDSS-integrated TT. Furthermore, we also seek to map those factors in the literature that have been identified to have an impact on the consistency of generated triage decisions. Methods As part of the TRANS-SENIOR international training and research network, a systematic review of the literature was conducted in November 2019. PubMed, Web of Science, CENTRAL, and the CINAHL database were searched. Quantitative articles including a CDSS component and addressing consistency of triage decisions and/or factors associated with triage decisions were eligible for inclusion in the current review. Studies exploring the use of other types of digital support systems for triage (i.e. web chat, video conferencing) were excluded. Quality appraisal of included studies were performed independently by two authors using the Methodological Index for Non-Randomized Studies. Results From a total of 1551 records that were identified, 39 full-texts were assessed for eligibility and seven studies were included in the review. All of the studies (n = 7) identified as part of our search were observational and were based on nurse-led telephone triage. Scientific efforts investigating our first aim was very limited. In total, two articles were found to investigate the consistency of decisions that are generated in CDSS-integrated TT. Research efforts were targeted largely towards the second aim of our study—all of the included articles reported factors related to the operator- (n = 6), patient- (n = 1), and/or CDSS-integrated (n = 2) characteristics to have an influence on the consistency of CDSS-integrated TT decisions. Conclusion To date, some efforts have been made to better understand how the use of CDSS-integrated TT systems may vary across settings. In general, however, the evidence-base surrounding this field of literature is largely inconclusive. Further evaluations must be prompted to better understand this area of research. Protocol registration The protocol for this study is registered in the PROSPERO database (registration number: CRD42020146323). Supplementary Information The online version contains supplementary material available at 10.1186/s12911-021-01472-3.
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Affiliation(s)
- Farah Islam
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 35, 3000, Leuven, Belgium
| | - Marc Sabbe
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 35, 3000, Leuven, Belgium.,Department of Emergency Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Pieter Heeren
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 35, 3000, Leuven, Belgium.,Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.,Research Foundation Flanders, Egmontstraat 5, 1000, Brussels, Belgium
| | - Koen Milisen
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 35, 3000, Leuven, Belgium. .,Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
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Mehta NK, Doerr K, Skipper A, Rojas-Pena E, Dixon S, Haines DE. Current strategies to minimize postoperative hematoma formation in patients undergoing cardiac implantable electronic device implantation: A review. Heart Rhythm 2020; 18:641-650. [PMID: 33242669 DOI: 10.1016/j.hrthm.2020.11.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 11/04/2020] [Accepted: 11/16/2020] [Indexed: 02/06/2023]
Abstract
There are an increasing number of cardiac electronic device implants and generator changes with a longer patient life expectancy along with concomitant increase in antiplatelet and anticoagulant regimens, which can increase the incidence of pocket hematomas. We have conducted an in-depth analysis on the relevant literature, which is rife with varying definition of hematomas, on ways to reduce pocket hematomas. We have analyzed studies on periprocedural medication management, intraprocedural use of prohemostatic agents, and postprocedure role of compression devices.
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Affiliation(s)
- Nishaki Kiran Mehta
- Department of Cardiovascular Medicine, Beaumont Hospital Royal Oak, Royal Oak, Michigan; Oakland University William Beaumont School of Medicine, Rochester, Michigan; Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia.
| | - Kimberly Doerr
- Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Andrew Skipper
- Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Edward Rojas-Pena
- Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Simon Dixon
- Department of Cardiovascular Medicine, Beaumont Hospital Royal Oak, Royal Oak, Michigan; Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia
| | - David E Haines
- Department of Cardiovascular Medicine, Beaumont Hospital Royal Oak, Royal Oak, Michigan; Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia
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Mori M, Ibayashi K, Kanayama M, Takenaka M, Kuroda K, Muramatsu K, Fujino Y, Matsuda S, Tanaka F. The role of heparin bridging in lung cancer surgery: a nationwide database analysis. Surg Today 2020; 51:923-930. [PMID: 33104876 DOI: 10.1007/s00595-020-02165-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/25/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE There is little evidence to demonstrate the impact of heparin bridging (HB) in major surgery. This study aimed to evaluate the benefits and risks of HB in lung cancer surgery by comparing HB and non-HB (NHB) groups. METHODS We extracted patients who were taking an anticoagulant, were diagnosed with lung cancer, and underwent lung resection between April 2014 and March 2018 from a nationwide database in Japan. We compared the HB and NHB groups to determine the benefits and risks of HB. The proportion of postoperative thromboembolism and bleeding events between the HB and NHB groups was the primary outcome. We performed propensity score matching to remove any HB assignment bias. RESULTS We selected 2416 patients, and among these, 1068 patients had HB and 1348 did not. Propensity score matching extracted 1500 patients: 750 with HB and 750 without HB. After matching, a Chi-square test showed no significant difference in the incidence of postoperative thromboembolism (1.5% vs 0.9%, p value = 0.343) and bleeding events (5.9% vs 4.0%, p value = 0.124) between the two groups. CONCLUSIONS There was no significant difference in the incidence of postoperative thromboembolism and bleeding in the patients with and those without HB.
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Affiliation(s)
- Masataka Mori
- Second Department of Surgery, School of Medicine, University of Occupational and Environmental Health, Yahatanishi, Kitakyushu, 807, Japan.
| | - Koki Ibayashi
- Department of Environmental Epidemiology, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Masatoshi Kanayama
- Second Department of Surgery, School of Medicine, University of Occupational and Environmental Health, Yahatanishi, Kitakyushu, 807, Japan
| | - Masaru Takenaka
- Second Department of Surgery, School of Medicine, University of Occupational and Environmental Health, Yahatanishi, Kitakyushu, 807, Japan
| | - Koji Kuroda
- Second Department of Surgery, School of Medicine, University of Occupational and Environmental Health, Yahatanishi, Kitakyushu, 807, Japan
| | - Keiji Muramatsu
- Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yoshihisa Fujino
- Department of Environmental Epidemiology, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Shinya Matsuda
- Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Fumihiro Tanaka
- Second Department of Surgery, School of Medicine, University of Occupational and Environmental Health, Yahatanishi, Kitakyushu, 807, Japan
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11
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Jilek C, Lewalter T. [Perioperative management of anticoagulation among patients with atrial fibrillation]. MMW Fortschr Med 2020; 162:44-47. [PMID: 32189261 DOI: 10.1007/s15006-020-0262-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Clemens Jilek
- Peter Osypka Herzzentrum München, Internistisches Klinikum München Süd, Am Isarkanal 36, D-81379, München, Deutschland.
| | - Thorsten Lewalter
- Peter Osypka Herzzentrum München, Internistisches Klinikum München Süd, Am Isarkanal 36, D-81379, München, Deutschland
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12
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Mori M, Ichiki Y, Kanayama M, Taira A, Shinohara S, Kuwata T, Imanishi N, Yoneda K, Kuroda K, Tanaka F. The impact of perioperative heparin bridging therapy in lung cancer surgery. Gen Thorac Cardiovasc Surg 2019; 68:623-628. [PMID: 31848903 DOI: 10.1007/s11748-019-01276-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 12/10/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE The impact of perioperative heparin bridging (HB) for lung surgery in patients on anti-clotting drugs remains unclear. We performed a retrospective study to assess its effect on surgical safety by comparing HB and non-HB groups. METHODS This study included 274 consecutive patients on anti-clotting drugs who underwent surgery for lung cancer. Of these, 77 received HB and 197 did not. Propensity score matching extracted 124 patients, consisting of 62 patients with HB and 62 patients without HB. Endpoints were surgical safety. RESULTS There was no statistically significant difference in the outcomes of surgical safety outcomes between the HB and non-HB group after propensity-score matching, operative time (172 vs. 203 min, p = 0.131), volume of blood loss (60 vs. 70 ml, p = 0.335), need for intraoperative RBC transfusion (3.2 vs. 6.5%, p = 0.680), chest tube drainage volume on the 1st postoperative day (200 vs. 200 ml, p = 0.796), and chest tube placement duration (3 vs. 3 days, p = 0.606). CONCLUSIONS The influence of perioperative HB on postoperative thromboembolic or bleeding events in lung cancer surgery is not obvious, but its surgical safety appears to be acceptable.
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Affiliation(s)
- Masataka Mori
- Second Department of Surgery, University of Occupational and Environmental Health, Kitakyushu, Japan.
| | - Yoshinobu Ichiki
- Department of General Thoracic Surgery, National Hospital Organization Saitama Hospital, Wako, Japan
| | - Masatoshi Kanayama
- Second Department of Surgery, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Akihiro Taira
- Second Department of Surgery, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Shinji Shinohara
- Second Department of Surgery, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Taiji Kuwata
- Second Department of Surgery, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Naoko Imanishi
- Second Department of Surgery, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Kazue Yoneda
- Second Department of Surgery, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Koji Kuroda
- Second Department of Surgery, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Fumihiro Tanaka
- Second Department of Surgery, University of Occupational and Environmental Health, Kitakyushu, Japan
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13
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Jilek C, Lewalter T. [Atrial fibrillation and anticoagulation]. MMW Fortschr Med 2019; 161:22-31. [PMID: 31713789 DOI: 10.1007/s15006-019-0026-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Clemens Jilek
- Peter Osypka Herzzentrum München, Internistisches Klinikum München Süd, Am Isarkanal 36, D-81379, München, Deutschland.
| | - Thorsten Lewalter
- Peter Osypka Herzzentrum München, Internistisches Klinikum München Süd, Am Isarkanal 36, D-81379, München, Deutschland
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14
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Budano C, Garrone P, Castagno D, Bissolino A, Andreis A, Bertolo L, Mazzini D, Bergamasco L, Marra S, Gaita F. Same-day CIED implantation and discharge: Is it possible? The E-MOTION trial (Early MObilization after pacemaker implantaTION). Int J Cardiol 2019; 288:82-86. [DOI: 10.1016/j.ijcard.2019.04.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 03/31/2019] [Accepted: 04/05/2019] [Indexed: 10/27/2022]
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15
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Stewart MH, Morin DP. Management of Perioperative Anticoagulation for Device Implantation. Card Electrophysiol Clin 2018; 10:99-109. [PMID: 29428146 DOI: 10.1016/j.ccep.2017.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Periprocedural management of anticoagulation for cardiac device implantation has evolved over the past 20 years. The traditional paradigm of vitamin K antagonist interruption with heparin bridging has now been shown to be less safe than continuation of vitamin K antagonists at therapeutic levels. Dual antiplatelet therapy during device implantation poses substantial risk but is often necessary. The safest dosing strategy for newer direct oral anticoagulants is still not clear.
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Affiliation(s)
- Merrill H Stewart
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, University of Queensland School of Medicine, 1514 Jefferson Highway, New Orleans, LA 70121, USA
| | - Daniel P Morin
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, University of Queensland School of Medicine, 1514 Jefferson Highway, New Orleans, LA 70121, USA.
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Chousou PA, Pugh PJ. Managing anticoagulation in patients receiving implantable cardiac devices. Future Cardiol 2017; 14:151-164. [PMID: 29226707 DOI: 10.2217/fca-2017-0044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
A substantial proportion of patients who undergo cardiac device implantation receive oral anticoagulation to prevent thromboembolism or antiplatelets to prevent thrombotic events. Anticoagulation and antiplatelets increase the risk of hemorrhagic complications, while discontinuation may increase thromboembolic risk and thrombotic events. With the introduction of non-vitamin K antagonist oral anticoagulant agents and the newer antiplatelet agents such as prasugrel or ticagrelor, the perioperative management of patients has become more challenging. In this article, we review the recent trials and meta-analysis and describe the available evidence, as well as the current recommendations in order to inform best practice. We also reinforce the importance of further trials in this complex and rapidly evolving area.
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Affiliation(s)
- Panagiota Anna Chousou
- Department of Cardiology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK
| | - Peter J Pugh
- Department of Cardiology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK
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18
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He H, Ke BB, Li Y, Han FS, Li X, Zeng YJ. Perioperative management of antithrombotic therapy in patients receiving cardiovascular implantable electronic devices: a network meta-analysis. J Interv Card Electrophysiol 2017; 50:65-83. [PMID: 28842832 DOI: 10.1007/s10840-017-0280-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 08/10/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE Network meta-analysis (NMA) has advantages including being able to simultaneously compare and rank multiple treatments over traditional meta-analysis. We evaluated by a NMA the optimal antithrombotic strategy during the perioperative period of implantation of cardiovascular implantable electronic devices (CIEDs). METHODS We performed a network meta-analysis of observational studies (cohort and case-control studies). The eligible studies tested the following antithrombotic therapy during the CIED placement: aspirin, clopidogrel, warfarin, novel oral anticoagulants (NOACs), and heparin bridging. RESULTS Thirty-one observational studies with 119 study arms were included (41,174 patients receiving long-term antithrombotic therapy; median age, 72.6 years; 70.1% males; median follow-up, 3.6 years). Aspirin (4.26 [2.88-7.22]), warfarin (3.37 [2.17-5.23]), and clopidogrel (3.30 [1.49-5.88]) reduced the risk of bleeding as compared with heparin bridging, and there was no significance difference between continued NOACs and heparin bridging (0.67 [0.21-2.18]). The comparison of commonly used protocols in the management of anticoagulant therapy revealed that continued warfarin (0.38 [0.20-0.74]), continued NOACs (0.19 [0.04-0.89]), and heparin bridging therapy (0.01 [0.05-0.21]) increased the risk of bleeding as compared that of control, and continued warfarin (3.74 [1.96-7.16]), interrupted warfarin (4.89 [2.20-10.88]), and interrupted NOACs (12.5 [1.25-100]) reduced the risk of bleeding compared with that of heparin bridging. CONCLUSIONS Among various antithrombotic drugs, aspirin had the lowest bleeding risk, followed by warfarin, clopidogrel and NOACs, and heparin, with the greatest bleeding risk. NOACs therapy appears safe and effective, and interrupted NOACs may be the optimal anticoagulation protocol for use during the perioperative period of CIED implantation.
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Affiliation(s)
- Hua He
- Department of Emergency Cardiology, Beijing Anzhen Hospital, Capital Medical University, Anzhen Road Second, Chaoyang District, Beijing, 100029, People's Republic of China.
| | - Bing-Bing Ke
- Department of Emergency Cardiology, Beijing Anzhen Hospital, Capital Medical University, Anzhen Road Second, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Yan Li
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing, 100029, China
| | - Fu-Sheng Han
- Department of Emergency Cardiology, Beijing Anzhen Hospital, Capital Medical University, Anzhen Road Second, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Xiaodong Li
- Department of Emergency Cardiology, Beijing Anzhen Hospital, Capital Medical University, Anzhen Road Second, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Yu-Jie Zeng
- Department of Emergency Cardiology, Beijing Anzhen Hospital, Capital Medical University, Anzhen Road Second, Chaoyang District, Beijing, 100029, People's Republic of China
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19
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Anticoagulant-Free but Dangerous: Perisurgical Consideration. J Stroke Cerebrovasc Dis 2017; 26:2038-2040. [PMID: 28711363 DOI: 10.1016/j.jstrokecerebrovasdis.2017.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 05/25/2017] [Accepted: 06/17/2017] [Indexed: 11/22/2022] Open
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20
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Garwood CL, Korkis B, Grande D, Hanni C, Morin A, Moser LR. Anticoagulation Bridge Therapy in Patients with Atrial Fibrillation: Recent Updates Providing a Rebalance of Risk and Benefit. Pharmacotherapy 2017; 37:712-724. [PMID: 28475278 DOI: 10.1002/phar.1937] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
In 2011 we reviewed clinical updates and controversies surrounding anticoagulation bridge therapy in patients with atrial fibrillation (AF). Since then, options for oral anticoagulation have expanded with the addition of four direct oral anticoagulant (DOAC) agents available in the United States. Nonetheless, vitamin K antagonist (VKA) therapy continues to be the treatment of choice for patients who are poor candidates for a DOAC and for whom bridge therapy remains a therapeutic dilemma. This literature review identifies evidence and guideline and consensus statements from the last 5 years to provide updated recommendations and insight into bridge therapy for patients using a VKA for AF. Since our last review, at least four major international guidelines have been updated plus a new consensus document addressing bridge therapy was released. Prospective trials and one randomized controlled trial have provided guidance for perioperative bridge therapy. The clinical trial data showed that bridging with heparin is associated with a significant bleeding risk compared with not bridging; furthermore, data suggested that actual perioperative thromboembolic risk may be lower than previously estimated. Notably, patients at high risk for stroke have not been adequately represented. These findings highlight the importance of assessing thrombosis and bleeding risk before making bridging decisions. Thrombosis and bleeding risk tools have emerged to facilitate this assessment and have been incorporated into guideline recommendations. Results from ongoing trials are expected to provide more guidance on safe and effective perioperative management approaches for patients at high risk for stroke.
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Affiliation(s)
- Candice L Garwood
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan.,Pharmacy Department, Harper University Hospital, Detroit Medical Center, Detroit, Michigan
| | - Bianca Korkis
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan.,Pharmacy Department, Harper University Hospital, Detroit Medical Center, Detroit, Michigan
| | - Domenico Grande
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan
| | - Claudia Hanni
- Pharmacy Department, Harper University Hospital, Detroit Medical Center, Detroit, Michigan
| | - Amy Morin
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan
| | - Lynette R Moser
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan
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21
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Black-Maier E, Kim S, Steinberg BA, Fonarow GC, Freeman JV, Kowey PR, Ansell J, Gersh BJ, Mahaffey KW, Naccarelli G, Hylek EM, Go AS, Peterson ED, Piccini JP. Oral anticoagulation management in patients with atrial fibrillation undergoing cardiac implantable electronic device implantation. Clin Cardiol 2017; 40:746-751. [PMID: 28543401 PMCID: PMC5638096 DOI: 10.1002/clc.22726] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Accepted: 04/19/2017] [Indexed: 01/22/2023] Open
Abstract
Background Oral anticoagulation (OAC) therapy is associated with increased periprocedural risks after cardiac implantable electronic device (CIED) implantation. Patterns of anticoagulation management involving non–vitamin K antagonist oral anticoagulants (NOACs) have not been characterized. Hypothesis Anticoagulation strategies and outcomes differ by anticoagulant type in patients undergoing CIED implantation. Methods Using the nationwide Outcomes Registry for Better Informed Treatment of Atrial Fibrillation, we assessed how atrial fibrillation (AF) patients undergoing CIED implantation were cared for and their subsequent outcomes. Outcomes were compared by oral anticoagulant therapy (none, warfarin, or NOAC) as well as by anticoagulation interruption status. Results Among 9129 AF patients, 416 (5%) underwent CIED implantation during a median follow‐up of 30 months (interquartile range, 24–36). Of these, 60 (14%) had implantation on a NOAC. Relative to warfarin therapy, those on a NOAC were younger (70.5 years [range, 65–77.5 years] vs 77 years [range, 70–82 years]), had less valvular heart disease (15.0% vs 31.3%), higher creatinine clearance (67.3 [range, 59.7–99.0] vs 65.8 [range, 50.0–91.6]), were more likely to have persistent AF (26.7% vs 22.9%), and use concomitant aspirin (51.7% vs 35.2%). OAC therapy was commonly interrupted for CIED in 64% (n = 183 of 284) of warfarin patients and 65% (n = 39 of 60) of NOAC patients. Many interrupted patients received intravenous bridging anticoagulation: 33/183 (18%) interrupted warfarin and 4/39 (10%) interrupted NOAC patients. Thirty‐day periprocedure bleeding and stroke adverse events were infrequent. Conclusions Management of anticoagulation among AF patients undergoing CIED implantation is highly variable, with OAC being interrupted in more than half of both warfarin‐ and NOAC‐treated patients. Bleeding and stroke events were infrequent in both warfarin and NOAC‐treated patients.
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Affiliation(s)
- Eric Black-Maier
- Cardiac Electrophysiology Section, Duke Center for Atrial Fibrillation, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Sunghee Kim
- Duke Clinical Research Institute, Durham, North Carolina
| | - Benjamin A Steinberg
- Cardiac Electrophysiology Section, Duke Center for Atrial Fibrillation, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Durham, North Carolina
| | - Gregg C Fonarow
- Division of Cardiology, University of California Los Angeles, Los Angeles, California
| | - James V Freeman
- Department of Cardiology, Yale University School of Medicine, New Haven, Connecticut
| | - Peter R Kowey
- Department of Cardiology, Lankenau Hospital and Medical Research Center, Philadelphia, Pennsylvania
| | - Jack Ansell
- Department of Cardiology, New York University School of Medicine, Lenox Hill Hospital, New York, New York
| | - Bernard J Gersh
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Kenneth W Mahaffey
- Department of Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Gerald Naccarelli
- Department of Cardiology, Penn State University School of Medicine, Hershey, Pennsylvania
| | - Elaine M Hylek
- Department of Cardiology, Boston University School of Medicine, Boston, Massachusetts
| | - Alan S Go
- Division of Research, Kaiser Permanente, Oakland, California
| | - Eric D Peterson
- Cardiac Electrophysiology Section, Duke Center for Atrial Fibrillation, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Durham, North Carolina
| | - Jonathan P Piccini
- Cardiac Electrophysiology Section, Duke Center for Atrial Fibrillation, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Durham, North Carolina
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22
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Ishigami H, Arai M, Matsumura T, Maruoka D, Minemura S, Okimoto K, Kasamatsu S, Saito K, Nakagawa T, Katsuno T, Yokosuka O. Heparin-bridging therapy is associated with a high risk of post-polypectomy bleeding regardless of polyp size. Dig Endosc 2017; 29:65-72. [PMID: 27368065 DOI: 10.1111/den.12692] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 06/08/2016] [Accepted: 06/29/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Evidence regarding safety and efficacy of heparin-bridging therapy for colonoscopic polypectomy remains scarce. The aim of the present study was to evaluate the risk of post-polypectomy bleeding (PPB) in patients receiving heparin-bridging therapy. METHODS We retrospectively reviewed the database of patients who underwent colonoscopic polypectomy with prophylactic clip closure between January 2007 and December 2014 at our institution. We evaluated patients receiving heparin-bridging therapy (HB group) compared with those who did not receive antithrombotic therapy (No-HB group). RESULTS A total of 1421 polypectomies were carried out on 773 patients; 45 patients were in the HB group and 728 patients were in the No-HB group. The incidence of PPB per patient was significantly higher in the HB group (22.2% vs 1.9%, P < 0.0001), and multivariate analysis showed that heparin-bridging therapy was an independent risk factor for PPB (OR 9.80, 95% CI 4.23-22.3, P < 0.0001). In the HB group, the polyp size was not a risk factor for PPB (OR 0.67, 95% CI 0.19-2.26, P = 0.55); the incidence of PPB in lesions of <10 mm and ≥10 mm in size was 14.6% and 10.2% respectively. In contrast, that was a significant risk factor in the No-HB group (OR 4.71, 95% CI 1.41-21.3, P = 0.011). Activated partial thromboplastin time and international normalized ratio were in or under the therapeutic range in the HB group when PPB occurred. CONCLUSIONS Heparin-bridging therapy is associated with a high risk of PPB regardless of polyp size.
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Affiliation(s)
- Hideaki Ishigami
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Makoto Arai
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tomoaki Matsumura
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Daisuke Maruoka
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shoko Minemura
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Kenichiro Okimoto
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shingo Kasamatsu
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Keiko Saito
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tomoo Nakagawa
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tatsuro Katsuno
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Osamu Yokosuka
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
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23
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Postoperative bleeding after gastric endoscopic submucosal dissection in patients receiving antithrombotic therapy. Gastric Cancer 2017; 20:207-214. [PMID: 26754296 DOI: 10.1007/s10120-015-0588-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 12/21/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS It is controversial whether antithrombotic therapy increases the risk of bleeding after endoscopic submucosal dissection (ESD). The aim of this study was to evaluate the effects of antithrombotic therapy on gastric ESD. METHODS Patients who underwent gastric ESD at Toranomon Hospital between April 2005 and July 2014 were enrolled. The risk of post-ESD bleeding was evaluated by multivariate logistic regression analysis. RESULTS Of 1781 patients enrolled, 253 were taking an antithrombotic; 186 discontinued taking a single antithrombotic (n = 150) or multiple antithrombotics (n = 36) before ESD, whereas 15 continued taking a single antiplatelet agent and another 52 switched to heparin alternative therapy during the peri-ESD period. Post-ESD bleeding occurred in 101 patients (5.7 %): 68 patients (3.8 %) who did not take an antithrombotic, 11 patients (7.3 %) who discontinued taking a single antithrombotic, six patients (16.7 %) who discontinued taking multiple antithrombotics, one patient (6.7 %) who continued taking a single antiplatelet agent, and 15 patients (28.8 %) who switched to heparin therapy. In multivariate analysis, heparin alternative therapy [odds ratio (OR) 10.04, 95 % confidence interval (CI) 4.35-23.16], discontinuation of the use of multiple antithrombotics before ESD (OR 5.44, 95 % CI 2.00-14.79), tumor location in the lower third of the stomach (OR 2.17, 95 % CI: 1.32-3.58), and a long procedure time (100 min or greater; OR 2.00, 95 % CI 1.25-3.20) were independent risk factors for post-ESD bleeding. Among 52 subjects who switched to heparin therapy, one developed acute renal infarction and one developed cerebral bleeding. CONCLUSIONS Because heparin alternative therapy significantly increases the risk of post-ESD bleeding and may not decrease the risk of thromboembolic events, other options should be considered for patients receiving anticoagulation therapy.
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24
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Yoshio T, Nishida T, Hayashi Y, Iijima H, Tsujii M, Fujisaki J, Takehara T. Clinical problems with antithrombotic therapy for endoscopic submucosal dissection for gastric neoplasms. World J Gastrointest Endosc 2016; 8:756-762. [PMID: 28042389 PMCID: PMC5159673 DOI: 10.4253/wjge.v8.i20.756] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 08/12/2016] [Accepted: 09/22/2016] [Indexed: 02/05/2023] Open
Abstract
Endoscopic submucosal dissection (ESD) is minimally invasive and thus has become a widely accepted treatment for gastric neoplasms, particularly for patients with comorbidities. Antithrombotic agents are used to prevent thrombotic events in patients with comorbidities such as cardio-cerebrovascular diseases and atrial fibrillation. With appropriate cessation, antithrombotic therapy does not increase delayed bleeding in low thrombosis-risk patients. However, high thrombosis-risk patients are often treated with combination therapy with antithrombotic agents and occasionally require the continuation of antithrombotic agents or heparin bridge therapy (HBT) in the perioperative period. Dual antiplatelet therapy (DAPT), a representative combination therapy, is frequently used after placement of drug-eluting stents and has a high risk of delayed bleeding. In patients receiving DAPT, gastric ESD may be postponed until DAPT is no longer required. HBT is often required for patients treated with anticoagulants and has an extremely high bleeding risk. The continuous use of warfarin or direct oral anticoagulants may be possible alternatives. Here, we show that some antithrombotic therapies in high thrombosis-risk patients increase delayed bleeding after gastric ESD, whereas most antithrombotic therapies do not. The management of high thrombosis-risk patients is crucial for improved outcomes.
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25
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Essebag V, Verma A, Healey JS, Krahn AD, Kalfon E, Coutu B, Ayala-Paredes F, Tang AS, Sapp J, Sturmer M, Keren A, Wells GA, Birnie DH. Clinically Significant Pocket Hematoma Increases Long-Term Risk of Device Infection: BRUISE CONTROL INFECTION Study. J Am Coll Cardiol 2016; 67:1300-8. [PMID: 26988951 DOI: 10.1016/j.jacc.2016.01.009] [Citation(s) in RCA: 128] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 12/02/2015] [Accepted: 01/05/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND The BRUISE CONTROL trial (Bridge or Continue Coumadin for Device Surgery Randomized Controlled Trial) demonstrated that a strategy of continued warfarin during cardiac implantable electronic device surgery was safe and reduced the incidence of clinically significant pocket hematoma (CSH). CSH was defined as a post-procedure hematoma requiring further surgery and/or resulting in prolongation of hospitalization of at least 24 h, and/or requiring interruption of anticoagulation. Previous studies have inconsistently associated hematoma with the subsequent development of device infection; reasons include the retrospective nature of many studies, lack of endpoint adjudication, and differing subjective definitions of hematoma. OBJECTIVES The BRUISE CONTROL INFECTION (Bridge or Continue Coumadin for Device Surgery Randomized Controlled Trial Extended Follow-Up for Infection) prospectively examined the association between CSH and subsequent device infection. METHODS The study included 659 patients with a primary outcome of device-related infection requiring hospitalization, defined as 1 or more of the following: pocket infection; endocarditis; and bloodstream infection. Outcomes were verified by a blinded adjudication committee. Multivariable analysis was performed to identify predictors of infection. RESULTS The overall 1-year device-related infection rate was 2.4% (16 of 659). Infection occurred in 11% of patients (7 of 66) with previous CSH and in 1.5% (9 of 593) without CSH. CSH was the only independent predictor and was associated with a >7-fold increased risk of infection (hazard ratio: 7.7; 95% confidence interval: 2.9 to 20.5; p < 0.0001). Empiric antibiotics upon development of hematoma did not reduce long-term infection risk. CONCLUSIONS CSH is associated with a significantly increased risk of infection requiring hospitalization within 1 year following cardiac implantable electronic device surgery. Strategies aimed at reducing hematomas may decrease the long-term risk of infection. (Bridge or Continue Coumadin for Device Surgery Randomized Controlled Trial [BRUISE CONTROL]; NCT00800137).
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Affiliation(s)
- Vidal Essebag
- Department of Medicine, Division of Cardiology, McGill University Health Centre, Montreal, Quebec, Canada; Department of Medicine, Division of Cardiology, Hôpital Sacré-Coeur de Montréal, Montreal, Quebec, Canada.
| | - Atul Verma
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Jeff S Healey
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Andrew D Krahn
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Eli Kalfon
- Department of Medicine, Division of Cardiology, McGill University Health Centre, Montreal, Quebec, Canada; Department of Cardiology, Galilee Medical Center, Nahariya, Israel
| | - Benoit Coutu
- Department of Medicine, Division of Cardiology, Centre Hospitalier Université de Montréal, Montreal, Quebec, Canada
| | | | - Anthony S Tang
- University of Western Ontario, London, Ontario, Canada; University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - John Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Marcio Sturmer
- Department of Medicine, Division of Cardiology, Hôpital Sacré-Coeur de Montréal, Montreal, Quebec, Canada
| | - Arieh Keren
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - George A Wells
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - David H Birnie
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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26
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Rebound thrombosis within 24 hours after interruption of therapy with rivaroxaban. Int J Cardiol 2016; 212:235-6. [DOI: 10.1016/j.ijcard.2016.03.148] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 03/19/2016] [Indexed: 11/18/2022]
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Melton BL, Howard PA, Goerdt A, Casey J. Association of Uninterrupted Oral Anticoagulation During Cardiac Device Implantation with Pocket Hematoma. Hosp Pharm 2016; 50:761-6. [PMID: 26912915 DOI: 10.1310/hpj5009-761] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE Implantation of permanent pacemakers (PPMs) or implantable cardiac defibrillators (ICDs) may be complicated by the development of pocket hematomas. Current practice guidelines provide little guidance to clinicians about the preferred strategy for chronic oral anticoagulation (OAC). The purpose of this study was to examine the frequency and clinical significance of pocket hematoma among patients receiving uninterrupted OAC during cardiac device implantation. METHODS This was a retrospective cohort study of adult patients undergoing cardiac device implantation between January 1, 2011, and December 31, 2012, at an academic teaching hospital. Medical records were reviewed for demographics, comorbidities, and medications. The primary outcome was development of pocket hematomas within 30 days of device implantation. Clinical significance was based on the need for additional intervention. Data were assessed using descriptive statistics, logistic regression, and chi-square tests. RESULTS The final cohort included 380 patients. The median age was 68.4 years, and 56.6% were male. Cardiovascular comorbidities were common. Among 80 patients receiving uninterrupted OAC, 71.3% were taking warfarin, 11.2% rivaroxaban, and 17.5% dabigatran. The incidence of pocket hematomas for the entire cohort was 9.7%, of which 1.3% were clinically significant. Pocket hematoma occurred in 21.4% of patients continued on OAC versus 7.7% of those not anticoagulated (P = .001). Pocket hematoma was more common among those receiving ICDs than PPMs (18.5% vs 5.7%, respectively; P < .001). CONCLUSIONS Continuing chronic OAC increased pocket hematoma formation but most were clinically insignificant. Pocket hematoma occurred irrespective of the oral anticoagulant drug used, but additional study is needed to determine comparative risks among the drugs.
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Affiliation(s)
- Brittany L Melton
- Assistant Professor, Department of Pharmacy Practice, University of Kansas School of Pharmacy , Lawrence, Kansas
| | - Patricia A Howard
- Professor and Vice Chair, Department of Pharmacy Practice, University of Kansas Medical Center , Kansas City, Kansas
| | - Abby Goerdt
- Clinical Pharmacist, University of Kansas Hospital , Kansas City, Kansas
| | - Jessica Casey
- Clinical Pharmacist, University of Kansas Hospital , Kansas City, Kansas
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28
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Madan S, Muthusamy P, Mowers KL, Elmouchi DA, Finta B, Gauri AJ, Woelfel AK, Fritz TD, Davis AT, Chalfoun NT. Safety of anticoagulation with uninterrupted warfarin vs. interrupted dabigatran in patients requiring an implantable cardiac device. Cardiovasc Diagn Ther 2016; 6:3-9. [PMID: 26885486 DOI: 10.3978/j.issn.2223-3652.2015.10.06] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND The optimal strategy of peri-procedural anticoagulation in patients undergoing permanent cardiac device implantation is controversial. Our objective was to compare the major bleeding and thromboembolic complications in patients managed with uninterrupted warfarin (UW) vs. interrupted dabigatran (ID) during permanent pacemaker (PPM) or implantable cardioverter defibrillators (ICD) implantation. METHODS A retrospective cohort study of all eligible patients from July 2011 through January 2012 was performed. UW was defined as patients who had maintained a therapeutic international normalized ratio (INR) on the day of the procedure. ID was defined as stopping dabigatran ≥12 hours prior to the procedure and then resuming after implantation. Major bleeding events included hemothorax, hemopericardium, intracranial hemorrhage, gastrointestinal bleed, epistaxis, or pocket hematoma requiring surgical intervention. Thromboembolic complications included stroke, transient ischemic attack, deep venous thrombosis, pulmonary embolism, or arterial embolism. RESULTS Of the 133 patients (73.4±11.0 years; 91 males) in the study, 86 received UW and 47 received ID. One (1.2%) patient in the UW group sustained hemopericardium perioperatively and died. In comparison, the ID patients had no complications. As compared to the ID group, the UW group had a higher median CHADS2 score (2 vs. 3, P=0.04) and incidence of Grade 1 pocket hematoma (0% vs. 7%, P=0.09). Neither group developed any thromboembolic complications. CONCLUSIONS Major bleeding rates were similar among UW and ID groups. Perioperative ID appears to be a safe anticoagulation strategy for patients undergoing PPM or ICD implantation.
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Affiliation(s)
- Shivanshu Madan
- 1 University of North Carolina Hospitals, Chapel Hill, NC, USA ; 2 St. Vincent Hospital, University of Massachusetts Medical School, Worcester, MA, USA ; 3 St. Louis Children's Hospital, Washington University, St. Louis, MO, USA ; 4 Spectrum Health, Department of Cardiovascular Services, Frederik Meijer Heart & Vascular Institute, Grand Rapids, MI, USA ; 5 Department of Research, Grand Rapids Medical Education Partners, Grand Rapids, MI, USA ; 6 Department of Surgery, Michigan State University, USA
| | - Purushothaman Muthusamy
- 1 University of North Carolina Hospitals, Chapel Hill, NC, USA ; 2 St. Vincent Hospital, University of Massachusetts Medical School, Worcester, MA, USA ; 3 St. Louis Children's Hospital, Washington University, St. Louis, MO, USA ; 4 Spectrum Health, Department of Cardiovascular Services, Frederik Meijer Heart & Vascular Institute, Grand Rapids, MI, USA ; 5 Department of Research, Grand Rapids Medical Education Partners, Grand Rapids, MI, USA ; 6 Department of Surgery, Michigan State University, USA
| | - Katie L Mowers
- 1 University of North Carolina Hospitals, Chapel Hill, NC, USA ; 2 St. Vincent Hospital, University of Massachusetts Medical School, Worcester, MA, USA ; 3 St. Louis Children's Hospital, Washington University, St. Louis, MO, USA ; 4 Spectrum Health, Department of Cardiovascular Services, Frederik Meijer Heart & Vascular Institute, Grand Rapids, MI, USA ; 5 Department of Research, Grand Rapids Medical Education Partners, Grand Rapids, MI, USA ; 6 Department of Surgery, Michigan State University, USA
| | - Darryl A Elmouchi
- 1 University of North Carolina Hospitals, Chapel Hill, NC, USA ; 2 St. Vincent Hospital, University of Massachusetts Medical School, Worcester, MA, USA ; 3 St. Louis Children's Hospital, Washington University, St. Louis, MO, USA ; 4 Spectrum Health, Department of Cardiovascular Services, Frederik Meijer Heart & Vascular Institute, Grand Rapids, MI, USA ; 5 Department of Research, Grand Rapids Medical Education Partners, Grand Rapids, MI, USA ; 6 Department of Surgery, Michigan State University, USA
| | - Bohuslav Finta
- 1 University of North Carolina Hospitals, Chapel Hill, NC, USA ; 2 St. Vincent Hospital, University of Massachusetts Medical School, Worcester, MA, USA ; 3 St. Louis Children's Hospital, Washington University, St. Louis, MO, USA ; 4 Spectrum Health, Department of Cardiovascular Services, Frederik Meijer Heart & Vascular Institute, Grand Rapids, MI, USA ; 5 Department of Research, Grand Rapids Medical Education Partners, Grand Rapids, MI, USA ; 6 Department of Surgery, Michigan State University, USA
| | - Andre J Gauri
- 1 University of North Carolina Hospitals, Chapel Hill, NC, USA ; 2 St. Vincent Hospital, University of Massachusetts Medical School, Worcester, MA, USA ; 3 St. Louis Children's Hospital, Washington University, St. Louis, MO, USA ; 4 Spectrum Health, Department of Cardiovascular Services, Frederik Meijer Heart & Vascular Institute, Grand Rapids, MI, USA ; 5 Department of Research, Grand Rapids Medical Education Partners, Grand Rapids, MI, USA ; 6 Department of Surgery, Michigan State University, USA
| | - Alan K Woelfel
- 1 University of North Carolina Hospitals, Chapel Hill, NC, USA ; 2 St. Vincent Hospital, University of Massachusetts Medical School, Worcester, MA, USA ; 3 St. Louis Children's Hospital, Washington University, St. Louis, MO, USA ; 4 Spectrum Health, Department of Cardiovascular Services, Frederik Meijer Heart & Vascular Institute, Grand Rapids, MI, USA ; 5 Department of Research, Grand Rapids Medical Education Partners, Grand Rapids, MI, USA ; 6 Department of Surgery, Michigan State University, USA
| | - Timothy D Fritz
- 1 University of North Carolina Hospitals, Chapel Hill, NC, USA ; 2 St. Vincent Hospital, University of Massachusetts Medical School, Worcester, MA, USA ; 3 St. Louis Children's Hospital, Washington University, St. Louis, MO, USA ; 4 Spectrum Health, Department of Cardiovascular Services, Frederik Meijer Heart & Vascular Institute, Grand Rapids, MI, USA ; 5 Department of Research, Grand Rapids Medical Education Partners, Grand Rapids, MI, USA ; 6 Department of Surgery, Michigan State University, USA
| | - Alan T Davis
- 1 University of North Carolina Hospitals, Chapel Hill, NC, USA ; 2 St. Vincent Hospital, University of Massachusetts Medical School, Worcester, MA, USA ; 3 St. Louis Children's Hospital, Washington University, St. Louis, MO, USA ; 4 Spectrum Health, Department of Cardiovascular Services, Frederik Meijer Heart & Vascular Institute, Grand Rapids, MI, USA ; 5 Department of Research, Grand Rapids Medical Education Partners, Grand Rapids, MI, USA ; 6 Department of Surgery, Michigan State University, USA
| | - Nagib T Chalfoun
- 1 University of North Carolina Hospitals, Chapel Hill, NC, USA ; 2 St. Vincent Hospital, University of Massachusetts Medical School, Worcester, MA, USA ; 3 St. Louis Children's Hospital, Washington University, St. Louis, MO, USA ; 4 Spectrum Health, Department of Cardiovascular Services, Frederik Meijer Heart & Vascular Institute, Grand Rapids, MI, USA ; 5 Department of Research, Grand Rapids Medical Education Partners, Grand Rapids, MI, USA ; 6 Department of Surgery, Michigan State University, USA
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Passaglia LG, de Barros GM, de Sousa MR. Early postoperative bridging anticoagulation after mechanical heart valve replacement: a systematic review and meta-analysis. J Thromb Haemost 2015; 13:1557-67. [PMID: 26178802 DOI: 10.1111/jth.13047] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 06/30/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To perform a systematic review and meta-analysis of studies evaluating anticoagulation during the early postoperative period following mechanical heart valve implantation. METHODS Five literature databases were searched to assess the rates of bleeding and thromboembolic events among patients receiving oral anticoagulation (OAC), both with and without bridging anticoagulation therapy with unfractionated heparin (UFH) or subcutaneous low molecular weight heparin (LMWH). The studies' results were pooled via a mixed effects meta-analysis. Heterogeneity (I(2) ) and publication bias were both evaluated. RESULTS Twenty-three studies including 9534 patients were included. The bleeding rates were 1.8% (95% confidence interval CI 1.0-3.3) in the group receiving OAC, 2.2% (95% CI 0.9-5.3) in the OAC + UFH group, and 5.5% (95% CI 2.9-10.4) in the OAC + LMWH group (P = 0.042). The thromboembolic event rate was 2.1% (95% CI 1.5-2.9) in the group receiving OAC, as compared with 1.1% (95% CI 0.7-1.8) when the bridging therapy groups were combined as follows: OAC + UFH and OAC + LMWH (P = 0.035). Most of the analyses showed moderate heterogeneity and negative test results for publication bias. CONCLUSIONS Bridging therapy following cardiac valve surgery was associated with a lower thromboembolic event rate, although the difference was small, with considerable overlap of the CIs. Direct comparisons are missing. Bridging therapy with UFH appears to be safe; however, this observation has a risk of bias. Early bridging therapy with LMWH appears to be associated with consistently high bleeding rates across multiple analyses. On the basis of the quality of the included studies, more trials are necessary to establish the clinical relevance of bridging therapy and the safety of LMWH.
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Affiliation(s)
- L G Passaglia
- School of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
- Postgraduate Program in Adult Health Sciences, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - G M de Barros
- School of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
| | - M R de Sousa
- School of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
- Postgraduate Program in Adult Health Sciences, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
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Crosato M, Calzolari V, Franceschini Grisolia E, Daniotti A, Baldessin F, Mantovan R, Olivari Z. Implanting cardiac rhythm devices during uninterrupted warfarin therapy. J Cardiovasc Med (Hagerstown) 2015; 16:503-6. [DOI: 10.2459/jcm.0000000000000011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Sticherling C, Marin F, Birnie D, Boriani G, Calkins H, Dan GA, Gulizia M, Halvorsen S, Hindricks G, Kuck KH, Moya A, Potpara T, Roldan V, Tilz R, Lip GY, Gorenek B, Indik JH, Kirchhof P, Ma CS, Narasimhan C, Piccini J, Sarkozy A, Shah D, Savelieva I. Antithrombotic management in patients undergoing electrophysiological procedures: a European Heart Rhythm Association (EHRA) position document endorsed by the ESC Working Group Thrombosis, Heart Rhythm Society (HRS), and Asia Pacific Heart Rhythm Society (APHRS). ACTA ACUST UNITED AC 2015; 17:1197-214. [DOI: 10.1093/europace/euv190] [Citation(s) in RCA: 134] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Vamos M, Erath JW, Hohnloser SH. Digoxin-associated mortality: a systematic review and meta-analysis of the literature. Eur Heart J 2015; 36:1831-8. [PMID: 25939649 DOI: 10.1093/eurheartj/ehv143] [Citation(s) in RCA: 175] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 04/08/2015] [Indexed: 12/21/2022] Open
Abstract
There are conflicting data regarding the effect of digoxin use on mortality in patients with atrial fibrillation (AF) or with congestive heart failure (CHF). The aim of this meta-analysis was to provide detailed analysis of the currently available study reports. We performed a MEDLINE and a COCHRANE search (1993-2014) of the English literature dealing with the effects of digoxin on all-cause-mortality in subjects with AF or CHF. Only full-sized articles published in peer-reviewed journals were considered for this meta-analysis. A total of 19 reports were identified. Nine reports dealt with AF patients, seven with patients suffering from CHF, and three with both clinical conditions. Based on the analysis of adjusted mortality results of all 19 studies comprising 326 426 patients, digoxin use was associated with an increased relative risk of all-cause mortality [Hazard ratio (HR) 1.21, 95% confidence interval (CI), 1.07 to 1.38, P < 0.01]. Compared with subjects not receiving glycosides, digoxin was associated with a 29% increased mortality risk (HR 1.29; 95% CI, 1.21 to 1.39) in the subgroup of publications comprising 235 047 AF patients. Among 91.379 heart failure patients, digoxin-associated mortality risk increased by 14% (HR 1.14, 95% CI, 1.06 to 1.22). The present systematic review and meta-analysis of all available data sources suggest that digoxin use is associated with an increased mortality risk, particularly among patients suffering from AF.
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Affiliation(s)
- Mate Vamos
- Department of Cardiology, Division of Clinical Electrophysiology, J.W. Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Julia W Erath
- Department of Cardiology, Division of Clinical Electrophysiology, J.W. Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Stefan H Hohnloser
- Department of Cardiology, Division of Clinical Electrophysiology, J.W. Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
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Risk of bleeding associated with interventional musculoskeletal radiology procedures. A comprehensive review of the literature. Skeletal Radiol 2015; 44:619-27. [PMID: 25433718 DOI: 10.1007/s00256-014-2065-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Revised: 10/11/2014] [Accepted: 11/11/2014] [Indexed: 02/07/2023]
Abstract
This review compiles the current literature on the bleeding risks in common musculoskeletal interventional procedures and attempts to provide guidance for practicing radiologists in making decisions regarding the periprocedural management of patients on antithrombotic therapy. The practitioner must weigh the risk of bleeding if therapy is continued against the possibility a thromboembolic occurring if anticoagulation therapy is withheld or reversed. Unfortunately, there is little empirical data to guide evidence-based decisions for many musculoskeletal interventions. However, a review of the literature shows that for low-risk procedures, such as arthrograms/arthrocenteses or muscle/tendon sheath injections, bleeding risks are sufficiently small that anticoagulants and antiplatelet therapies need not be withheld. Additionally, relatively higher-risk procedures, such as needle biopsies of bone and soft tissue, may be safely performed without holding antithrombotic therapy, provided pre-procedural INR is within therapeutic range. Thus, while a patient's particular clinical circumstances should dictate optimal individualized management, anticoagulation alone is not a general contraindication to most interventional musculoskeletal radiology procedures.
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Stent loss in the radial artery - surgical vs. interventional approach - report of two cases. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2015; 11:50-4. [PMID: 25848372 PMCID: PMC4372633 DOI: 10.5114/pwki.2015.49186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Revised: 12/21/2014] [Accepted: 01/08/2015] [Indexed: 11/17/2022] Open
Abstract
Stent loss during coronary angioplasty is a complication that can be managed in various manners; however, transradial access limits the options available. We describe two coronary interventions complicated by stent dislodgement, initially managed by pulling the stent back to the radial artery. Both stents were unwillingly lost on different levels in radial arteries. The first case was managed with a direct radial artery cut-down because distal location made it a quick and straightforward procedure. In the second case a partially deployed stent was lost in the proximal part of the radial artery. It was rewired, deployed, and post-dilated with a larger balloon. This enabled continuation of the procedure using the same access. Both cases were asymptomatic during 24 months of follow-up. It is crucial to avoid leaving artificial bodies in arteries supplying vital organs because stent-related thrombosis or stenosis may seriously compromise blood flow. Removing the stent via the introducer sheath should be considered the optimal treatment. Unfortunately it is common that a partially expanded stent will not pass through the sheath. The superficial location of the distal radial artery segment facilitates surgical cut-down with local anaesthesia. When dislodgement occurs in deeper segments of the radial artery, the benefits from cut-down seem to be less because the procedure might take more time and be more difficult - as in the presented case in which we decided to rewire and fully expand the stent in situ. Retrieval of the stent at all costs might have led to further complications; hence stent deployment may be a good alternative to retrieval in such cases.
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Utility of a dedicated pediatric cardiac anticoagulation program: the Boston Children's Hospital experience. Pediatr Cardiol 2015; 36:842-50. [PMID: 25573076 DOI: 10.1007/s00246-014-1089-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Accepted: 12/11/2014] [Indexed: 10/24/2022]
Abstract
Congenital heart disease is the leading cause of stroke in children. Warfarin therapy can be difficult to manage safely in this population because of its narrow therapeutic index, multiple drug and dietary interactions, small patient size, high-risk cardiac indications, and lack of data to support anticoagulation recommendations. We sought to describe our institution's effort to develop a dedicated cardiac anticoagulation service to address the special needs of this population and to review the literature. In 2009, in response to Joint Commission National Patient Safety Goals for Anticoagulation, Boston Children's Hospital created a dedicated pediatric Cardiac Anticoagulation Monitoring Program (CAMP). The primary purpose was to provide centralized management of outpatient anticoagulation to cardiac patients, to serve as a disease-specific resource to families and providers, and to devise strategies to evolve clinical care with rapidly emerging trends in anticoagulation care. Over 5 years the CAMP Service, staffed by a primary pediatric cardiology attending, a full-time nurse practitioner, and administrative assistant with dedicated support from pharmacy and nutrition, has enrolled over 240 patients ranging in age from 5 months to 55 years. The most common indications include a prosthetic valve (34 %), Fontan prophylaxis (20 %), atrial arrhythmias (11 %), cardiomyopathy (10 %), Kawasaki disease (7 %), and a ventricular assist device (2 %). A patient-centered multi-disciplinary cardiac anticoagulation clinic was created in 2012. Overall program international normalized ratio (INR) time in therapeutic range (TTR) is favorable at 67 % (81 % with a 0.2 margin) and has improved steadily over 5 years. Pediatric-specific guidelines for VKOR1 and CYP2C9 pharmacogenomics testing, procedural bridging with enoxaparin, novel anticoagulant use, and quality metrics have been developed. Program satisfaction is rated highly among families and providers. A dedicated pediatric cardiac anticoagulation program offers a safe and effective strategy to standardize anticoagulation care for pediatric cardiology patients, is associated with high patient and provider satisfaction, and is capable of evolving care strategies with emerging trends in anticoagulation.
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CANO ÓSCAR, ANDRÉS ANA, JIMÉNEZ REBECA, OSCA JOAQUÍN, ALONSO PAU, RODRÍGUEZ YDELISE, SANCHO-TELLO MARÍAJOSÉ, OLAGÜE JOSÉ, CASTRO JOSÉE, SALVADOR ANTONIO, MARTÍNEZ-DOLZ LUIS. Systematic Implantation of Pacemaker/ICDs under Active Oral Anticoagulation Irrespective of Patient's Individual Preoperative Thromboembolic Risk. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 38:723-30. [DOI: 10.1111/pace.12613] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Revised: 01/18/2015] [Accepted: 02/09/2015] [Indexed: 11/26/2022]
Affiliation(s)
- ÓSCAR CANO
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe; Valencia Spain
- Instituto Investigación Sanitaria La Fe; Valencia Spain
| | - ANA ANDRÉS
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe; Valencia Spain
- Instituto Investigación Sanitaria La Fe; Valencia Spain
| | - REBECA JIMÉNEZ
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe; Valencia Spain
| | - JOAQUÍN OSCA
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe; Valencia Spain
| | - PAU ALONSO
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe; Valencia Spain
- Instituto Investigación Sanitaria La Fe; Valencia Spain
| | - YDELISE RODRÍGUEZ
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe; Valencia Spain
| | - MARÍA-JOSÉ SANCHO-TELLO
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe; Valencia Spain
| | - JOSÉ OLAGÜE
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe; Valencia Spain
| | - JOSÉ E. CASTRO
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe; Valencia Spain
| | - ANTONIO SALVADOR
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe; Valencia Spain
| | - LUIS MARTÍNEZ-DOLZ
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe; Valencia Spain
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Zaca V, Marcucci R, Parodi G, Limbruno U, Notarstefano P, Pieragnoli P, Di Cori A, Bongiorni MG, Casolo G. Management of antithrombotic therapy in patients undergoing electrophysiological device surgery. Europace 2015; 17:840-54. [DOI: 10.1093/europace/euu357] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 11/13/2014] [Indexed: 11/14/2022] Open
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Yang X, Wang Z, Zhang Y, Yin X, Hou Y. The safety and efficacy of antithrombotic therapy in patients undergoing cardiac rhythm device implantation: a meta-analysis. Europace 2015; 17:1076-84. [PMID: 25713013 DOI: 10.1093/europace/euu369] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 11/27/2014] [Indexed: 11/14/2022] Open
Abstract
AIMS The meta-analysis was to assess the safety and efficacy of periprocedural antithrombotic therapy and to evaluate the risk factors potentially associated with bleeding among patients undergoing cardiac implantable electronic devices implantations. METHODS AND RESULTS A systematic literature search of PubMed, EMBASE, and Cochrane Controlled Trials Register was performed. Anticoagulation and antiplatelet therapies were assessed separately. Uninterrupted anticoagulation was associated with significant lower bleeding risk compared with heparin bridging strategy [odds ratio (OR) = 0.31, 95% confidence interval (CI) 0.18-0.53, and P < 0.0001], but there was no significant difference in thromboembolic risk between these two strategies (OR = 0.82, 95% CI 0.32-2.09, and P = 0.65). The haematoma rate was significantly increased in dual antiplatelet therapy group (OR = 6.84, 95% CI 4.16-11.25, and P < 0.00001), but not in single antiplatelet therapy (OR = 1.52, 95% CI 0.93-2.46, and P = 0.09). Clopidogrel increased the risk of haematoma vs. aspirin (OR = 2.91, 95% CI 1.27-6.69, and P = 0.01). Otherwise, a lower risk of haematoma was observed in pacemaker group vs. cardiac resynchronization therapy and/or implantable cardioverter defibrillator group (OR = 0.64, 95% CI 0.50-0.82, and P = 0.0004). CONCLUSION This meta-analysis suggested that uninterrupted oral anticoagulation seems to be the better strategy, associated with a lower risk of bleeding complications rather than heparin bridging, and dual antiplatelet therapy carried a significant risk of bleeding whereas single antiplatelet therapy was relatively safe among patients undergoing cardiac implantable electronic devices implantations. Meanwhile, cardiac resynchronization therapy and/or implantable cardioverter defibrillator implantations increase the bleeding.
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Affiliation(s)
- Xiaowei Yang
- Qianfoshan Hospital of Shandong University, Jinan City, Shandong, People's Republic of China Department of Clinical Pharmacy (Seven-Year), School of Pharmaceutical Sciences, Shandong University, Jinan City, Shandong, People's Republic of China
| | - Zhongsu Wang
- Department of Cardiology, Shandong Provincial Qianfoshan Hospital, Shandong University, No. 16766 Jingshi Road, Jinan City 250014, People's Republic of China
| | - Yong Zhang
- Department of Cardiology, Shandong Provincial Qianfoshan Hospital, Shandong University, No. 16766 Jingshi Road, Jinan City 250014, People's Republic of China
| | - Xiangcui Yin
- Department of Science and Education, Shandong Provincial Qianfoshan Hospital, Shandong University, No. 16766 Jingshi Road, Jinan City 250014, People's Republic of China
| | - Yinglong Hou
- Department of Cardiology, Shandong Provincial Qianfoshan Hospital, Shandong University, No. 16766 Jingshi Road, Jinan City 250014, People's Republic of China
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Olaya A, Calvo H, Pinzón C, Alba M, Cepeda M, Liévano J, Solano MH, Mora G. Guía basada en la evidencia para el manejo perioperatorio de la anticoagulación oral con warfarina en pacientes con alto riesgo embólico que serán llevados a implante de dispositivos de estimulación cardiaca. REVISTA COLOMBIANA DE CARDIOLOGÍA 2015. [DOI: 10.1016/j.rccar.2014.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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SANT'ANNA ROBERTOT, LEIRIA TIAGOL, NASCIMENTO THAIS, SANT'ANNA JOÃORICARDOM, KALIL RENATOAK, LIMA GUSTAVOG, VERMA ATUL, HEALEY JEFFS, BIRNIE DAVIDH, ESSEBAG VIDAL. Meta-Analysis of Continuous Oral Anticoagulants Versus Heparin Bridging in Patients Undergoing CIED Surgery: Reappraisal after the BRUISE Study. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2014; 38:417-23. [DOI: 10.1111/pace.12557] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 11/02/2014] [Accepted: 11/13/2014] [Indexed: 01/22/2023]
Affiliation(s)
| | - TIAGO L. LEIRIA
- Instituto de Cardiologia do Rio Grande do Sul; Porto Alegre Brazil
| | | | | | | | - GUSTAVO G. LIMA
- Instituto de Cardiologia do Rio Grande do Sul; Porto Alegre Brazil
| | - ATUL VERMA
- Southlake Regional Health Centre; Newmarket Canada
| | | | | | - VIDAL ESSEBAG
- McGill University Health Centre; Montréal Canada
- Hôpital Sacré-Coeur de Montréal; Montréal Canada
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Datino T, Miracle Blanco Á, Núñez García A, González-Torrecilla E, Atienza Fernández F, Arenal Maíz Á, Hernández-Hernández J, Ávila Alonso P, Eidelman G, Fernández-Avilés F. Safety of Outpatient Implantation of the Implantable Cardioverter-defibrillator. ACTA ACUST UNITED AC 2014; 68:579-84. [PMID: 25435093 DOI: 10.1016/j.rec.2014.07.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 07/03/2014] [Indexed: 11/16/2022]
Abstract
INTRODUCTION AND OBJECTIVES Strategies are needed to reduce health care costs and improve patient care. The objective of our study was to analyze the safety of outpatient implantation of cardioverter-defibrillators. METHODS A retrospective study was conducted in 401 consecutive patients who received an implantable cardioverter-defibrillator between 2007 and 2012. The rate of intervention-related complications was compared between 232 patients (58%) whose implantation was performed in the outpatient setting and 169 patients (42%) whose intervention was performed in the inpatient setting. RESULTS The mean age (standard deviation) of the patients was 62 (14) years; 336 (84%) were male. Outpatients had lower left ventricular ejection fraction and a higher percentage had an indication for primary prevention of sudden death, compared to inpatients. Only 21 outpatients (9%) required subsequent hospitalization. The rate of complications until the third month postimplantation was similar for outpatients (6.0%) and inpatients (5.3%); P = .763. In multivariate analysis, only previous anticoagulant therapy was related to the presence of complications (odds ratio = 3.2; 95% confidence interval, 1.4-7.4; P < .01), mainly due to an increased rate of pocket hematomas. Each outpatient implantation saved approximately €735. CONCLUSIONS Outpatient implantation of implantable cardioverter-defibrillators is safe and reduces costs. Close observation is recommended for patients receiving chronic anticoagulation therapy due to an increased risk of complications.
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Affiliation(s)
- Tomás Datino
- Departamento de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital General Universitario Gregorio Marañón, Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | - Ángel Miracle Blanco
- Departamento de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital General Universitario Gregorio Marañón, Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Alberto Núñez García
- Departamento de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital General Universitario Gregorio Marañón, Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Esteban González-Torrecilla
- Departamento de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital General Universitario Gregorio Marañón, Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Felipe Atienza Fernández
- Departamento de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital General Universitario Gregorio Marañón, Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ángel Arenal Maíz
- Departamento de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital General Universitario Gregorio Marañón, Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Jesús Hernández-Hernández
- Departamento de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital General Universitario Gregorio Marañón, Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Pablo Ávila Alonso
- Departamento de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital General Universitario Gregorio Marañón, Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Gabriel Eidelman
- Departamento de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital General Universitario Gregorio Marañón, Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Francisco Fernández-Avilés
- Departamento de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital General Universitario Gregorio Marañón, Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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DU LING, ZHANG YONG, WANG WEIZONG, HOU YINGLONG. Perioperative Anticoagulation Management in Patients on Chronic Oral Anticoagulant Therapy Undergoing Cardiac Devices Implantation: A Meta-Analysis. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2014; 37:1573-86. [PMID: 25234639 DOI: 10.1111/pace.12517] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 07/20/2014] [Accepted: 07/25/2014] [Indexed: 11/29/2022]
Affiliation(s)
- LING DU
- Department of Cardiology; Shandong Provincial Qianfoshan Hospital; Shandong University; Jinan China
- Department of Clinical Pharmacy (seven-year); School of Pharmaceutical Sciences; Shandong University; Jinan China
| | - YONG ZHANG
- Department of Cardiology; Shandong Provincial Qianfoshan Hospital; Shandong University; Jinan China
| | - WEIZONG WANG
- Department of Cardiology; Shandong Provincial Qianfoshan Hospital; Shandong University; Jinan China
- School of medicine; Shandong University; Jinan China
| | - YINGLONG HOU
- Department of Cardiology; Shandong Provincial Qianfoshan Hospital; Shandong University; Jinan China
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Affiliation(s)
- David H Birnie
- From the University of Ottawa Heart Institute, Ottawa, ON, Canada (D.H.B.); Population Health Research Institute, Hamilton, ON, Canada (J.S.H.); and McGill University Health Center and Hôpital Sacré-Coeur de Montréal, Montreal, QC, Canada (V.E.).
| | - Jeff S Healey
- From the University of Ottawa Heart Institute, Ottawa, ON, Canada (D.H.B.); Population Health Research Institute, Hamilton, ON, Canada (J.S.H.); and McGill University Health Center and Hôpital Sacré-Coeur de Montréal, Montreal, QC, Canada (V.E.)
| | - Vidal Essebag
- From the University of Ottawa Heart Institute, Ottawa, ON, Canada (D.H.B.); Population Health Research Institute, Hamilton, ON, Canada (J.S.H.); and McGill University Health Center and Hôpital Sacré-Coeur de Montréal, Montreal, QC, Canada (V.E.)
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Almendral J, Pombo M, Martínez-Alday J, González-Rebollo JM, Rodríguez-Font E, Martínez-Ferrer J, Castellanos E, García-Fernández FJ, Ruiz-Mateas F. Update on arrhythmias and cardiac pacing 2013. ACTA ACUST UNITED AC 2014; 67:294-304. [PMID: 24774592 DOI: 10.1016/j.rec.2013.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 12/12/2013] [Indexed: 11/19/2022]
Abstract
This report discusses a selection of the most relevant articles on cardiac arrhythmias and pacing published in 2013. The first section discusses arrhythmias, classified as regular paroxysmal supraventricular tachyarrhythmias, atrial fibrillation, and ventricular arrhythmias, together with their treatment by means of an implantable cardioverter defibrillator. The next section reviews cardiac pacing, subdivided into resynchronization therapy, remote monitoring of implantable devices, and pacemakers. The final section discusses syncope.
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Affiliation(s)
- Jesús Almendral
- Unidad de Arritmias, Centro Integral de Enfermedades Cardiovasculares, Grupo HM Hospitales, Universidad CEU San Pablo, Madrid, Spain.
| | - Marta Pombo
- Unidad de Estimulación Cardiaca, Área de Cardiología, Hospital Costa del Sol, Marbella, Málaga, Spain
| | - Jesús Martínez-Alday
- Unidad de Arritmias, Servicio de Cardiología, Hospital de Basurto, Bilbao, Vizcaya, Spain
| | - José M González-Rebollo
- Unidad de Arritmias, Servicio de Cardiología, Complejo Asistencial Universitario de León, León, Spain
| | - Enrique Rodríguez-Font
- Unidad de Arritmias, Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - José Martínez-Ferrer
- Unidad de Arritmias, Servicio de Cardiología, Hospital Universitario de Araba, Vitoria, Álava, Spain
| | - Eduardo Castellanos
- Unidad de Arritmias, Centro Integral de Enfermedades Cardiovasculares, Grupo HM Hospitales, Universidad CEU San Pablo, Madrid, Spain
| | | | - Francisco Ruiz-Mateas
- Unidad de Estimulación Cardiaca, Área de Cardiología, Hospital Costa del Sol, Marbella, Málaga, Spain
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Almendral J, Pombo M, Martínez-Alday J, González-Rebollo JM, Rodríguez-Font E, Martínez-Ferrer J, Castellanos E, García-Fernández FJ, Ruiz-Mateas F. Novedades en arritmias y estimulación cardiaca en 2013. Rev Esp Cardiol 2014. [DOI: 10.1016/j.recesp.2013.12.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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47
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Parkash R, Philippon F, Shanks M, Thibault B, Cox J, Low A, Essebag V, Bashir J, Moe G, Birnie DH, Larose E, Yee R, Swiggum E, Kaul P, Redfearn D, Tang AS, Exner DV. Canadian Cardiovascular Society guidelines on the use of cardiac resynchronization therapy: implementation. Can J Cardiol 2014; 29:1346-60. [PMID: 24182753 DOI: 10.1016/j.cjca.2013.09.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 09/12/2013] [Accepted: 09/13/2013] [Indexed: 01/11/2023] Open
Abstract
Recent studies have provided the impetus to update the recommendations for cardiac resynchronization therapy (CRT). This article provides guidance on the implementation of CRT and is intended to serve as a framework for the implementation of CRT within the Canadian health care system and beyond. These guidelines were developed through a critical evaluation of the existing literature, and expert consensus. The panel unanimously adopted each recommendation. The 9 recommendations relate to patient selection in the presence of comorbidities, delivery and optimization of CRT, and resources required to deliver this therapy. The strength of evidence was weighed, taking full consideration of any risk of bias, and any imprecision, inconsistency, and indirectness of the available data. The strength of each recommendation and the quality of evidence were adjudicated. Trade-offs between desirable and undesirable consequences of alternative management strategies were considered, as were values, preferences, and resource availability. These guidelines were externally reviewed by experts, modified based on those reviews, and will be updated as new knowledge is acquired.
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Affiliation(s)
- Ratika Parkash
- Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
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Managing novel oral anticoagulants in patients with atrial fibrillation undergoing device surgery: Canadian survey. Can J Cardiol 2013; 30:231-6. [PMID: 24461924 DOI: 10.1016/j.cjca.2013.11.027] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 11/21/2013] [Accepted: 11/21/2013] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Approximately 10% of patients who undergo surgical procedures require chronic oral anticoagulation. Physicians must balance the thromboembolic and bleeding risks to make informed decisions on whether to continue anticoagulant medication. Evidence is lacking regarding the perioperative management of novel oral anticoagulant (NOAC) agents. This survey aims to describe the management of perioperative NOAC use during device implantation by Canadian centres. METHODS A Web-based tool was used to survey all Canadian adult pacemaker/defibrillator implant centres. The survey collected data regarding the perioperative management of NOACs in atrial fibrillation patients at high risk for thromboembolism who undergo device implantation. RESULTS Twenty-two centres performed approximately 14,971 device implants; 1150 (8%) of these implants were in patients who were prescribed a NOAC. In 82% of centres, the NOAC is discontinued in anticipation of device implantation; 73% of these centres do not bridge with heparin. In patients with normal renal function at high risk of thromboembolic events (Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack; CHADS2 ≥ 2), 72% of the centres restart the NOAC within 48 hours of the procedure. For patients with abnormal renal function (glomerular filtration rate < 80 mL/min), the timing of NOAC discontinuation is variable. Hematoma rates vary from 0 to 30%. CONCLUSIONS Most Canadian centres perform device implantation with NOAC interruption without the use of bridging. The timing of stopping and restarting anticoagulation and incidence of bleeding complications is variable. These findings emphasize the need for randomized controlled studies to guide the optimal approach to management of NOACs during device implantation.
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Tyagi G, Pai SM, Pai RG. Cardiac rhythm device surgery with uninterrupted oral anticoagulation. Future Cardiol 2013; 9:763-6. [PMID: 24180532 DOI: 10.2217/fca.13.80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Current guidelines recommend interrupting anticoagulation and bridging therapy with heparin or low-molecular-weight heparin for cardiac rhythm device surgeries in patients with high thrombotic risk. However, there are some studies that suggest continuing warfarin may be safe. The study by Birnie et al. investigates this important clinical question in a randomized controlled trial setting. They randomly assigned 681 patients with high thrombotic risk (5% or more per year), in 18 centers, to receive either stopping warfarin combined with heparin bridging (standard of care) or continued uninterrupted warfarin therapy for cardiac rhythm device surgery. The trial was terminated after a second prespecified interim analysis by the data and safety monitoring board. Clinically significant device-pocket hematoma was noted in 12 out of 343 patients (3.5%) in the uninterrupted warfarin group, compared with 54 out of 338 (16.0%) in the heparin-bridging group (relative risk: 0.19; 95% CI: 0.10-0.36; p < 0.001). Uninterrupted warfarin was associated with better patient satisfaction, and there was no significant difference in thromboembolic or surgical complications between the two groups. These results demonstrate that device surgeries can be safely performed with continued warfarin, and bridging with heparin is associated with high risk of device-pocket hematoma.
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Affiliation(s)
- Gaurav Tyagi
- Department of Cardiology, Loma Linda University Medical Center, Loma Linda, CA, USA
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Airaksinen KJ, Korkeila P, Lund J, Ylitalo A, Karjalainen P, Virtanen V, Raatikainen P, Koivisto UM, Koistinen J. Safety of pacemaker and implantable cardioverter–defibrillator implantation during uninterrupted warfarin treatment — The FinPAC study. Int J Cardiol 2013; 168:3679-82. [DOI: 10.1016/j.ijcard.2013.06.022] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Revised: 04/04/2013] [Accepted: 06/15/2013] [Indexed: 11/27/2022]
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