1
|
Fang F, Wang P, Yao W, Wang X, Zhang Y, Chong W, Hai Y, You C, Jiang Y. Association between D-dimer levels and long-term mortality in patients with aneurysmal subarachnoid hemorrhage. Neurosurg Focus 2022; 52:E8. [PMID: 35231898 DOI: 10.3171/2021.12.focus21512] [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: 08/28/2021] [Accepted: 12/21/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE D-dimer is a marker for hypercoagulability and thrombotic events. The authors sought to investigate whether D-dimer levels predicted long-term mortality in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS This was a retrospective study of patients with aSAH in West China Hospital, Sichuan University, between December 2013 and June 2019. D-dimer levels were measured within 24 hours after admission and were grouped by quartiles. The primary outcome was long-term mortality. Patient deaths were determined through the Household Registration Administration System in China, with a median of 4.4 years of follow-up. RESULTS This study included 2056 patients. Compared with patients with the lowest quartile (0.00-0.97 mg/L) of D-dimer levels, the odds of long-term mortality were significantly higher in all other patients, including those with D-dimer levels between 0.97 mg/L and 1.94 mg/L (adjusted hazard ratio [aHR] 1.85, 95% CI 1.32-2.60), those with D-dimer levels between 1.94 mg/L and 4.18 mg/L (aHR 1.94, 95% CI 1.40-2.70), and those patients with the highest quartile (> 4.18 mg/L) of D-dimer levels (aHR 2.35, 95% CI 1.70-3.24; p < 0.001). Similar results were observed for the endpoints of 1-year mortality and long-term mortality in 1-year survivors. CONCLUSIONS Elevated D-dimer levels at admission were associated with short-term and long-term mortality. This biomarker could be considered in future risk nomograms for long-term outcomes and might support future management decisions.
Collapse
Affiliation(s)
- Fang Fang
- 1Department of Neurosurgery, West China Hospital, Sichuan University
| | - Peng Wang
- 1Department of Neurosurgery, West China Hospital, Sichuan University.,3Department of Neurosurgery, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Wei Yao
- 3Department of Neurosurgery, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Xing Wang
- 1Department of Neurosurgery, West China Hospital, Sichuan University
| | - Yu Zhang
- 1Department of Neurosurgery, West China Hospital, Sichuan University.,3Department of Neurosurgery, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Weelic Chong
- 4Department of Medical Oncology, Thomas Jefferson University; and
| | - Yang Hai
- 5Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Chao You
- 1Department of Neurosurgery, West China Hospital, Sichuan University
| | - Yan Jiang
- 1Department of Neurosurgery, West China Hospital, Sichuan University.,2Department of Nursing, West China Hospital, Sichuan University
| |
Collapse
|
2
|
Xia X, Fu J, Wu T, Chen W, Jiang S, Lv M, Zhang J. Effect of gene polymorphism on bleeding complications in Chinese Han patients taking warfarin. Eur J Clin Pharmacol 2021; 78:205-214. [PMID: 34596727 DOI: 10.1007/s00228-021-03204-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 08/12/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE The purpose of this study was to analyse the effects of demographic factors, clinical factors, and genetic polymorphisms of related gene loci on warfarin bleeding-related complications in the Han population. METHODS Retrospective medical record review. The study cases were patients treated at the Fujian Medical University Union Hospital from March 2016 to February 2020, and all received regular warfarin anticoagulation treatment for at least 3 months, and were provided the initial standard dose and stable dose of warfarin. RESULTS Data were collected from 451 qualifying patients (47% male, 53% female). The average age of patients was 53.8 ± 12.2 years, and the average body surface area was 1.6 ± 0.18 m2. There were nine major bleeding events and 141 minor bleeding events. In the univariate logistic analysis, the p-value of the four factors body weight, body surface area (BSA), amiodarone, and rs429358 was < 0.10. However, the final p-values for amiodarone and rs429358 were < 0.05 in the multifactorial logistic analysis. CONCLUSIONS The ApoE (rs429358) gene polymorphism influences bleeding complications in Chinese Han patients treated with warfarin. The sample size of this study was relatively small; hence an international study with a larger sample size is needed in the future.
Collapse
Affiliation(s)
- Xiaotong Xia
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Jinglan Fu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Tingting Wu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Wenjun Chen
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Shaojun Jiang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Meina Lv
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China.
| |
Collapse
|
3
|
Johansson K, Jansson JH, Johansson L, Wiklund PG, Nilsson TK, Lind M. D-Dimer Is Associated With First-Ever Intracerebral Hemorrhage. Stroke 2019; 49:2034-2039. [PMID: 30354971 DOI: 10.1161/strokeaha.118.021751] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Hypertension is the most important risk factor for intracerebral hemorrhage (ICH), but further characterization is needed for groups at high risk of ICH. One way to predict the risk of developing a disease is with plasma biomarkers. This study aimed to investigate the association between the biomarker, D-dimer, and ICH risk. Methods- This population-based, nested case-control study was conducted using data from 2 population-based surveys; the Västerbotten Intervention Programme and MONICA Northern Sweden (Monitoring Trends and Determinants in Cardiovascular Disease). All participants underwent a health examination and blood sampling at baseline before the event. Cases (n=141) were diagnosed with a first-ever ICH between 1985 and March 2007. One or 2 controls (n=255) were matched to each case. Results- The median age was 60 years; 39% of participants were women; and the median time from blood sampling to ICH was 5.2 years. When D-dimer was evaluated as a continuous variable, it was significantly associated with ICH. After multivariable adjustment (for hypertension, body mass index, cholesterol levels, diabetes mellitus, and smoking), the odds ratio was 1.36 per SD of D-dimer (95% CI, 1.05-1.77). When participants were stratified in 3 groups according to time from blood sampling at health examination to ICH, we found that the association between D-dimer levels and ICH was most pronounced in individuals with the shortest time from blood sampling to ICH event (<3.5 years; odds ratio, 1.78; 95% CI, 1.05-3.05). Conclusions- High plasma concentrations of D-dimer were associated with increased risk of a future ICH, after adjusting for cardiovascular risk factors. This association was predominantly driven by the cases with the shortest time from blood sampling to ICH event.
Collapse
Affiliation(s)
- Kristina Johansson
- From the Department of Public Health and Clinical Medicine, Skellefteå Research Unit, Umeå University, Sweden (K.J., J.-H.J., L.J., M.L.)
| | - Jan-Håkan Jansson
- From the Department of Public Health and Clinical Medicine, Skellefteå Research Unit, Umeå University, Sweden (K.J., J.-H.J., L.J., M.L.)
| | - Lars Johansson
- From the Department of Public Health and Clinical Medicine, Skellefteå Research Unit, Umeå University, Sweden (K.J., J.-H.J., L.J., M.L.)
| | - Per-Gunnar Wiklund
- From the Department of Public Health and Clinical Medicine, Skellefteå Research Unit, Umeå University, Sweden (K.J., J.-H.J., L.J., M.L.).,Department of Public Health and Clinical Medicine (P.-G.W.)
| | - Torbjörn K Nilsson
- Department of Medical Biosciences/Clinical Chemistry (T.K.N.), Umeå University, Sweden
| | - Marcus Lind
- From the Department of Public Health and Clinical Medicine, Skellefteå Research Unit, Umeå University, Sweden (K.J., J.-H.J., L.J., M.L.)
| |
Collapse
|
4
|
Johnsen HS, Hindberg K, Bjøri E, Brodin EE, Brækkan SK, Morelli VM, Hansen JB. D-Dimer Measured at Diagnosis of Venous Thromboembolism is Associated with Risk of Major Bleeding. TH OPEN 2019; 3:e77-e84. [PMID: 31249986 PMCID: PMC6524911 DOI: 10.1055/s-0039-1683395] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 02/01/2019] [Indexed: 01/16/2023] Open
Abstract
Identification of patients at risk of major bleeding is pivotal for optimal management of anticoagulant therapy in venous thromboembolism (VTE). Studies have suggested that D-dimer may predict major bleeding during anticoagulation; however, this is scarcely investigated in VTE patients. We aimed to investigate the role of D-dimer, measured at VTE diagnosis, as a predictive biomarker of major bleeding. The study population comprised 555 patients with a first community-acquired VTE (1994-2016), who were identified among participants from the Tromsø study. Major bleeding events were recorded during the first year after VTE and defined according to the criteria of the International Society on Thrombosis and Haemostasis. Cox-regression was used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs) adjusted for age, sex, and duration of anticoagulant therapy. In total, 29 patients experienced major bleeding (incidence rate: 5.7/100 person-years, 95% CI: 4.0-8.2). The major bleeding risk was highest during the first 3 months, especially in patients with D-dimer ≥8.3 µg/mL (upper 20th percentile), with 28.8 major bleedings/100 person-years (95% CI: 13.7-60.4). Patients with D-dimer ≥8.3 µg/mL had a 2.6-fold (95% CI: 1.1-6.6) higher risk of major bleeding than patients with D-dimer ≤2.3 µg/mL (lower 40th percentile). Major bleeding risk according to D-dimer ≥8.3 versus ≤2.3 µg/mL was particularly pronounced among those with deep vein thrombosis (HR: 4.6, 95% CI: 1.3-16.2) and provoked events (HR: 4.2, 95% CI: 1.0-16.8). In conclusion, our results suggest that D-dimer measured at diagnosis may serve as a predictive biomarker of major bleeding after VTE, especially within the initial 3 months.
Collapse
Affiliation(s)
- Håkon S Johnsen
- Department of Clinical Medicine, K.G Jebsen - Thrombosis Research and Expertise Center (TREC), UiT - The Arctic University of Norway, Tromsø, Norway
| | - Kristian Hindberg
- Department of Clinical Medicine, K.G Jebsen - Thrombosis Research and Expertise Center (TREC), UiT - The Arctic University of Norway, Tromsø, Norway
| | - Esben Bjøri
- Department of Clinical Medicine, K.G Jebsen - Thrombosis Research and Expertise Center (TREC), UiT - The Arctic University of Norway, Tromsø, Norway
| | - Ellen E Brodin
- Department of Clinical Medicine, K.G Jebsen - Thrombosis Research and Expertise Center (TREC), UiT - The Arctic University of Norway, Tromsø, Norway.,Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Sigrid K Brækkan
- Department of Clinical Medicine, K.G Jebsen - Thrombosis Research and Expertise Center (TREC), UiT - The Arctic University of Norway, Tromsø, Norway.,Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Vânia M Morelli
- Department of Clinical Medicine, K.G Jebsen - Thrombosis Research and Expertise Center (TREC), UiT - The Arctic University of Norway, Tromsø, Norway
| | - John-Bjarne Hansen
- Department of Clinical Medicine, K.G Jebsen - Thrombosis Research and Expertise Center (TREC), UiT - The Arctic University of Norway, Tromsø, Norway.,Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
| |
Collapse
|
5
|
Egbe AC, Miranda WR, Ammash NM, Missula VR, Jadav R, Najam M, Kothapalli S, Connolly HM. Outcomes of Anticoagulation Therapy in Adults With Tetralogy of Fallot. J Am Heart Assoc 2019; 8:e011474. [PMID: 30803288 PMCID: PMC6474918 DOI: 10.1161/jaha.118.011474] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Available outcomes data for anticoagulation therapy in adults with congenital heart disease ( CHD ) provide assessment of global risk of this therapy for CHD patients (a heterogeneous population), but the risk of complications for the different CHD diagnoses is unknown. The purpose of the study was to describe the indications for anticoagulation, and the incidence and risk factors for major bleeding complication in adults with tetralogy of Fallot. Methods and Results We queried Mayo Adult Congenital Heart Disease (MACHD) database for tetralogy of Fallot patients (aged ≥18 years) that received anticoagulation, 1990-2017. Of 130 patients (42±14 years, 75 men [58%]), warfarin and direct oral anticoagulants were used in 125 (96%) and 5 (4%), respectively because atrial arrhythmias (n=109), mechanical prosthetic valve (n=29), intracardiac thrombus (n=4), pulmonary embolism (n=6), stroke (n=3), and perioperative anticoagulation (n=44). The median hypertension, abnormal renal or liver function; stroke; bleeding history or predisposition; labile international normalized ratio; elderly (>65 years); drug or alcohol use score for the entire cohort was 1 (0-2) and 27 (21%) had hypertension, abnormal renal or liver function; stroke; bleeding history or predisposition; labile international normalized ratio; elderly (>65 years); drug or alcohol use score ≥2. There were 14 minor bleeding events (1.6% per year) and 11 major bleeding events (1.3% per year) in 8 patients during median follow-up of 74 months (856 patient-years). Mechanical prosthesis (hazard ratio 1.78, CI 1.29-3.77, P=0.021) and hypertension, abnormal renal or liver function; stroke; bleeding history or predisposition; labile international normalized ratio; elderly (>65 years); drug or alcohol use score ≥2 (hazard ratio 1.41, CI 1.03-3.88, P=0.046) were risk factors for major bleeding events. All-cause mortality was higher in patients with major bleeding events (n=6, 75%) compared with patients without major bleeding events (n=25, 21%), P=0.001. Conclusions Considering the heterogeneity of the CHD population, data from the current study may be better suited for clinical decision-making in tetralogy of Fallot patients.
Collapse
Affiliation(s)
- Alexander C Egbe
- 1 Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | | | - Naser M Ammash
- 1 Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | | | - Raja Jadav
- 1 Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | - Maria Najam
- 1 Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | | | - Heidi M Connolly
- 1 Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| |
Collapse
|
6
|
Christersson C, Wallentin L, Andersson U, Alexander JH, Alings M, De Caterina R, Gersh BJ, Granger CB, Halvorsen S, Hanna M, Huber K, Hylek EM, Lopes RD, Oh BH, Siegbahn A. Effect of apixaban compared with warfarin on coagulation markers in atrial fibrillation. Heart 2018; 105:235-242. [PMID: 30209126 PMCID: PMC6388910 DOI: 10.1136/heartjnl-2018-313351] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 07/13/2018] [Accepted: 08/02/2018] [Indexed: 12/31/2022] Open
Abstract
Objectives Compare the effect of apixaban and warfarin on coagulation and primary haemostasis biomarkers in atrial fibrillation (AF). Methods The biomarker substudy from the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation trial included 4850 patients with AF randomised to treatment with apixaban or warfarin. Sixty per cent of patients used vitamin K antagonist (VKA) within 7 days before randomisation. Prothrombin fragment 1+2 (F1+2), D-dimer, soluble CD40 ligand (sCD40L) and von Willebrand factor (vWF) antigen were analysed at randomisation and after 2 months of study treatment. Results In patients not on VKA treatment at randomisation, F1+2 and D-dimer levels were decreased by 25% and 23%, respectively, with apixaban, and by 59% and 38%, respectively, with warfarin (p<0.0001 for treatment differences for both). In patients on VKA at randomisation, F1+2 and D-dimer levels increased by 41% and 10%, respectively, with apixaban and decreased by 37% and 11%, respectively, with warfarin (p<0.0001 for treatment differences for both). sCD40L levels were slightly increased at 2 months, regardless of VKA or randomised treatment. Apixaban and warfarin also both reduced vWF antigen regardless of VKA treatment. The efficacy (stroke) and safety (bleeding) of apixaban compared with warfarin was similar irrespectively of biomarker levels at 2 months. Conclusions Treatment with apixaban compared with warfarin for stroke prevention in patients with AF was associated with less reduction in thrombin generation and fibrin turnover. This effect of apixaban could contribute to the clinical results where apixaban was superior to warfarin both in stroke prevention and in reducing bleeding risk. Trial registration number NCT00412984.
Collapse
Affiliation(s)
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center (UCR), Uppsala University, Uppsala, Sweden
| | - Ulrika Andersson
- Uppsala Clinical Research Center (UCR), Uppsala University, Uppsala, Sweden
| | - John H Alexander
- Medical Duke Clinical Research Institute, Duke University, Medical Center, Durham, North Carolina, USA
| | - Marco Alings
- Working Group on Cardiovascular Research, Utrecht, The Netherlands
| | - Raffaele De Caterina
- Gabriele d'Annunzio University, Chieti, and Gabriele Monasterio Foundation, Pisa, Italy
| | | | - Christopher B Granger
- Medical Duke Clinical Research Institute, Duke University, Medical Center, Durham, North Carolina, USA
| | - Sigrun Halvorsen
- Department of Cardiology B, Oslo University Hospital and University of Oslo, Oslo, Norway
| | | | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, and Sigmund Freud University, Medical School, Vienna, Austria
| | - Elaine M Hylek
- Boston University Medical Center, Boston, Massachusetts, USA
| | - Renato D Lopes
- Medical Duke Clinical Research Institute, Duke University, Medical Center, Durham, North Carolina, USA
| | - Byung-Hee Oh
- Seoul National University Hospital, Seoul, Korea
| | - Agneta Siegbahn
- Uppsala Clinical Research Center (UCR), Uppsala University, Uppsala, Sweden.,Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| |
Collapse
|
7
|
Christersson C, Lindahl B, Berglund L, Siegbahn A, Oldgren J. The utility of coagulation activity for prediction of risk of mortality and cardiovascular events in guideline-treated myocardial infarction patients. Ups J Med Sci 2017; 122:224-233. [PMID: 29299952 PMCID: PMC5810226 DOI: 10.1080/03009734.2017.1407849] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Despite improved treatment of myocardial infarction (MI), real-world patients still suffer substantial risk for subsequent cardiovascular events. Little is known about coagulation activity shortly after MI and whether coagulation activity markers may identify patients at increased risk despite contemporary treatment. OBJECTIVE To evaluate D-dimer concentration and thrombin generation potential shortly after discharge after MI and evaluate if these markers could predict the risk of future cardiovascular and bleeding events. METHODS Unselected MI patients (n = 421) were included in the observational REBUS study (NCT01102933) and followed for two years. D-dimer concentrations, thrombin peak, and endogenous thrombin potential (ETP) were analyzed at inclusion (3-5 days after MI) and at early follow-up (after 2-3 weeks). RESULTS Seventy-five patients (17.8%) experienced the composite endpoint (all-cause death, MI, congestive heart failure, or all-cause stroke), and 31 patients (7.4%) experienced a clinically relevant bleeding event. D-dimer concentrations at early follow-up were associated with the composite endpoint (HR [per SD increase] 1.51 [95% CI 1.22-1.87]) and with clinically relevant bleeding (HR [per SD increase] 1.80 [95% CI 1.32-2.44]). Thrombin generation potential was not significantly associated with either the composite endpoint or with clinically relevant bleeding. Higher thrombin peak and ETP at early follow-up were both inversely associated with stroke (HR [per SD increase] 0.50 [95% CI 0.30-0.81] and 0.43 [95% CI 0.22-0.83], respectively). CONCLUSION In unselected MI patients treated according to contemporary guidelines, D-dimer measurements may identify patients at increased risk of new cardiovascular and bleeding events. The inverse association of thrombin generation potential and risk of stroke has to be further investigated.
Collapse
Affiliation(s)
- Christina Christersson
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- CONTACT Christina Christersson Department of Medical Sciences, Cardiology, Uppsala University, 75185 Uppsala, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Lars Berglund
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Agneta Siegbahn
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Jonas Oldgren
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| |
Collapse
|
8
|
Rocca B, Husted S. Safety of Antithrombotic Agents in Elderly Patients with Acute Coronary Syndromes. Drugs Aging 2016; 33:233-48. [PMID: 26941087 DOI: 10.1007/s40266-016-0359-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
There are unique challenges in the treatment and prevention of acute coronary syndromes (ACS) with antithrombotics in elderly patients: elderly patients usually require multiple drugs due to comorbidities, are highly susceptible to adverse drug reactions and drug-drug interactions, may have cognitive problems affecting compliance and complications, are especially exposed to the risk of falls and, most importantly, ageing is an independent risk factor for bleeding. Antithrombotic drugs, alone or in association, further and variously amplify age-related bleeding risk. Moreover, age-related changes in primary haemostasis may potentially affect the pharmacodynamics of some antiplatelet drugs. Thus, elderly subjects might be more or less sensitive to standard antiplatelet regimens depending on individual characteristics affecting antiplatelet drug response. Importantly, elderly patients are a rapidly growing population worldwide, have the highest incidence of ACS, but are poorly represented in clinical trials. As a consequence, evidence on antithrombotic drug benefits and risks is limited. Thus, in the real-world setting, older people are often denied antithrombotic drugs because of unjustified concerns, or might be over-treated and exposed to excessive bleeding risk. Personalized antithrombotic therapy in elderly patients is particularly critical, to minimize risks without affecting efficacy.
Collapse
Affiliation(s)
- Bianca Rocca
- Institute of Pharmacology, Catholic University School of Medicine, Largo F.Vito 1, 00168, Rome, Italy.
| | - Steen Husted
- Medical Department, Hospital Unit West, Herning/Holstebro and Institute of Biomedicine, Aarhus University, Aarhus, Denmark
| |
Collapse
|
9
|
Moodley O, Goubran H. Should lifelong anticoagulation for unprovoked venous thromboembolism be revisited? Thromb J 2015; 13:33. [PMID: 26500456 PMCID: PMC4618533 DOI: 10.1186/s12959-015-0063-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 06/17/2015] [Indexed: 01/17/2023] Open
Abstract
Venous thromboembolism [VTE] is a common medical condition that has significant morbidity and mortality. Although stringent guidelines recommend lifelong anticoagulation for patients with unprovoked VTE, the optimal management strategy for their long term treatment remains controversial. Whereas in cancer-associated VTE and second unprovoked VTE lifelong anticoagulation is universally accepted, a careful analysis of the benefit vs. risk of long-term anticoagulation following a first unprovoked VTE should be considered as case fatality rates [CFR] from VTE appear more pronounced in the first few months. The CFR from major bleeding remains constant throughout therapy. Therefore, the risk of bleeding may be underestimated over longer treatment periods relative to the morbidity of recurrent VTE which appears to peak in the first year. The current review highlights the balance between the recurrence risk and bleeding risks in the era of direct oral anticoagulants. Vitamin K antagonists have been the standard of care for over 50 years bearing significant bleeding risks. The new oral anticoagulants [NOACs] have shown similar efficacy and perhaps a questionable improved safety profile when compared to warfarin. Aspirin has historically not been a useful agent in the management of VTE. However, two recent trials [WARFASA and ASPIRE] showed a likely 20-30 % risk reduction when compared to placebo for recurrent VTE after initial anticoagulation. The risk of major hemorrhage was low in both trials. With the emergence of NOACs and the increased utility of aspirin, there are multiple therapeutic options for long term management for VTE. Given comparable efficacy and improved safety of NOACs and aspirin, the risk benefit of anticoagulation is improving. A risk stratification model may help identifying patients at high risk for recurrence necessitating a lifelong anticoagulation. This cohort should be separated from a low risk group that may benefit from clinical observation, aspirin or NOACs. Prospective clinical trials are needed to support these clinical observations.
Collapse
Affiliation(s)
- Otto Moodley
- Saskatoon Cancer Centre and College of Medicine, University of Saskatchewan, 20, Campus Drive, Saskatoon, SK S7N4H4 Canada
| | - Hadi Goubran
- Saskatoon Cancer Centre and College of Medicine, University of Saskatchewan, 20, Campus Drive, Saskatoon, SK S7N4H4 Canada
| |
Collapse
|