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Ribas Sola J, Sánchez-Corral Mena MÁ, Riera-Mestre A. [Update in the management of chronic thrombo-embolic pulmonary hypertension]. Med Clin (Barc) 2024; 162:126-133. [PMID: 37925273 DOI: 10.1016/j.medcli.2023.08.006] [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: 07/12/2023] [Revised: 08/18/2023] [Accepted: 08/19/2023] [Indexed: 11/06/2023]
Abstract
Chronic thrombo-embolic pulmonary hypertension (CTEPH) is a potentially curable form of pulmonary hypertension (PH) that develops in up to 3% of patients after pulmonary embolism (PE). In these patients, PE does not resolve, leading to organized fibrotic clots, with the development of precapillary PH as a result of the proximal obstruction of the pulmonary arteries. In addition, a distal microvasculopathy may also develop, contributing to the increase of pulmonary vascular resistance. Transthoracic echocardiography is the diagnostic tool that allows to establish the suspicion of PH. Ventilation-perfusion lung scintigraphy is the fundamental tool in the study of patients with suspected CTEPH; if it is normal, virtually rules out the diagnosis. Right heart catheterization is mandatory for the diagnosis of these patients. CTEPH is defined as the existence of symptoms, residual perfusion defects and precapillary PH after a minimum period of three months of anticoagulation. Pulmonary angiography helps determine the extent and surgical accessibility of thromboembolic lesions. CTEPH patients are candidates for long-term anticoagulation. Pulmonary endarterectomy is the treatment of choice, resulting in significant clinical and hemodynamic improvement. About 25% of patients have residual PH post-endarterectomy. Balloon pulmonary angioplasty is an endovascular technique that targets more distal lesions, being potentially useful for patients with inoperable CTEPH or persistent/recurrent PH post-endarterectomy. Both types of patients may also benefit from pharmacological treatment for PH. These three therapies are the cornerstone of CTEPH treatment, which has evolved towards a multimodal approach.
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Affiliation(s)
- Jesús Ribas Sola
- Unidad de Enfermedades Vasculares Pulmonares, Servicio de Neumología, Hospital Universitari de Bellvitge, Barcelona, España; Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Barcelona, España.
| | - Miguel Ángel Sánchez-Corral Mena
- Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Barcelona, España; Unidad de Imagen Cardiaca Avanzada, Servicio de Cardiología, Hospital Universitari de Bellvitge, Barcelona, España
| | - Antoni Riera-Mestre
- Unidad de Imagen Cardiaca Avanzada, Servicio de Cardiología, Hospital Universitari de Bellvitge, Barcelona, España; Unidad Funcional de ETV, Servicio de Medicina Interna, Hospital Universitari de Bellvitge, Barcelona, España; Facultad de Medicina y Ciencias de la Salud, Universitat de Barcelona, Barcelona, España.
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Pengo V, Denas G. Antiphospholipid Syndrome in Patients with Venous Thromboembolism. Semin Thromb Hemost 2023; 49:833-839. [PMID: 35728601 DOI: 10.1055/s-0042-1749590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Unprovoked (or provoked by mild risk factors) venous thromboembolism (VTE) in young patients, VTE in uncommon sites, or cases of unexplained VTE recurrence may be positive for antiphospholipid antibodies (aPL) and thus may be diagnosed with antiphospholipid syndrome (APS). The evaluation of aPL is standardized using immunological tests for anticardiolipin and anti-β2-glycoprotein I. The determination of functional antibodies (lupus anticoagulant) is less standardized, especially in patients on anticoagulant treatment. Patients positive for all the three tests are at high risk of recurrence, which, in turn, might lead to chronic obstruction of pulmonary vessels (chronic thromboembolic pulmonary hypertension). Randomized clinical trials have shown that triple-positive patients should be treated with vitamin K antagonists maintaining an international normalized ratio between 2 and 3. Whether patients with VTE and incomplete aPL profile can be treated with direct oral anticoagulants should be further investigated.
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Affiliation(s)
- Vittorio Pengo
- Department of Cardio-Thoracic-Vascular Sciences and Public Health, Thrombosis Research Laboratory, University of Padova, Padova, Italy
- Arianna Foundation on Anticoagulation, Bologna, Italy
| | - Gentian Denas
- Department of Cardio-Thoracic-Vascular Sciences and Public Health, Thrombosis Research Laboratory, University of Padova, Padova, Italy
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Shah BB, Shankar A, Kumar V, Kumar S, Malik UA, Majeed A, Kumar V, Berkha, Suman, Kumar S, Netha A, Subedi S, Ahmed S. Direct oral anticoagulants vs. vitamin K antagonists in patients with antiphospholipid syndrome: a systematic review and meta-analysis. Ann Med Surg (Lond) 2023; 85:3574-3582. [PMID: 37427194 PMCID: PMC10328675 DOI: 10.1097/ms9.0000000000000903] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/14/2023] [Indexed: 10/31/2023] Open
Abstract
UNLABELLED Optimal treatment regimen for patients with antiphospholipid syndrome (APS) remain unclear. Therefore, the authors sought to compare the outcomes of vitamin K antagonists (VKAs) vs. direct oral anticoagulants (DOACs) in patients with APS. METHODS MEDLINE, Embase, and Cochrane Central databases were searched for randomized controlled trials comparing efficacy and safety of VKAs and DOACs inhibitors in patients with APS. Recurrent thrombosis, all-cause mortality, stroke, adverse reactions, and bleeding were among outcomes of interest. Mantel-Haenszel weighted random-effects model was used to calculate relative risks (RRs) with 95% CIs. RESULTS The analysis included 625 patients from four randomized controlled trials and one post hoc analysis. Meta-analysis showed statistically non-significant difference between DOACs inhibitors and VKAs in the recurrent thrombosis risk (arterial or venous) [RR 2.77 (95%, CI 0.79, 9.65); P=0.11, I2=50%]. Consistent results were revealed among patients with the previous history of arterial thrombosis [RR 2.76 (95% CI 0.93, 8.16); P=0.75, I2=0%], venous thrombosis [RR 1.71 (95% CI 0.60, 4.84); P=0.31, I2=15%] and patients who were triple antiphospholipid positive [RR 4.12 (95% CI 0.46, 37.10); P=0.21, I2=58%]. DOACs inhibitors were significantly associated with increased risk of stroke [RR 8.51 (95% CI 2.35, 3.82); P=0.47, I2=0%]. CONCLUSION DOACs exhibited increased risk of stroke among patients with APS. In addition, although not significant, the higher RRs among patients on DOACs may indicate higher risk of thrombotic events associated with DOACs.
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Affiliation(s)
| | - Abhirami Shankar
- Department of Internal Medicine, West Anaheim Medical Centre, Anaheim, CA
| | - Vinesh Kumar
- Department of Medicine, Chandka Medical College, Larkana
| | - Sumeet Kumar
- Department of Internal Medicine, Dow University of Health Sciences
| | | | - Abdul Majeed
- Department of Medicine, Liaquat College of Medicine and Dentistry
| | | | - Berkha
- Department of Medicine, Peoples Medical College, Nawabshah, Pakistan
| | - Suman
- Department of Medicine, Chandka Medical College, Larkana
| | - Sumeet Kumar
- Medicine, Liaquat University of Medical & Health Sciences, Karachi
| | - Aadarsh Netha
- Department of Medicine, Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, Melmaruvathur, Tamil Nadu, India
| | - Sonika Subedi
- Department of Medicine, Chitwan Medical College, Bharatpur, Nepal
| | - Shoaib Ahmed
- Department of Medicine, Kabul Medical University, Kabul, Afghanistan
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Girón-Ortega JA, Girón-González JA. Direct-acting oral anticoagulants in antiphospholipid syndrome: A systematic review. Med Clin (Barc) 2023:S0025-7753(23)00157-4. [PMID: 37105842 DOI: 10.1016/j.medcli.2023.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/16/2023] [Accepted: 03/20/2023] [Indexed: 04/29/2023]
Abstract
The objective of the systematic review is to analyze the efficacy of direct-acting oral anticoagulants (DOAC) in the prophylaxis of thrombosis in antiphospholipid syndrome (APS). We searched for clinical trials, cohort studies and meta-analyses published from January 1, 2012 to September 30, 2022. Articles that analyzed the efficacy of DOAC in the prevention of thrombosis recurrence, with or without comparison with antivitamin K (VKA) drugs, were selected. DOACs, specifically rivaroxaban and apixaban, were significantly less effective than VKAs in preventing recurrence of thrombosis in patients with APS and prior arterial thrombosis or the concomitant presence of two or three different antiphospholipid antibodies. The proportion of patients with severe bleeding as side effect are similar in those treated with DOAC and with VKA. The results argue against the use of DOAC in the treatment of patients with thrombotic APS.
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Affiliation(s)
| | - José Antonio Girón-González
- Servicio de Medicina Interna, Hospital Universitario Puerta del Mar, Facultad de Medicina, Universidad de Cádiz, Instituto para la Investigación e Innovación Biomédica de Cádiz (INiBICA), Cádiz, España
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Abstract
Antiphospholipid syndrome (APS) is an autoimmune prothrombotic disease characterized by thrombosis and/or pregnancy complications caused by antiphospholipid antibodies (aPL). The history of APS can be traced back to observations made during screening programs for syphilis conducted in the mid-20th century, with identification of patients with the so-called biological false-positive serological reactions for syphilis. Initial observation linking aPL with recurrent miscarriages was first reported more than 40 years ago. Since then, our understanding of the pathogenesis and management of APS has evolved markedly. Although APS is an autoimmune disease, anticoagulation mainly with vitamin K antagonists (VKAs) rather than immunomodulation, is the treatment of choice for thrombotic APS. Direct acting oral anticoagulants are inferior to VKAs, especially those with triple-positive APS and arterial thrombosis. Inflammation, complement activation, and thrombosis in the placenta may contribute to pathogenesis of obstetric APS. Heparin, mainly low-molecular-weight heparin, and low-dose aspirin represent the treatments of choice for women with obstetric complications. Increasingly, immunomodulatory agents such as hydroxychloroquine for thrombotic and obstetric APS are being used, especially in patients who are refractory to present standard treatment.
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Affiliation(s)
- Deepa R J Arachchillage
- Department of Immunology and Inflammation, Centre for Haematology, Imperial College London, London, United Kingdom
- Department of Haematology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Charis Pericleous
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
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Misra DP, Ahmed S, Goyal M, Sharma A, Agarwal V. Venous Thromboembolism in the Inflammatory Rheumatic Diseases. Rheum Dis Clin North Am 2023; 49:97-127. [PMID: 36424029 DOI: 10.1016/j.rdc.2022.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Venous thromboembolism (VTE), which includes deep venous thrombosis and pulmonary embolism, is a cardiovascular event whose risk is increased in most inflammatory rheumatic diseases (IRDs). Mechanisms that increase VTE risk include antiphospholipid antibodies (APLs), particularly anticardiolipin antibodies, anti-beta2glycoprotein I antibodies and lupus anticoagulant present together, and inflammation-mediated endothelial injury. Patients with IRDs should receive long-term anticoagulation drugs when the risk of VTE recurrence is high. In the light of recent warnings from regulatory agencies regarding heightened VTE risk with Janus kinase inhibitors, these drugs should be initiated only after a careful assessment of VTE risk in those with IRDs.
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Affiliation(s)
- Durga Prasanna Misra
- Department of Clinical Immunology and Rheumatology, C block, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Rae Bareli Road, Lucknow 226014, India.
| | - Sakir Ahmed
- Department of Clinical Immunology and Rheumatology, Kalinga Institute of Medical Sciences (KIMS), Bhubaneswar 751024, India. https://twitter.com/sakir_rheum
| | - Mohit Goyal
- Department of Rheumatology and Clinical Immunology, CARE Pain and Arthritis Centre, Udaipur 313002, Rajasthan, India. https://twitter.com/drmohitgoyal
| | - Aman Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India. https://twitter.com/Amansharmapgi
| | - Vikas Agarwal
- Department of Clinical Immunology and Rheumatology, C block, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Rae Bareli Road, Lucknow 226014, India. https://twitter.com/vikasagrIMMUNO
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Siriez R, Yildiz H, Bouvy C, Haguet H, Maloteau V, Hardy M, Mullier F, Dogné J, Hainaut P, Douxfils J. The edoxaban‐M4 metabolite and measurement of edoxaban by chromogenic assays in human plasma. Res Pract Thromb Haemost 2022; 6:e12680. [PMID: 35434470 PMCID: PMC9001858 DOI: 10.1002/rth2.12680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/13/2022] [Accepted: 01/26/2022] [Indexed: 11/08/2022] Open
Abstract
Introduction Edoxaban is the only anti-Xa inhibitor metabolized in pharmacologically active moiety that could interfere with chromogenic anti-Xa assays, especially in case of drug-drug interactions or physiological disorders. Materials and methods We evaluated the contribution of the main metabolite of edoxaban, edoxaban-M4 (M4), in 79 plasma samples from patients taking edoxaban. The total anti-Xa activity was evaluated on three different chromogenic factor Xa-based assays. Results were compared with a validated ultra-high-performance liquid chromatography coupled with a tandem mass spectrometry measurement. Edoxaban and its active M4 metabolite have also been spiked separately in normal pooled plasma to assess the sensitivity of chromogenic anti-Xa assays to both molecules individually. Results Spiked edoxaban or M4 provided different slopes of linear regression models between chromogenic and chromatographic measurement (from 0.97 for STA Liquid Anti-Xa to 1.10 for Biophen Heparin LRT Low with edoxaban and from 0.70 for Biophen DiXaI High to 0.83 for Biophen Heparin LRT High, respectively). A positive correlation is observed between the increase of the ratio M4/edoxaban with the difference between chromogenic and chromatographic measurements. Conclusion Edoxaban and M4 do not similarly impact chromogenic assays, leading to biased chromogenic estimations of ponderal concentrations. In patient samples, this impact is even more important at low concentrations or in the case of an increase in the M4/edoxaban ratio because of hepatic or renal impairments or in case of drug interactions. This study highlights the limitations and risks of error of expressing results in ponderal concentrations instead of global activity anti-Xa.
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Affiliation(s)
- Romain Siriez
- Department of Pharmacy Namur Thrombosis and Hemostasis Center (NTHC) Namur Research Institute for LIfe Sciences (NARILIS) University of Namur Namur Belgium
| | - Halil Yildiz
- Departement of Internal Medicine and Infectious Diseases Cliniques Universitaires Saint‐Luc Université Catholique de Louvain Brussels Belgium
| | | | - Hélène Haguet
- Department of Pharmacy Namur Thrombosis and Hemostasis Center (NTHC) Namur Research Institute for LIfe Sciences (NARILIS) University of Namur Namur Belgium
- Qualiblood s.a. Namur Belgium
| | - Vincent Maloteau
- Department of Pharmacy Namur Thrombosis and Hemostasis Center (NTHC) Namur Research Institute for LIfe Sciences (NARILIS) University of Namur Namur Belgium
| | - Michaël Hardy
- Université catholique de Louvain CHU UCL Namur Hematology Laboratory Namur Thrombosis and Hemostasis Center (NTHC) Namur Research Institute for Life Sciences (NARILIS) Yvoir Belgium
- Department of Anesthesiology Namur Thrombosis and Hemostasis Center (NTHC) Université catholique de Louvain CHU UCL Namur Yvoir Belgium
| | - François Mullier
- Université catholique de Louvain CHU UCL Namur Hematology Laboratory Namur Thrombosis and Hemostasis Center (NTHC) Namur Research Institute for Life Sciences (NARILIS) Yvoir Belgium
| | - Jean‐Michel Dogné
- Department of Pharmacy Namur Thrombosis and Hemostasis Center (NTHC) Namur Research Institute for LIfe Sciences (NARILIS) University of Namur Namur Belgium
| | - Philippe Hainaut
- Departement of Internal Medicine and Infectious Diseases Cliniques Universitaires Saint‐Luc Université Catholique de Louvain Brussels Belgium
| | - Jonathan Douxfils
- Department of Pharmacy Namur Thrombosis and Hemostasis Center (NTHC) Namur Research Institute for LIfe Sciences (NARILIS) University of Namur Namur Belgium
- Qualiblood s.a. Namur Belgium
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Mavromanoli AC, Barco S, Konstantinides SV. Antithrombotics and new interventions for venous thromboembolism: Exploring possibilities beyond factor IIa and factor Xa inhibition. Res Pract Thromb Haemost 2021; 5:S2475-0379(22)01378-4. [PMID: 34027284 PMCID: PMC8130658 DOI: 10.1002/rth2.12509] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 02/19/2021] [Accepted: 03/04/2021] [Indexed: 12/17/2022] Open
Abstract
Direct oral anti-activated factor X and antithrombin agents have largely replaced vitamin K antagonists as the standard of care in treatment of venous thromboembolism. However, gaps in efficacy and safety persist, notably in end-stage renal disease, implantable heart valves or assist devices, extracorporeal support of the circulation, and antiphospholipid syndrome. Inhibition of coagulation factor XI (FXI) emerges as a promising new therapeutic target. Antisense oligonucleotides offer potential advantages as a prophylactic or therapeutic modality, with one dose-finding trial in orthopedic surgery already published. In addition, monoclonal antibodies blocking activation and/or activity of activated factor XI are investigated, as are small-molecule inhibitors with rapid offset of action. Further potential targets include upstream components of the contact pathway such as factor XII, polyphosphates, or kallikrein. Finally, catheter-directed, pharmacomechanical antithrombotic strategies have been developed for high- and intermediate-risk pulmonary embolism, and large randomized trials aiming to validate their efficacy, safety, and prognostic impact are about to start.
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Affiliation(s)
- Anna C. Mavromanoli
- Center for Thrombosis and Hemostasis (CTH)University Medical Center of the Johannes Gutenberg UniversityMainzGermany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH)University Medical Center of the Johannes Gutenberg UniversityMainzGermany
- Clinic of AngiologyUniversity Hospital ZurichZurichSwitzerland
| | - Stavros V. Konstantinides
- Center for Thrombosis and Hemostasis (CTH)University Medical Center of the Johannes Gutenberg UniversityMainzGermany
- Department of CardiologyDemocritus University of ThraceAlexandroupolisGreece
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Verhamme P, Budts W, Van de Werf F. Non-vitamin K oral anticoagulants in adults with congenital heart disease: quod non? Eur Heart J 2021; 41:4178-4180. [PMID: 33166997 DOI: 10.1093/eurheartj/ehaa867] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Peter Verhamme
- Division of Cardiovascular Diseases, University Hospitals Leuven and Department of Cardiovascular Sciences, KU Leuven-University of Leuven, Belgium
| | - Werner Budts
- Division of Cardiovascular Diseases, University Hospitals Leuven and Department of Cardiovascular Sciences, KU Leuven-University of Leuven, Belgium
| | - Frans Van de Werf
- Division of Cardiovascular Diseases, University Hospitals Leuven and Department of Cardiovascular Sciences, KU Leuven-University of Leuven, Belgium
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Ghofrani HA, D'Armini AM, Kim NH, Mayer E, Simonneau G. Interventional and pharmacological management of chronic thromboembolic pulmonary hypertension. Respir Med 2021; 177:106293. [PMID: 33465538 DOI: 10.1016/j.rmed.2020.106293] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 12/11/2020] [Accepted: 12/27/2020] [Indexed: 11/24/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is caused by obstruction of the pulmonary vasculature, leading to increased pulmonary vascular resistance and ultimately right ventricular failure, the leading cause of death in non-operated patients. This article reviews the current management of CTEPH. The standard of care in CTEPH is pulmonary endarterectomy (PEA). However, up to 40% of patients with CTEPH are ineligible for PEA, and up to 51% develop persistent/recurrent PH after PEA. Riociguat is currently the only medical therapy licensed for treatment of inoperable or persistent/recurrent CTEPH after PEA based on the results of the Phase III CHEST-1 study. Studies of balloon pulmonary angioplasty (BPA) have shown benefits in patients with inoperable or persistent/recurrent CTEPH after PEA; however, data are lacking from large, prospective, controlled studies. Studies of macitentan in patients with inoperable CTEPH and treprostinil in patients with inoperable or persistent/recurrent CTEPH showed positive results. Combination therapy is under evaluation in CTEPH, and long-term data are not available. In the future, CTEPH may be managed by PEA, medical therapy or BPA - alone or in combination, according to individual patient needs. Patients should be referred to experienced centers capable of assessing and delivering all options.
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Affiliation(s)
- Hossein-Ardeschir Ghofrani
- Department of Internal Medicine, University of Giessen and Marburg Lung Center, Giessen, Germany; Department of Pneumology, Kerckhoff-Klinik, Bad Nauheim, Germany; Department of Medicine, Imperial College London, London, UK.
| | - Andrea M D'Armini
- Department of Cardio-Thoracic and Vascular Surgery, Heart and Lung Transplantation and Pulmonary Hypertension Unit, Foundation IRCCS Policlinico San Matteo, University of Pavia School of Medicine, Pavia, Italy
| | - Nick H Kim
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, USA
| | - Eckhard Mayer
- Department of Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany; Member of the German Center for Lung Research (DZL), Germany
| | - Gérald Simonneau
- Assistance Publique-Hôpitaux de Paris, Service de Pneumologie, Hôpital Bicêtre, Université Paris-Saclay, Laboratoire d'Excellence en Recherche sur le Médicament et Innovation Thérapeutique, Le Kremlin, Bicêtre, France
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11
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Pengo V. Oral anticoagulants in thrombotic antiphospholipid syndrome: Leave the old road for a new trail? Eur J Intern Med 2020; 79:29-30. [PMID: 32768160 DOI: 10.1016/j.ejim.2020.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 07/31/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Vittorio Pengo
- Thrombosis Research Laboratory, University of Padova, Campus Biomedico, 'Pietro d'Abano', Via Orus 2/B, 35129 Padova, Italy; Arianna Foundation on Anticoagulation, Bologna, Italy.
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