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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 156] [Impact Index Per Article: 156.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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2
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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3
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de Abreu de Vasconcellos SJ, Souza Dos Santos Marques R, Gomes Magalhães de Melo E, Silva de Almeida C, de Almeida Góes Silva JV, de Almeida Souza LM, Martins-Filho PR. Risk of bleeding in anticoagulated patients undergoing dental extraction treated with topical tranexamic acid compared to collagen-gelatin sponge: Randomized clinical trial. J Craniomaxillofac Surg 2023:S1010-5182(23)00102-6. [PMID: 37422339 DOI: 10.1016/j.jcms.2023.06.003] [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: 02/24/2023] [Revised: 05/05/2023] [Accepted: 06/25/2023] [Indexed: 07/10/2023] Open
Abstract
This two-arm, parallel-group, double-blind, randomized clinical trial design evaluated the risk of postoperative bleeding in anticoagulated patients undergoing dental extraction treated with topical TXA in comparison to collagen-gelatin sponge. Forty patients were randomly included in one of the study groups: (1) topical use of 4.8% TXA solution; and (2) resorbable hydrolyzed collagen-gelatin sponge applied to the surgical alveolus. Primary outcomes were postoperative bleeding episodes and secondary outcomes were thromboembolic events and postoperative INR values. The relative risk (RR), the absolute risk reduction (RAR) and the number needed to treat (NNT) were used as effect estimates and calculated from the counting of bleeding episodes observed during the first postoperative week. The bleeding rate under the TXA treatment was 22.2%, while in the collagen-gelatin sponge group it was 45.7%, resulting in a RR of 0.49 (95% CI 0.24-099; p = 0.046), RAR 23.5% and NNT 4.3. TXA was more effective in reducing bleeding in surgical sites located in the mandible (RR = 0.10; 95% CI 0.01-0.71; p = 0.021) and the posterior region (RR = 0.39; 95% CI 0.18-0.84; p = 0.016). Within the limitations of the study it seems that topical TXA is more effective in controlling bleeding after tooth extractions in anticoagulated patients than collagen-gelatin sponge. CLINICAL TRIAL REGISTRATION: RBR-83qw93.
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Affiliation(s)
- Sara Juliana de Abreu de Vasconcellos
- Graduate Program in Health Sciences, Federal University of Sergipe, Sergipe, Brazil; Department of Dentistry, Tiradentes University, Sergipe, Brazil
| | | | | | | | | | | | - Paulo Ricardo Martins-Filho
- Graduate Program in Health Sciences, Federal University of Sergipe, Sergipe, Brazil; Graduate Program in Dentistry, Federal University of Sergipe, Sergipe, Brazil.
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Boccatonda A, Frisone A, Lorusso F, Bugea C, Di Carmine M, Schiavone C, Cocco G, D’Ardes D, Scarano A, Guagnano MT. Perioperative Management of Antithrombotic Therapy in Patients Who Undergo Dental Procedures: A Systematic Review of the Literature and Network Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:5293. [PMID: 37047909 PMCID: PMC10093975 DOI: 10.3390/ijerph20075293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 03/10/2023] [Accepted: 03/14/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND The surgical dental treatment of subjects admitted for anticoagulants therapy represents a consistent risk for peri-operative bleeding. The aim of the present study was to investigate the clinical findings of dental surgery operative management of the patients under anticoagulants drugs protocol. METHODS The literature screening was performed using Pubmed/Medline, EMBASE and Cochrane library, considering only randomized clinical trials (RCTs) papers. No limitations about the publication's period, follow-up time or clinical parameters were considered. RESULTS A total of eight RCTs were included for the qualitative synthesis. No thromboembolic complications were reported in any studies. Several bleeding episodes associated with anticoagulant drugs in dental surgery were mild and generally happened on the first day after the treatment. CONCLUSIONS The use of local haemostatic measures is generally effective for bleeding control with no further pharmacological drug management or suspension.
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Affiliation(s)
- Andrea Boccatonda
- Internal Medicine, Bentivoglio Hospital, AUSL Bologna, 40010 Bentivoglio, Italy
| | - Alessio Frisone
- Department of Innovative Technologies in Medicine & Dentistry, University of Chieti-Pescara, Via Dei Vestini 31, 66100 Chieti, Italy
| | - Felice Lorusso
- Department of Innovative Technologies in Medicine & Dentistry, University of Chieti-Pescara, Via Dei Vestini 31, 66100 Chieti, Italy
| | - Calogero Bugea
- Department of Innovative Technologies in Medicine & Dentistry, University of Chieti-Pescara, Via Dei Vestini 31, 66100 Chieti, Italy
| | - Maristella Di Carmine
- Department of Innovative Technologies in Medicine & Dentistry, University of Chieti-Pescara, Via Dei Vestini 31, 66100 Chieti, Italy
| | - Cosima Schiavone
- Department of Medicine and Science of Aging, “G. d’Annunzio” University, 66100 Chieti, Italy
| | - Giulio Cocco
- Department of Medicine and Science of Aging, “G. d’Annunzio” University, 66100 Chieti, Italy
| | - Damiano D’Ardes
- Department of Medicine and Science of Aging, “G. d’Annunzio” University, 66100 Chieti, Italy
| | - Antonio Scarano
- Department of Innovative Technologies in Medicine & Dentistry, University of Chieti-Pescara, Via Dei Vestini 31, 66100 Chieti, Italy
- Department of Oral Implantology, Dental Research Division, College Ingà, UNINGÁ, Cachoeiro de Itapemirim 29312, ES, Brazil
| | - Maria Teresa Guagnano
- Department of Medicine and Science of Aging, “G. d’Annunzio” University, 66100 Chieti, Italy
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Shah S, Nayfeh T, Hasan B, Urtecho M, Firwana M, Saadi S, Abd-Rabu R, Nanaa A, Flynn DN, Rajjoub NS, Hazem W, Seisa MO, Hassett LC, Spyropoulos AC, Douketis JD, Murad MH. Perioperative Management of Vitamin K Antagonists and Direct Oral Anticoagulants: A Systematic Review and Meta-analysis. Chest 2022; 163:1245-1257. [PMID: 36462533 DOI: 10.1016/j.chest.2022.11.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 09/30/2022] [Accepted: 11/22/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The management of patients who are receiving chronic oral anticoagulation therapy and require an elective surgery or an invasive procedure is a common clinical scenario. RESAERCH QUESTION What is the best available evidence to support the development of American College of Chest Physicians guidelines on the perioperative management of patients who are receiving long-term vitamin K agonist (VKA) or direct oral anticoagulant (DOAC) and require elective surgery or procedures? STUDY DESIGH AND METHODS A literature search including multiple databases from database inception through July 16, 2020, was performed. Meta-analyses were conducted when appropriate. RESULTS In patients receiving VKA (warfarin) undergoing elective noncardiac surgery, shorter (< 5 days) VKA interruption is associated with an increased risk of major bleeding. In patients who required VKA interruption, heparin bridging (mostly with low-molecular-weight heparin [LMWH]) was associated with a statistically significant increased risk of major bleed (relative risk [RR], 9.1; 95% CI, 1.62-51.3), representing a very low certainty of evidence (COE). Compared with DOAC interruption 1 to 4 days before surgery, continuing DOACs was not associated with a statistically significant difference in the risk of bleeding, representing a very low COE. Continuing dabigatran was associated with a statistically significant increased risk of thromboembolism (RR, 2.2; 95% CI, 1.3-3.8), representing a low COE. In patients who needed DOAC interruption, bridging with LMWH was associated a with statistically significant increased risk of minor bleeding compared with no bridging (RR, 1.7; 95% CI, 1.13-2.7), representing a low COE. INTERPRETATION The certainty in the evidence supporting the perioperative management of anticoagulants remains limited. No high-quality evidence exists to support the practice of heparin bridging during the interruption of VKA or DOAC therapy for an elective surgery or procedure or for the practice of interrupting VKA therapy for minor procedures, including cardiac device implantation, or continuation of a DOAC vs short-term interruption of a DOAC (1-4 days) in the perioperative period.
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Affiliation(s)
- Sahrish Shah
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Tarek Nayfeh
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Bashar Hasan
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Meritxell Urtecho
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Mohammed Firwana
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Samer Saadi
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Rami Abd-Rabu
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Ahmad Nanaa
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - David N Flynn
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Noora S Rajjoub
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Walid Hazem
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Mohamed O Seisa
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | | | - Alex C Spyropoulos
- Institute of Health Systems Science-Feinstein Institutes for Medical Research and The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, and Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, NY
| | - James D Douketis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
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Douketis JD, Spyropoulos AC, Murad MH, Arcelus JI, Dager WE, Dunn AS, Fargo RA, Levy JH, Samama CM, Shah SH, Sherwood MW, Tafur AJ, Tang LV, Moores LK. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest 2022; 162:e207-e243. [PMID: 35964704 DOI: 10.1016/j.chest.2022.07.025] [Citation(s) in RCA: 78] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/10/2022] [Accepted: 07/11/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug. METHODS Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines. RESULTS A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures. CONCLUSIONS Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.
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Affiliation(s)
- James D Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton and McMaster University, Hamilton, ON, Canada.
| | - Alex C Spyropoulos
- Department of Medicine, Northwell Health at Lenox Hill Hospital, New York, NY; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Institute of Health Systems Science at The Feinstein Institutes for Medical Research, Manhasset, NY
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | - Juan I Arcelus
- Department of Surgery, Facultad de Medicina, University of Granada, Granada, Spain
| | - William E Dager
- Department of Pharmacy, University of California-Davis, Sacramento, CA
| | - Andrew S Dunn
- Division of Hospital Medicine, Department of Medicine, Mt. Sinai Health System, New York, NY
| | - Ramiz A Fargo
- Department of Internal Medicine, Loma Linda University Medical Center, Loma Linda, CA; Department of Internal Medicine, Riverside University Health System Medical Center, Moreno Valley, CA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, NC
| | - C Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP, Centre-Université Paris-Cité-Cochin Hospital, Paris, France
| | - Sahrish H Shah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | | | - Alfonso J Tafur
- Department of Medicine, Cardiovascular, NorthShore University HealthSystem, Evanston, IL
| | - Liang V Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong, University of Science and Technology, Wuhan, China
| | - Lisa K Moores
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
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Altiok E, Almalla M. Bridging unter Antikoagulation und Thrombozytenaggregationshemmung. PHLEBOLOGIE 2022. [DOI: 10.1055/a-1679-0677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AbtractWhen bridging anticoagulation, the risk of bleeding - compared to the thromboembolic risk - is often underestimated. Bridging is only indicated in case of high (and possibly moderate) thromboembolic risk. When bridging patients with indication for dual antiplatelet therapy, an interdisciplinary case discussion should take place to assess the risk.
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8
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Manfredini M, Poli PP, Creminelli L, Porro A, Maiorana C, Beretta M. Comparative Risk of Bleeding of Anticoagulant Therapy with Vitamin K Antagonists (VKAs) and with Non-Vitamin K Antagonists in Patients Undergoing Dental Surgery. J Clin Med 2021; 10:5526. [PMID: 34884228 PMCID: PMC8658703 DOI: 10.3390/jcm10235526] [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: 10/24/2021] [Revised: 11/22/2021] [Accepted: 11/22/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES A wide variety of approaches have been proposed to manage anticoagulant drugs in patients undergoing dental surgery; vitamin K antagonists and novel direct oral anticoagulants have been used. The present study aims to explore the existing evidence concerning the management of patients in anticoagulant therapy undergoing oral surgery procedures and to give suggestions related to peri- and post-operative measures. MATERIALS AND METHODS A comprehensive search of databases was conducted to identify studies that evaluated the relationship between direct oral anticoagulants and dental procedures. The present scoping review was realized in adherence with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. The publications varied from randomized controlled trials (RCT) to cohort trials. Only articles written in English language and published between 2000 to 2020 were screened. The studies were included if discussing the management of a patient in anticoagulant therapy (warfarin or direct oral anticoagulants) scheduled for tooth extraction. RESULTS 33 studies were selected and included in the qualitative review. Nineteen considered anticoagulant therapy with warfarin, six considered anticoagulant therapy with new oral anticoagulants and eight compared patients taking warfarin with patients taking direct oral anticoagulants. CONCLUSIONS No case of extractive surgery should alter the posology of the drug: thromboembolic risks derived from discontinuation are heavier than hemorrhagic risks. CLINICAL RELEVANCE direct oral anticoagulants are safer in terms of bleeding and manageability and bleeding episodes are manageable with local hemostatic measures.
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Affiliation(s)
| | | | | | - Alberto Porro
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Implant Center for Edentulism and Jawbone Atrophies, Maxillofacial Surgery and Odontostomatology Unit, University of Milan, Via della Commenda 10, 20122 Milan, Italy; (M.M.); (P.P.P.); (L.C.); (C.M.); (M.B.)
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9
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Eljilany I, El-Bardissy A, Nemir A, Elzouki AN, El Madhoun I, Al-Badriyeh D, Elewa H. Assessment of the attitude, awareness and practice of periprocedural warfarin management among health care professional in Qatar. A cross sectional survey. J Thromb Thrombolysis 2021; 50:957-968. [PMID: 32307632 PMCID: PMC7575475 DOI: 10.1007/s11239-020-02111-w] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
It is estimated that 10-15% of oral anticoagulant (OAC) patients, would need to hold their OAC for scheduled surgery. Especially for warfarin, this process is complex and requires multi-layer risk assessment and decisions across different specialties. Clinical guidelines deliver broad recommendations in the area of warfarin management before surgery which can lead to different trends and practices among practitioners. To evaluate the current attitude, awareness, and practice among health care providers (HCPs) on warfarin periprocedural management. A multiple-choice questionnaire was developed, containing questions on demographics and professional information and was completed by187 HCPs involved in warfarin periprocedural management. The awareness median (IQR) score was moderate [64.28% (21.43)]. The level of awareness was associated with the practitioner's specialty and degree of education (P = 0.009, 0.011 respectively). Practice leans to overestimate the need for warfarin discontinuation as well as the need for bridging. Participants expressed interest in using genetic tests to guide periprocedural warfarin management [median (IQR) score (out of 10) = 7 (5)]. In conclusion, the survey presented a wide variation in the clinical practice of warfarin periprocedural management. This study highlights that HCPs in Qatar have moderate awareness. We suggest tailoring an educational campaign or courses towards the identified gaps.
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Affiliation(s)
- Islam Eljilany
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Ahmed El-Bardissy
- Department of Pharmacy, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Arwa Nemir
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Abdel-Naser Elzouki
- Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.,College of Medicine, Qatar University & Weill Cornell Medical College- Qatar, Doha, Qatar
| | - Ihab El Madhoun
- Department of Medicine, Al Wakra Hospital Hamad Medical Corporation, Al Wakra, Qatar.,Weill Cornell Medical College, Al Wakra, Qatar
| | | | - Hazem Elewa
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar.
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10
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Moreno-Drada JA, Abreu LG, Lino PA, Parreiras Martins MA, Pordeus IA, Nogueira Guimarães de Abreu MH. Effectiveness of local hemostatic to prevent bleeding in dental patients on anticoagulation: A systematic review and network meta-analysis. J Craniomaxillofac Surg 2021; 49:570-583. [PMID: 33994071 DOI: 10.1016/j.jcms.2021.04.014] [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: 01/05/2021] [Revised: 03/14/2021] [Accepted: 04/20/2021] [Indexed: 10/21/2022] Open
Abstract
This study aimed to determine the effectiveness of hemostatic protocols to prevent bleeding in dental procedures among individuals undergoing oral anticoagulation therapy. A systematic review and network meta-analysis were accomplished. Searches of literature and grey literature were performed in different electronic databases. Clinical trials were considered as part of the inclusion criteria. Data extraction and assessment of the risk of bias of the included articles were performed. Assessment of the certainty of evidence was also performed. As results we find that the N-butyl-2-cyanoacrylate [RR -35.00 (95% CI - 107.12, -5.78)], calcium sulfate (CaSO4) [RR -5.62 (95% CI -11.41, -1.03)], and tranexamic acid (TXA) [RR -3.46 (95% CI -7.63, -0.77)] showed beneficial effects compared to placebo. However, only TXA presented beneficial effects with moderate certainty evidence. N-butyl-2-cyanoacrylate and CaSO4 presented very low certainty evidence. In the comparisons between the hemostatic agents, no differences were observed. For the mean bleeding time, no significant difference in the comparisons was observed as well. Concluding, bleeding events in individuals on oral anticoagulation decreased with the use of TXA compared to placebo. N-butyl-2-cyanoacrylate and CaSO4 were also superior to placebo, but the certainty of evidence was low. For the mean bleeding time, no significant difference in hemostatic agents was observed.
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11
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Management of anticoagulated patients in dentoalveolar surgery: a retrospective study comparing bridging with heparin versus unpaused vitamin K antagonist medication. BMC Oral Health 2021; 21:96. [PMID: 33663474 PMCID: PMC7934390 DOI: 10.1186/s12903-021-01464-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 02/22/2021] [Accepted: 02/25/2021] [Indexed: 11/27/2022] Open
Abstract
Background The aim of this study was to investigate the occurrence of postoperative bleeding following dentoalveolar surgery in patients with either continued vitamin K antagonist medication or perioperative bridging using heparin. Methods A retrospective study was performed analyzing patients who underwent tooth extraction between 2012 and 2017. Patients were retrospectively allocated into two comparative groups: un-paused vitamin K antagonist medication versus bridging using heparin. A healthy, non-anticoagulated cohort with equivalent surgery served as a control group. Main outcome measures were: the occurrence and frequency of postoperative bleeding, the number of removed teeth, the surgical technique of tooth removal (extraction/osteotomy/combined extraction and osteotomy) and the prothrombin time. Results
In total, 475 patients were included in the study with 170 patients in the group of un-paused vitamin K antagonist medication VG, 135 patients in the Bridging group BG and 170 patients in the control group CG. Postoperative bleeding was significant: CG versus VG p = 0.004; CG versus BG p < 0.001, BG versus VG p < 0.001. A significant correlation of number of the extracted teeth in the BG (p = 0.014) and no significance in VG (p = 0.298) and CG (p = 0.210) and in the BG versus VG and CG with p < 0.001 in terms of surgical intervention extraction. No difference observed in terms of prothrombin time. Conclusions Bridging with heparin increases the risk for bleeding compared to un-paused vitamin K antagonist medication. The perioperative management of anticoagulated patients requires a well-coordinated interdisciplinary teamwork to minimize or at best avoid both: postoperative bleeding and thromboembolic incidences.
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Pippi R, Luigetti L, Scorsolini MG, Pietrantoni A, Cafolla A. Is telephone follow-up useful in preventing post-extraction bleeding in patients on antithrombotic treatment? J Clin Exp Dent 2021; 13:e140-e147. [PMID: 33574998 PMCID: PMC7864370 DOI: 10.4317/jced.57401] [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: 06/02/2020] [Accepted: 08/10/2020] [Indexed: 11/27/2022] Open
Abstract
Background The aim of the study was to investigate the usefulness of telephone follow-up in preventing post-extraction bleeding and improving wound healing in patients on chronic antithrombotic treatment.
Material and Methods A prospective randomized clinical trial was carried out on 256 patients (test group = 128; control group = 128). The exact two-tailed Fisher test and the two-tailed non-parametric Mann-Whitney test were used for statistical analysis.
Results The incidence of post-extraction bleeding was 15.6% and there was no difference between test and control groups. However, the study group was significantly, though weakly, associated with the severity of bleeding. Patient satisfaction with post-operative follow-up differed significantly between patients who had and those who did not have post-extraction bleeding.
Conclusions Telephone follow-up after tooth extraction may play a role in the prevention of severe post-operative bleeding as well as in monitoring and managing the surgical wound. Key words:Post-operative instructions, patient satisfaction, wound healing.
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Affiliation(s)
- Roberto Pippi
- Associate Professor of Oral Surgery. Department of Odontostomatological and Maxillo Facial Sciences, Sapienza University of Rome
| | - Luca Luigetti
- Oral surgeon. Department of Odontostomatological and Maxillo Facial Sciences, Sapienza University of Rome
| | - Maria-Giulia Scorsolini
- Post-graduate student in Oral Surgery. Department of Odontostomatological and Maxillo Facial Sciences, Sapienza University of Rome
| | - Alessandra Pietrantoni
- Oral surgeon. Department of Odontostomatological and Maxillo Facial Sciences, Sapienza University of Rome
| | - Arturo Cafolla
- Aggregate Professor of Hematology. Sapienza University of Rome
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13
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Bajkin BV, Wahl MJ, Miller CS. Dental implant surgery and risk of bleeding in patients on antithrombotic medications: A review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol 2020; 130:522-532. [DOI: 10.1016/j.oooo.2020.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/17/2020] [Accepted: 07/18/2020] [Indexed: 12/13/2022]
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14
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Moreno-Drada JA, Abreu LG, Martins MAP, Pordeus IA, de Abreu MHNG. Effectiveness of hemostatic protocols for the prevention of bleeding during oral procedures among individuals receiving anticoagulation therapy: a systematic review protocol. JBI Evid Synth 2020; 18:2409-2415. [PMID: 33181593 DOI: 10.11124/jbisrir-d-19-00342] [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: 10/31/2022]
Abstract
OBJECTIVE The objective of this review is to determine the effectiveness of hemostatic protocols for the prevention of bleeding during dental procedures among individuals receiving oral anticoagulation therapy. INTRODUCTION Dental procedures may increase the chance of bleeding in individuals receiving oral anticoagulation therapy. The literature suggests different hemostatic protocols for the prevention of bleeding in these individuals but offers no consensus regarding their effectiveness. INCLUSION CRITERIA Randomized controlled clinical trials comparing the effectiveness of different hemostatic protocols for the prevention of bleeding during oral procedures among individuals 18 years or older receiving oral anticoagulation therapy will be included. METHODS Computerized searches will be conducted in seven electronic databases. Gray literature and searches in the reference lists of the included articles will also be screened. Two independent reviewers will assess titles/abstracts for potential inclusion against the eligibility criteria. References that meet the eligibility criteria will be included without restriction on the language or date of publication. Assessment of the methodological quality of the included articles and data extraction will be performed. Statistical heterogeneity of meta-analysis will be assessed. In the event of high statistical heterogeneity, sensitivity analysis will be performed. Subgroup analysis will be planned. The certainty of the evidence will be evaluated with the Grading of Recommendations, Assessment, Development and Evaluation. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42019136744.
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Affiliation(s)
| | - Lucas Guimarães Abreu
- Department of Pediatric Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Isabela Almeida Pordeus
- Department of Pediatric Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
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15
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Lee JS, Kim MK, Kang SH. Effect of warfarin discontinuation on the incidence of postoperative bleeding in tooth extraction. J Korean Assoc Oral Maxillofac Surg 2020; 46:228-234. [PMID: 32855369 PMCID: PMC7469966 DOI: 10.5125/jkaoms.2020.46.4.228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 12/06/2019] [Accepted: 12/09/2019] [Indexed: 12/03/2022] Open
Abstract
Objectives The number of patients undergoing oral anticoagulant therapy for cardiovascular and cerebrovascular disease is increasing. However, the risk of bleeding after tooth extraction in patients receiving warfarin is unclear. Here, we assess the risk of bleeding after tooth extraction in patients on warfarin. Materials and Methods The study included 260 patients taking warfarin who underwent tooth extraction (694 teeth). The patients were divided into those whose teeth were extracted while they were taking warfarin, those who discontinued warfarin before extraction, and those who underwent extraction while receiving heparin bridging therapy. Bleeding complications in the two groups were compared. Results Of the 260 patients, 156 underwent extraction while taking warfarin, 70 stopped taking warfarin before extractions, and 34 received heparin bridging therapy and stopped taking either medication before extractions. Bleeding complications occurred in 9 patients (3.5%) and 9 tooth sites (1.3%). Among the 9 patients with bleeding complications, 6 underwent extraction while taking warfarin, 2 stopped warfarin before extraction, and 1 underwent extraction after receiving heparin bridging therapy. No significant difference was seen between patient groups regarding bleeding after extractions (P=0.917). Conclusion Warfarin use does not increase the risk of post-extraction bleeding and can therefore be continued during tooth extraction.
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Affiliation(s)
- Jung-Soo Lee
- Department of Oral and Maxillofacial Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Moon-Key Kim
- Department of Oral and Maxillofacial Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Sang-Hoon Kang
- Department of Oral and Maxillofacial Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
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16
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Gotoh S, Yasaka M, Nakamura A, Kuwashiro T, Okada Y. Management of Antithrombotic Agents During Surgery or Other Kinds of Medical Procedures With Bleeding: The MARK Study. J Am Heart Assoc 2020; 9:e012774. [PMID: 32079478 PMCID: PMC7335562 DOI: 10.1161/jaha.119.012774] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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 Optimal management of antithrombotic agents during surgery has yet to be established. We performed a prospective multicenter observational study to determine the current status of the management of antithrombotic agents during surgery or other medical procedures with bleeding (MARK [Management of Antithrombotic Agents During Surgery or Other Kinds of Medical Procedures With Bleeding] study) in Japan. Methods and Results The participants were 9700 patients who received oral antithrombotic agents and underwent scheduled medical procedures with bleeding at 59 National Hospital Organization institutions in Japan. Primary outcomes were thromboembolic events, bleeding events, and death within 2 weeks before and 4 weeks after the procedures. We investigated the relationships between each outcome and patient demographics, comorbidities, type of procedure, and management of antithrombotic therapy. With respect to the periprocedural management of antithrombotic agents, 3551 patients continued oral antithrombotic agents (36.6%, continuation group) and 6149 patients discontinued them (63.4%, discontinuation group). The incidence of any thromboembolic event (1.7% versus 0.6%, P<0.001), major bleeding (7.6% versus 0.4%, P<0.001), and death (0.8% versus 0.4%, P<0.001) was all greater in the discontinuation group than the continuation group. In multivariate analysis, even after adjusting for confounding factors, discontinuation of anticoagulant agents was significantly associated with higher risk for both thromboembolic events (odds ratio: 4.55; 95% CI, 1.67-12.4; P=0.003) and major bleeding (odds ratio: 11.1; 95% CI, 2.03-60.3; P=0.006) in procedures with low bleeding risk. In contrast, heparin bridging therapy was significantly associated with higher risk for both thromboembolic events (odds ratio: 2.03; 95% CI, 1.28-3.22; P=0.003) and major bleeding (odds ratio: 1.36; 95% CI, 1.10-1.68; P=0.005) in procedures with high bleeding risk. Conclusions Discontinuation of oral antithrombotic agents and addition of low-dose heparin bridging therapy appear to be significantly associated with adverse events in the periprocedural period.
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Affiliation(s)
- Seiji Gotoh
- Department of Cerebrovascular Medicine and Neurology Cerebrovascular Center and Clinical Research Institute National Hospital Organization Kyushu Medical Center Fukuoka Japan
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology Cerebrovascular Center and Clinical Research Institute National Hospital Organization Kyushu Medical Center Fukuoka Japan
| | - Asako Nakamura
- Department of Cerebrovascular Medicine and Neurology Cerebrovascular Center and Clinical Research Institute National Hospital Organization Kyushu Medical Center Fukuoka Japan
| | - Takahiro Kuwashiro
- Department of Cerebrovascular Medicine and Neurology Cerebrovascular Center and Clinical Research Institute National Hospital Organization Kyushu Medical Center Fukuoka Japan
| | - Yasushi Okada
- Department of Cerebrovascular Medicine and Neurology Cerebrovascular Center and Clinical Research Institute National Hospital Organization Kyushu Medical Center Fukuoka Japan
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Sohn JB, Lee H, Han YS, Jung DU, Sim HY, Kim HS, Oh S. When do we need more than local compression to control intraoral haemorrhage? J Korean Assoc Oral Maxillofac Surg 2020; 45:343-350. [PMID: 31966979 PMCID: PMC6955419 DOI: 10.5125/jkaoms.2019.45.6.343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 10/05/2019] [Accepted: 10/28/2019] [Indexed: 11/07/2022] Open
Abstract
Objectives The aims of this study were to determine the effectiveness of local compression in patients presenting to the emergency room with intraoral bleeding and to identify when complex haemostatic measures may be required. Materials and Methods Five hundred forty patients who had experienced intraoral haemorrhage were retrospectively reviewed. The outcome variable was the haemostasis method used, i.e., simple (local compression with gauze) or complex (an alternative method after local compression has failed). Predictor variables were sex, age, American Society of Anesthesiologists (ASA) class, hepatic cirrhosis, bleeding disorder, use of antithrombotic agents, and site/cause of haemorrhage. Results The mean patient age was 48.9±23.9 years, 53.5% were male, 42.8% were ASA class II or higher, and 23.7% were taking antithrombotic agents. Local compression was used most often (68.1%), followed by local haemostatic agents, sutures, systemic tranexamic acid or blood products, and electrocautery. The most common site of bleeding was the gingiva (91.7%), and the most common cause was tooth extraction (45.7%). Risk factors for needing a complex haemostasis method were use of antithrombotic agents (odds ratio 2.047, P=0.009) and minor oral surgery (excluding extraction and implant procedures; odds ratio 6.081, P=0.001). Conclusion A haemostasis method other than local compression may be needed in patients taking antithrombotic agents or having undergone minor oral surgery.
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Affiliation(s)
- Jun-Bae Sohn
- Department of Oral and Maxillofacial Surgery, Seoul Metropolitan Government-Seoul National University (SMG-SNU) Boramae Medical Center, Seoul, Korea
| | - Ho Lee
- Department of Oral and Maxillofacial Surgery, Seoul Metropolitan Government-Seoul National University (SMG-SNU) Boramae Medical Center, Seoul, Korea
| | - Yoon-Sic Han
- Department of Oral and Maxillofacial Surgery, Seoul Metropolitan Government-Seoul National University (SMG-SNU) Boramae Medical Center, Seoul, Korea
| | - Da-Un Jung
- Section of Dentistry, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Hye-Young Sim
- Section of Dentistry, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Hee-Sun Kim
- Section of Dentistry, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Sohee Oh
- Medical Research Collaborating Center, SMG-SNU Boramae Medical Center, Seoul, Korea
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18
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Kuo HC, Liu FL, Chen JT, Cherng YG, Tam KW, Tai YH. Thromboembolic and bleeding risk of periprocedural bridging anticoagulation: A systematic review and meta-analysis. Clin Cardiol 2020; 43:441-449. [PMID: 31944351 PMCID: PMC7244304 DOI: 10.1002/clc.23336] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 01/06/2020] [Accepted: 01/08/2020] [Indexed: 12/26/2022] Open
Abstract
The risk and benefit of periprocedural heparin bridging is not completely clarified. We aimed to assess the safety and efficacy of bridging anticoagulation prior to invasive procedures or surgery. Heparin bridging was associated with lower risks of thromboembolism and bleeding compared to non‐bridging. PubMed, Ovid and Elsevier, and Cochrane Library (2000‐2016) were searched for English‐language studies. Studies comparing interrupted anticoagulation with or without bridging and continuous oral anticoagulation in patients at moderate‐to‐high thromboembolic risk before invasive procedures were included. Primary outcomes were thromboembolic events and bleeding events. Mantel‐Haenszel method and random‐effects models were used to analyze the pooled risk ratio (RR) and 95% confidence interval (CI) for thromboembolic and bleeding risks. Eighteen studies (six randomized controlled trials and 12 cohort studies) were included (N = 23 364). There was no difference in thromboembolic risk between bridged and non‐bridged patients (RR: 1.26, 95% CI: 0.61‐2.58; RCTs: RR: 0.71, 95% CI: 0.23‐2.24; cohorts: RR: 1.45, 95% CI: 0.63‐3.37). However, bridging anticoagulation was associated with higher risk of overall bleeding (RR: 2.83, 95% CI: 2.00‐4.01; RCTs: RR: 2.24, 95% CI: 0.99‐5.09; cohorts: RR: 3.09, 95% CI: 2.07‐4.62) and major bleeding (RR: 3.00, 95% CI: 1.78‐5.06; RCTs: RR: 2.48, 95% CI: 1.29‐4.76; cohorts: RR: 3.22, 95% CI: 1.65‐6.32). Bridging anticoagulation was associated with increased bleeding risk compared to non‐bridging. Thromboembolism risk was similar between two strategies. Our results do not support routine use of bridging during anticoagulation interruption.
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Affiliation(s)
- Hsien-Cheng Kuo
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Feng-Lin Liu
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Jui-Tai Chen
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yih-Giun Cherng
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ka-Wai Tam
- Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Division of General Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Center for Evidence-Based Health Care, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Ying-Hsuan Tai
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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19
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Management of anticoagulated patients in dentoalveolar surgery: a clinical comparative study. Clin Oral Investig 2019; 24:2653-2662. [PMID: 31713746 DOI: 10.1007/s00784-019-03124-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 10/14/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES This prospective, comparative, clinical study analyzed the postoperative bleeding risk of patients on anticoagulation therapy (AT) who were undergoing tooth extractions and osteotomies. MATERIALS AND METHODS Patients with the following ATs were included (test groups): (1.) platelet aggregation inhibitors (PAIs), (2.) vitamin K inhibitors, (3.) low molecular weight heparin (LMWH), and (4.) direct oral anticoagulants (DOACs). Patients in the control group were not on any AT (non-AT group). Patients were subdivided into the following treatment groups: (1.) single tooth extraction, (2.) serial extraction (≥ 2 adjacent teeth), and (3.) tooth osteotomy. Pre-, intra-, and postoperative data concerning the treatment, extent of the surgery, and bleeding were recorded and statistically evaluated. RESULTS There were 15 postoperative bleeding events in 838 patients (1.7%): four (0.7%) in the non-AT group (n = 603 patients) and 11 (4.7%) in the AT group (n = 235 patients). The surgical procedure had no statistically significant effect on postoperative bleeding frequencies. Patients taking vitamin K inhibitors had a significantly higher risk of postoperative bleeding compared with patients without AT (p < 0.00001). Four patients were hospitalized due to the severity of the bleeding (vitamin K inhibitor group). Postoperative bleeding events were all controlled with local hemostatic measures. CONCLUSIONS The postoperative bleeding risk after tooth extractions and osteotomies in patients continuing AT is low, and bleeding can be controlled with local hemostatic measures. CLINICAL RELEVANCE AT should be continued in patients undergoing tooth removal procedures under the provision that local hemostatic measures are applied.
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20
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Altiok E, Marx N. Oral Anticoagulation. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 115:776-783. [PMID: 30602410 DOI: 10.3238/arztebl.2018.0776] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 03/27/2018] [Accepted: 07/22/2018] [Indexed: 01/06/2023]
Abstract
BACKGROUND Much new evidence on oral anticoagulation has come to light in recent years. Non-vitamin-K-dependent oral anti- coagulants (NOAC) have been developed and have been introduced into clinical practice. In this review, we present the current state of the evidence on anticoagulation for various indications with vitamin K antagonists (VKA) and with NOAC. METHODS This review is based on pertinent articles retrieved by a selective search in PubMed (search terms: anticoagulation, atrial fibrillation, prosthetic valve, thrombosis, pulmonary embolism) and on specialty society recommendations and relevant guidelines from the years 2000-2018. RESULTS The main indications for oral anticoagulation are atrial fibrillation, venous thromboembolism, and status post heart valve replacement. In patients with atrial fibrillation and without valvular heart disease, anticoagulation is recommended for men with a CHA2DS2-VASc score ≥ 1 and for women with a score ≥ 2. NOAC for this indication are associated with a marginally lower rate of stroke than VKA (3.5% vs. 3.8%, number needed to treat [NNT] = 333) as well as a lower rate of major hemorrhage (5.1% vs. 6.2%, NNT = 91). NOAC are contraindicated for patients with mechanical heart valves. Anticoagulation with VKA can be predictably antagonized. Among the various types of NOAC, the anticoagulant effect of dabigatran can be safely antagonized with an antidote; no specific antidote is yet available for apixaban, rivaroxaban, or edoxaban. CONCLUSION The evidence base for anticoagulation over a time frame of several years is inadequate at present, and direct comparative data for the different types of NOAC are not yet available.
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Affiliation(s)
- Ertunc Altiok
- Department of Cardiology, Angiology and Intensive Care Medicine (Department of Internal Medicine I), University Hospital Aachen, RWTH Aachen University, Aachen, Germany
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21
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Anticoagulation Use prior to Common Dental Procedures: A Systematic Review. Cardiol Res Pract 2019; 2019:9308631. [PMID: 31275643 PMCID: PMC6589257 DOI: 10.1155/2019/9308631] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 04/28/2019] [Accepted: 05/09/2019] [Indexed: 11/27/2022] Open
Abstract
Currently, the number of patients on oral anticoagulation is increasing. There is a paucity of data regarding maintaining oral anticoagulation (especially novel oral anticoagulants) around the time of specific dental procedures. A dentist has three options: either to stop anticoagulation, to continue it, or to bridge with heparin. A systematic review of 10 clinical trials was conducted to address this issue. It was found that continuing anticoagulation during dental procedures did not increase the risk of bleeding in most trials. Although none of the studies reported a thromboembolic event after interruption of anticoagulation, the follow-up periods were short and inconsistent, and the heightened thromboembolic risk when stopping anticoagulation is well known in the literature. Heparin bridging was associated with an increased bleeding incidence. We recommend maintaining oral anticoagulation with vitamin K antagonists and novel oral anticoagulants for the vast majority of dental procedures along with the use of local hemostatic agents.
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Baumgartner C, de Kouchkovsky I, Whitaker E, Fang MC. Periprocedural Bridging in Patients with Venous Thromboembolism: A Systematic Review. Am J Med 2019; 132:722-732.e7. [PMID: 30659809 PMCID: PMC6588421 DOI: 10.1016/j.amjmed.2019.01.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 01/08/2019] [Accepted: 01/08/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Vitamin K antagonists (VKA) are the most widely used anticoagulants, and bridging is commonly administered during periprocedural VKA interruption. Given the unclear benefits and risks of periprocedural bridging in patients with previous venous thromboembolism, we aimed to assess recurrent venous thromboembolism and bleeding outcomes with and without bridging in this population. METHODS We performed a systematic review searching the PubMed and Embase databases from inception to December 7, 2017 for randomized and nonrandomized studies that included adults with previous venous thromboembolism requiring VKA interruption to undergo an elective procedure, and that reported venous thromboembolism or bleeding outcomes. Quality of evidence was graded by consensus. RESULTS We included 28 cohort studies (20 being single-arm cohorts) with, overall, 6915 procedures for analysis. In 27 studies reporting perioperative venous thromboembolism outcomes, the pooled incidence of recurrent venous thromboembolism with bridging was 0.7% (95% confidence interval [CI], 0.4%-1.2%) and 0.5% (95% CI, 0.3%-0.8%) without bridging. Eighteen studies reported major or nonmajor bleeding outcomes. The pooled incidence of any bleeding was 3.9% (95% CI, 2.0%-7.4%) with bridging and 0.4% (95% CI, 0.1%-1.7%) without bridging. In bridged patients at high thromboembolic risk, the pooled incidence for venous thromboembolism was 0.8% (95% CI, 0.3%-2.5%) and 7.5% (95% CI, 3.1%-17.4%) for any bleeding. Quality of available evidence was very low, primarily due to a high risk of bias of included studies. CONCLUSIONS Periprocedural bridging increases the risk of bleeding compared with VKA interruption without bridging, without a significant difference in periprocedural venous thromboembolism rates.
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Affiliation(s)
- Christine Baumgartner
- Division of Hospital Medicine, University of California, San Francisco; Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Evans Whitaker
- UCSF Medical Library, University of California, San Francisco
| | - Margaret C Fang
- Division of Hospital Medicine, University of California, San Francisco.
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Rocha AL, Oliveira SR, Souza AF, Travassos DV, Abreu LG, Ribeiro DD, Silva TA. Bleeding assessment in oral surgery: A cohort study comparing individuals on anticoagulant therapy and a non-anticoagulated group. J Craniomaxillofac Surg 2019; 47:798-804. [PMID: 30792032 DOI: 10.1016/j.jcms.2019.01.049] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 01/15/2019] [Accepted: 01/31/2019] [Indexed: 01/19/2023] Open
Abstract
Some prospective studies have been designed specifically to investigate perioperative bleeding in dental surgery. The quantitative assessment of intraoperative blood loss can be useful for indicating the real risk of bleeding complications, especially in medically compromised individuals. The aim of this study was to evaluate the pattern of bleeding in individuals under vitamin K antagonist (VKA) therapy and non-anticoagulated individuals submitted to dental extractions. Perioperative bleeding was evaluated by using a total collected bleeding corrected by absorbance reading (dental bleeding score). 138 procedures were performed. When the perioperative dental bleeding score was correlated with the number of extracted teeth, the quantity of bleeding was found to be directly proportional to the procedure. Extractions of two or more teeth presented higher scores than single extractions (p = 0.003). In a comparative analysis between the VKA and non-anticoagulated groups, no significant difference in the scores was found. The previous history of complications in dental procedures (p = 0.001) and the use of additional hemostatic measures were higher in the VKA group (p = 0.017). VKA therapy did not impact significantly the volume of blood lost during dental extractions. Perioperative bleeding assessment might be a useful parameter for evaluating patients under antithrombotic treatment.
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Affiliation(s)
- Amanda Leal Rocha
- Department of Oral Surgery and Pathology, Faculty of Dentistry, Universidade Federal de Minas Gerais, Minas Gerais, Brazil
| | - Sicilia Rezende Oliveira
- Department of Oral Surgery and Pathology, Faculty of Dentistry, Universidade Federal de Minas Gerais, Minas Gerais, Brazil
| | - Alessandra Figueiredo Souza
- Department of Oral Surgery and Pathology, Faculty of Dentistry, Universidade Federal de Minas Gerais, Minas Gerais, Brazil
| | - Denise Vieira Travassos
- Department of Community and Preventive Dentistry, Faculty of Dentistry, Universidade Federal de Minas Gerais, Minas Gerais, Brazil
| | - Lucas Guimarães Abreu
- Department of Pediatric Dentistry and Orthodontics, Faculty of Dentistry, Universidade Federal de Minas Gerais, Minas Gerais, Brazil
| | - Daniel Dias Ribeiro
- Department of Hematology, Faculty of Medicine, Universidade Federal de Minas Gerais, Minas Gerais, Brazil
| | - Tarcília Aparecida Silva
- Department of Oral Surgery and Pathology, Faculty of Dentistry, Universidade Federal de Minas Gerais, Minas Gerais, Brazil.
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Saksena D, Mishra YK, Muralidharan S, Kanhere V, Srivastava P, Srivastava CP. Follow-up and management of valvular heart disease patients with prosthetic valve: a clinical practice guideline for Indian scenario. Indian J Thorac Cardiovasc Surg 2019; 35:3-44. [PMID: 33061064 PMCID: PMC7525528 DOI: 10.1007/s12055-019-00789-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
PURPOSE Valvular heart disease (VHD) patients after prosthetic valve implantation are at risk of thromboembolic events. Follow-up care of patients with prosthetic valve has a paramount role in reducing the morbidity and mortality. Currently, in India, there is quintessential need to stream line the follow-up care of prosthetic valve patients. This mandates the development of a consensus guideline for the antithrombotic therapy in VHD patients post prosthetic valve implantation. METHODS A national level panel was constituted comprising 13 leading cardio care experts in India who thoroughly reviewed the up to date literature, formulated the recommendations, and developed the consensus document. Later on, extensive discussions were held on this draft and the recommendations in 8 regional meetings involving 79 additional experts from the cardio care in India, to arrive at a consensus. The final consensus document is developed relying on the available evidence and/or majority consensus from all the meetings. RESULTS The panel recommended vitamin K antagonist (VKA) therapy with individualized target international normalized ratio (INR) in VHD patients after prosthetic valve implantation. The panel opined that management of prosthetic valve complications should be personalized on the basis of type of complications. In addition, the panel recommends to distinguish individuals with various co-morbidities and attend them appropriately. CONCLUSIONS Anticoagulant therapy with VKA seems to be an effective option post prosthetic valve implantation in VHD patients. However, the role for non-VKA oral therapy in prosthetic valve patients and the safety and efficacy of novel oral anticoagulants in patients with bioprosthetic valve need to be studied extensively.
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Local haemostatic measures after tooth removal in patients on antithrombotic therapy: a systematic review. Clin Oral Investig 2018; 23:1695-1708. [PMID: 30155575 DOI: 10.1007/s00784-018-2576-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 08/13/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The interruption of antithrombotics prior to tooth removal because of the fear of bleeding or following postoperative bleeding increases the risk of thromboembolic events. The aim of this systematic review was to investigate which local haemostatic measures can effectively prevent postoperative bleeding in patients continuing oral antithrombotics. METHODS A systematic review was conducted by running a search in PubMed, Embase, Web of Science and Cochrane Library. Clinical randomised trials investigating bleeding and haemostatics after tooth removal in patients on antithrombotics were identified. RESULTS In total, 15 articles were included. The investigated haemostatics included gauze pressure, tranexamic acid-soaked gauze, sponges, glue, calcium sulfate, plant extract Ankaferd Blood Stopper, epsilon-aminocaproic acid and tranexamic acid. In patients treated with vitamin K antagonists, tranexamic acid mouthwash significantly reduced bleeding compared to placebo. Further, histoacryl glue was proven better than gelatin sponges. Other studies failed to show significant differences between haemostatics, but bleeding events were low. CONCLUSIONS Tranexamic acid seems to effectively reduce bleeding, although its superiority to other haemostatics was not proven. In view of the rapidly changing landscape of antithrombotics and the lack of standardization of bleeding outcome, adequately powered clinical studies are required to optimise postoperative management in patients on antithrombotics. CLINICAL RELEVANCE In order to optimise postoperative management, the best haemostatics over different patient groups have to be identified and implemented in guidelines.
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Li L, Zhang W, Yang Y, Zhao L, Zhou X, Zhang J. Dental management of patient with dual antiplatelet therapy: a meta-analysis. Clin Oral Investig 2018; 23:1615-1623. [PMID: 30145662 DOI: 10.1007/s00784-018-2591-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 08/20/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND It is more common to need dual antiplatelet therapy (DAPT) for patients who had recently inserted coronary artery stent. However, the postoperative bleeding risk of patients in DAPT could significantly increase. The dental management of patients with antithrombotic therapy has always been a controversial problem. Focusing on this issue, this review discussed the available evidence to provide optimal strategy for patients taking dual antiplatelet agents in the dental setting. METHODS We searched the PubMed, Embase, ScienceDirect, Web of Science (WOS), Cochrane Library, and China National Knowledge Infrastructure (CNKI) which was performed in May 2018. Relevant articles were included according to our inclusion and exclusion criteria. Meta-analysis was conducted with fixed effects models. Subgroup analysis was used due to different dental surgeries. RESULTS Our meta-analysis included ten studies (continue DAPT vs. placebo, 535 patients vs.2907 patients). The quantitative results indicated that the risk of postoperative bleeding with continuing DAPT experienced significantly increase (RR = 1.95 95% CI [1.07, 3.54]; p = 0.03). There was no statistically significant difference between the postoperative bleeding rate and different dental surgeries (p = 0.72). CONCLUSION On the current studies, postoperative hemorrhage is exacerbated with DAPT, but it could be controlled by enhancing hemostasis methods. We recommend continuing long-term DAPT before tooth extraction. CLINICAL RELEVANCE In this work, we systematically evaluated and summarized the results of small clinical trials after reviewing the present literatures on this topic, so that we could propose more objective and more accurate evidence-based recommendations on dental management for patient with dual antiplatelet therapy.
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Affiliation(s)
- Lin Li
- Dental Student, School and Hospital of Stomatology, Tianjin Medical University, Tianjin, China
| | - Wenyi Zhang
- Department of Prosthodontics, Hospital of Stomatology, Tianjin Medical University, Tianjin, China
| | - Yun Yang
- Dental Student, School and Hospital of Stomatology, Tianjin Medical University, Tianjin, China
| | - Liyuan Zhao
- Dental Student, School and Hospital of Stomatology, Tianjin Medical University, Tianjin, China
| | - Xinyao Zhou
- Dental Student, School and Hospital of Stomatology, Tianjin Medical University, Tianjin, China
| | - Jian Zhang
- Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Tianjin Medical University, Tianjin, China.
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Dézsi CA, Dézsi BB, Dézsi AD. Management of dental patients receiving antiplatelet therapy or chronic oral anticoagulation: A review of the latest evidence. Eur J Gen Pract 2018; 23:196-201. [PMID: 28743214 PMCID: PMC5774272 DOI: 10.1080/13814788.2017.1350645] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The perioperative management of patients treated with antithrombotic medications who undergo surgical procedures represents a common clinical problem. Dental interventions are usually associated with a low risk of bleeding; however, the dental implications of new antithrombotic agents are not yet fully understood. The present review is based on the latest evidence and recommendations published on the periprocedural management of dental patients treated with single or dual antiplatelet therapy, vitamin K antagonists, or direct oral anticoagulants for a variety of indications.
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Affiliation(s)
- Csaba András Dézsi
- a Department of Cardiology , Petz Aladár County Teaching Hospital , Győr , Hungary
| | | | - András Döme Dézsi
- c Department of Cardiology , State Hospital for Cardiology , Balatonfüred , Hungary
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Zirk M, Zinser M, Buller J, Bilinsky V, Dreiseidler T, Zöller JE, Kreppel M. Supportive topical tranexamic acid application for hemostasis in oral bleeding events – Retrospective cohort study of 542 patients. J Craniomaxillofac Surg 2018; 46:932-936. [DOI: 10.1016/j.jcms.2018.03.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 02/14/2018] [Accepted: 03/13/2018] [Indexed: 12/26/2022] Open
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Tranexamic acid as a local hemostasis method after dental extraction in patients on warfarin: a randomized controlled clinical study. Clin Oral Investig 2018; 22:2281-2289. [DOI: 10.1007/s00784-017-2327-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 12/21/2017] [Indexed: 10/18/2022]
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Youness HA, Keddissi J, Berim I, Awab A. Management of oral antiplatelet agents and anticoagulation therapy before bronchoscopy. J Thorac Dis 2017; 9:S1022-S1033. [PMID: 29214062 DOI: 10.21037/jtd.2017.05.45] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Although, bronchoscopy is a relatively safe procedure, small amount of bleeding in the airway can have serious consequences. Careful consideration of the risks of diagnostic and therapeutic bronchoscopic intervention can help minimize potential complications. With increasing number of patients using antiplatelet and anticoagulation therapies, strategies for minimizing thromboembolic and operative bleeding events need to be included in the risk and benefit analyses. Growing evidence suggests that aspirin is safe and does not increase bleeding during bronchoscopy. In addition, despite small studies reporting that it may be safe to perform bronchoscopic procedures that have low risk for bleeding such as endobronchial ultrasound with transbronchial needle aspiration on clopidogrel, it is still recommended to hold it for 7 days prior to performing elective bronchoscopy. It is recommended to hold vitamin K antagonist, as well as new oral anticoagulation agents prior to bronchoscopy. The timing for pre-procedural discontinuation of anticoagulation therapy and the decision to bridge depend on the agent used, the renal function and the thromboembolic risk. In this review article, we will discuss available data regarding management of anticoagulation and antiplatelet therapy as it applies to bronchoscopic procedures.
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Affiliation(s)
- Houssein A Youness
- Department of Medicine, Section of Pulmonary Diseases, Critical Care and Sleep Medicine, University of Oklahoma Health Sciences Center, OK, USA
| | - Jean Keddissi
- Department of Medicine, Section of Pulmonary Diseases, Critical Care and Sleep Medicine, University of Oklahoma Health Sciences Center, OK, USA
| | - Ilya Berim
- Department of Medicine, Section of Pulmonary Diseases, Critical Care and Sleep Medicine, Creighton University, NE, USA
| | - Ahmed Awab
- Department of Medicine, Section of Pulmonary Diseases, Critical Care and Sleep Medicine, University of Oklahoma Health Sciences Center, OK, USA
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Bleeding Rate After Tooth Extraction in Patients Under Oral Anticoagulant Therapy. J Craniofac Surg 2017; 27:1228-33. [PMID: 27380567 DOI: 10.1097/scs.0000000000002713] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES The aim of this single-cohort prospective study was to evaluate the risk of adverse outcomes after tooth extraction in patients suffering from cardiovascular disorders and under oral anticoagulant therapy with an international normalized ratio within the value of 3.0. METHODS Two hundred ninety-three patients (mean age of 58.7 years) were enrolled and 560 tooth extractions were performed. Fresh extraction sockets were treated with collagen tablets and sutures. The risk of increased bleeding rate was evaluated for type of drug therapy (acenocoumarol or warfarin), type of cardiovascular diseases, and number of tooth extractions. Level of significance was set at 0.05. RESULTS The overall bleeding event rate was 6.8%. Among patients who had bleeding events, 4 suffered from valvular disorders, whereas 11 suffered from arrhythmias (8) or cardiomyopathies (3). The remaining 5 patients had a history of cardiomyopathy and arrhythmia.The bleeding events in patients who had more than 2 tooth extractions were significantly higher than those observed in patients who had only 1 tooth extraction (P <0.05). CONCLUSION Patients who received more than 2 tooth extractions, who were under treatment with acenocoumarol, and who suffered from multiple cardiovascular diseases were at high risk for bleeding events.
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Wamala H, Scott IA, Caney X. Perioperative management of new oral anticoagulants in patients undergoing elective surgery at a tertiary hospital. Intern Med J 2017; 47:1412-1421. [PMID: 28589690 DOI: 10.1111/imj.13513] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 03/10/2017] [Accepted: 06/01/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Increasing numbers of patients receiving new oral anticoagulants (NOAC) are undergoing elective surgery. The extent to which perioperative interruption of NOAC therapy and use of bridging heparin are concordant with best evidence is uncertain. AIMS To determine: (i) concordance of NOAC and bridging heparin use with guidelines; and (ii) associations between guideline concordance and patient characteristics, surgical factors and perioperative adverse events. METHODS Retrospective study of consecutive adult patients undergoing elective surgery at a tertiary hospital between 1 January 2014 and 30 June 2015 and were receiving NOAC for at least 3 months prior to surgery. Concordance of perioperative anticoagulation management with hospital guidelines was rated by two independent researchers according to explicit thrombosis and bleeding risk tables. RESULTS One hundred and fifty patients of mean (±SD) age 72.0 (±11.6) years were studied; 75% had atrial fibrillation as NOAC indication. Decision to interrupt anticoagulation in 142 patients was rated guideline-concordant in 59 (41.5%) based on low bleeding risk in all cases and high thrombotic risk in one-third. Concordant decisions were associated with past myocardial infarction (P = 0.009), chronic kidney disease (P = 0.05), use of dabigatran (P = 0.06) and major surgery (P < 0.001). Bridging heparin was prescribed in 51 (35.9%) patients and not prescribed in 91 (64.1%), with 64 (45.1%) decisions rated guideline-discordant comprising 27 decisions to prescribe and 37 not to prescribe. Guideline concordant bridging was associated with chronic kidney disease (P = 0.02); discordant bridging with use of dabigatran (P = 0.04), high thrombotic risk (P = 0.004), past ischaemic stroke (P = 0.07). At 30 days, only one adverse event (major bleed) was noted. CONCLUSION Considerable discordance exists between guideline recommendations and perioperative NOAC management. Assistive tools are required that better align decision-making with current best practice.
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Affiliation(s)
- Henry Wamala
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Ian A Scott
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Xenia Caney
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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Halaszynski TM. Administration of Coagulation-Altering Therapy in the Patient Presenting for Oral Health and Maxillofacial Surgery. Oral Maxillofac Surg Clin North Am 2016; 28:443-460. [PMID: 27745616 DOI: 10.1016/j.coms.2016.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Oral health care providers are concerned with how to manage patients prescribed coagulation-altering therapy during the perioperative/periprocedural period for dental and oral surgery interventions. Management and recommendation can be based on medication pharmacology and the clinical relevance of coagulation factor levels/deficiencies. Caution should be used with concurrent use of medications that affect other components of the clotting mechanisms; prompt diagnosis and any necessary intervention to optimize outcome is warranted. However, evidence-based data on management of anticoagulation therapy during oral and maxillofacial surgery/interventions is lacking. Therefore, clinical understanding and judgment are needed along with appropriate guidelines matching patient- and intervention-specific recommendations.
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Affiliation(s)
- Thomas M Halaszynski
- Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, TMP 3 Library, New Haven, CT 203 785-2804, USA.
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Zirk M, Fienitz T, Edel R, Kreppel M, Dreiseidler T, Rothamel D. Prevention of post-operative bleeding in hemostatic compromised patients using native porcine collagen fleeces-retrospective study of a consecutive case series. Oral Maxillofac Surg 2016; 20:249-54. [PMID: 27139018 DOI: 10.1007/s10006-016-0560-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 04/25/2016] [Indexed: 04/16/2023]
Abstract
INTRODUCTION Various anticoagulant therapy regimes bear the risk of postsurgical bleeding events after dental extractions. Local hemostyptic measures, e.g., collagen fleeces, are applied by surgeons to prevent such bleedings. No standard protocol in prevention of bleeding events has met general acceptance among surgeons yet. PURPOSE The purpose of this retrospective study was to determine if post-operative bleeding can be prevented by suturing native collagen fleeces into extraction wounds immediately after teeth removal, regardless what anticoagulant regime is performed. METHODS A total of 741 extraction units were removed from 200 consecutive in-ward patients with or without alternation of different anticoagulant therapy regimes. Anti-vitamin K agents were the most prescribed drugs (n = 104, 52 %), followed by Acetylsalicylate (ASS) (n = 78, 39 %). Nineteen (9.5 %) patients received a dual anti-platelet therapy. Out of 104 patients receiving an anti-vitamin K agent (phenprocoumon), 84 patients were bridged, 20 patients continued to their anticoagulant therapy without alterations. Following careful tooth extraction, extraction sockets were filled using a native type I and III porcine collagen sponge (Collacone, Botiss Biomaterials, Berlin), supported by single and mattress sutures for local hemostasis. Post-operative bleeding events were rated according to their clinical relevance. RESULTS In the post-operative phase, 8 out of 200 consecutively treated patients experienced a post-operative bleeding event. All of them had been designated for a long-term anti-vitamin K therapy (p ≤ 0.05), and extractions were performed under a heparin bridging regime (n = 6) or an uninterrupted anti-vitamin K agent therapy (n = 2). No bleeding events occurred in patients with ASS 100 therapy or low-dose LMWH therapy (p ≤ 0.05), or in patients with dual anti-platelet therapy (0 out of 24). None of the bleeding events put patients' health at risk or required systemic intervention. CONCLUSION Sufficiently performed local hemostyptic measures, like the application of collagen fleeces in combination with atraumatic surgery, bears a great potential for preventing heavy bleeding events in hemostatic compromised patients, regardless of their anticoagulant therapy.
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Affiliation(s)
- Matthias Zirk
- Department of Craniomaxillofacial and Plastic Surgery, University of Cologne, Kerpener Strasse 62, 50931, Cologne, Germany.
| | - Tim Fienitz
- Department of Craniomaxillofacial and Plastic Surgery, University of Cologne, Kerpener Strasse 62, 50931, Cologne, Germany
| | - Robin Edel
- Department of Craniomaxillofacial and Plastic Surgery, University of Cologne, Kerpener Strasse 62, 50931, Cologne, Germany
| | - Matthias Kreppel
- Department of Craniomaxillofacial and Plastic Surgery, University of Cologne, Kerpener Strasse 62, 50931, Cologne, Germany
| | - Timo Dreiseidler
- Department of Craniomaxillofacial and Plastic Surgery, University of Cologne, Kerpener Strasse 62, 50931, Cologne, Germany
| | - Daniel Rothamel
- Department of Craniomaxillofacial and Plastic Surgery, University of Cologne, Kerpener Strasse 62, 50931, Cologne, Germany
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Yang S, Shi Q, Liu J, Li J, Xu J. Should oral anticoagulant therapy be continued during dental extraction? A meta-analysis. BMC Oral Health 2016; 16:81. [PMID: 27566540 PMCID: PMC5002166 DOI: 10.1186/s12903-016-0278-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 08/12/2016] [Indexed: 01/24/2023] Open
Abstract
Background Oral anticoagulation therapy is widely used to reduce the risks of thromboembolism. However, the therapy increases the risk of hemorrhage during the surgical procedures. The aim of this meta-analysis was to evaluate the bleeding risk of patients continuing or discontinuing oral anticoagulant therapy while undergoing dental extractions. Methods Six electronic databases, including PubMed, Embase, Cochrane library, Web of Science, China Biology Medicine disc (CBM), and China National Knowledge Infrastructure (CNKI), were searched in March, 2016. Relevant articles were screened by two independent reviewers under our inclusion criteria. Quality was evaluated using the Cochrane Collaboration risk of bias tool. Meta-analyses were conducted with fixed and random effects models as appropriate. Results Six studies (with a total of 591 patients) were included in our meta-analysis. Our results showed that there was no significant difference in the bleeding risk between patients continuing or discontinuing oral anticoagulant therapy while undergoing dental extractions (risk ratio, 1.31; 95 % CI, 0.79, 2.14; P > 0.05). There was also no significant difference in bleeding risk 1 day (risk ratio, 0.91; 95 % CI, 0.35, 2.37; P > 0.05) and 7 days (risk ratio, 1.47; 95 % CI, 0.83, 2.59; P > 0.05) after the dental extraction. Conclusion Under current studies and evidence, it appears that patients continuing oral anticoagulant therapy do not have an increased risk of bleeding after dental extractions compared to patients who discontinue oral anticoagulant therapy.
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Affiliation(s)
- Shuo Yang
- Department of Stomatology, Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Quan Shi
- Department of Stomatology, Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Jinglong Liu
- Department of Stomatology, Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Jinru Li
- Department of Stomatology, Chinese People's Liberation Army 322 Hospital, 2 Yunzhong Road, Datong, 037000, China
| | - Juan Xu
- Department of Stomatology, Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Beijing, 100853, China.
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Flaker GC, Theriot P, Binder LG, Dobesh PP, Cuker A, Doherty JU. Management of Periprocedural Anticoagulation. J Am Coll Cardiol 2016; 68:217-26. [DOI: 10.1016/j.jacc.2016.04.042] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 04/05/2016] [Accepted: 04/12/2016] [Indexed: 10/21/2022]
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Palomäki A, Kiviniemi T, Hartikainen JEK, Mustonen P, Ylitalo A, Nuotio I, Hartikainen P, Jaakkola J, Luite R, Airaksinen KEJ. Postoperative Strokes and Intracranial Bleeds in Patients With Atrial Fibrillation: The FibStroke Study. Clin Cardiol 2016; 39:471-6. [PMID: 27240121 DOI: 10.1002/clc.22554] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Revised: 04/15/2016] [Accepted: 04/15/2016] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Patients with atrial fibrillation (AF) frequently undergo invasive procedures. Optimal perioperative use of oral anticoagulation (OAC) and heparin bridging is not well defined. HYPOTHESIS Discontinuation of OAC for minor procedures/operations places AF patients at risk for thromboembolism. METHODS In this study, we assessed perioperative antithrombotic treatment in patients with AF who suffered a postoperative stroke or intracranial bleeding. The FibStroke Study includes AF patients with an ischemic stroke or intracranial bleed identified from the discharge registries of 4 Finnish hospitals. In total, 3632 consecutive patients developed 3252 ischemic strokes and 794 intracranial bleeds. All invasive procedures during the 30 days preceding the stroke or intracranial bleed were identified. RESULTS A total of 194/3252 (6.0%) ischemic strokes and 23/794 (2.9%) intracranial bleeds were preceded by a procedure. Altogether, 69% of the patients were on OAC prior to index procedure, OAC was interrupted in 81.2% of the procedures preceding a stroke, and heparin bridging was used in 27.8% of interruptions. Of the procedures leading to stroke, 42.3% were low-bleeding-risk procedures, and OAC was interrupted in 84.7% of these procedures. The median time from procedure to stroke was 4 days. Heparin bridging was used in 54.5% of OAC interruptions preceding intracranial bleeding and combination of anticoagulation with antiplatelet therapy by 43.5% of patients with postoperative intracranial bleeding. CONCLUSIONS Perioperative interruption of OAC is common in patients who suffer a postoperative stroke, even in patients with low-bleeding-risk procedures. Postoperative intracranial bleeding is frequently preceded by perioperative heparin bridging.
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Affiliation(s)
- Antti Palomäki
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Tuomas Kiviniemi
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Pirjo Mustonen
- Department of Medicine, Keski-Suomi Central Hospital, Jyväskylä, Finland
| | - Antti Ylitalo
- Heart Center, Satakunta Central Hospital, Pori, Finland
| | - Ilpo Nuotio
- Department of Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - Päivi Hartikainen
- Heart Center, Kuopio University Hospital, Kuopio, Finland.,NeuroCenter, Neurology Department, Kuopio University Hospital, Kuopio, Finland
| | - Jussi Jaakkola
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Riho Luite
- Heart Center, Kuopio University Hospital, Kuopio, Finland
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Sadeghi-Ghahrody M, Yousefi-Malekshah SH, Karimi-Sari H, Yazdanpanah H, Rezaee-Zavareh MS, Yavarahmadi M. Bleeding after tooth extraction in patients taking aspirin and clopidogrel (Plavix®) compared with healthy controls. Br J Oral Maxillofac Surg 2016; 54:568-72. [PMID: 26975576 DOI: 10.1016/j.bjoms.2016.02.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 02/29/2016] [Indexed: 01/22/2023]
Abstract
The risk of perioperative bleeding is high in patients who take aspirin and clopidogrel after a percutaneous coronary intervention, and whether to stop the drugs is a matter of concern for dentists. The aim of this study was to answer the specific question: should aspirin and clopidogrel bisulphate (Plavix®) be discontinued during a conventional forceps extraction? We studied 64 patients during the first year after percutaneous insertion of coronary stents who were taking aspirin (ASA) 80mg and clopidogrel (Plavix(®)) 75mg, and 50 healthy patients who were to have a conventional forceps extraction at this polyclinic in 2013-2014 and acted as controls. Clinical details (underlying diseases; number of roots; type of tooth; type of haemostasis; and bleeding immediately, 30minutes, and 48hours after intervention) were compared. We evaluated 114 patients with the mean (range) age of 56 (43-76) years, and there were no significant differences in demographic data, underlying diseases, type of tooth, number of roots, and dose of anaesthetic between the groups. There were also no significant differences in the number of bleeds immediately and 30minutes after intervention (P=0.310 and 0.205). The time that the last dose of aspirin had been taken correlated with 30-minute haemostasis (20 compared with 12hours, p=0.037). During the 48hours after the intervention, there were no uncontrolled bleeds or emergency referrals. We conclude that using aspirin and Plavix® simultaneously has no considerable effect on the risk of bleeding in patients having conventional forceps extraction of a single tooth.
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Affiliation(s)
- Mohsen Sadeghi-Ghahrody
- Atherosclerosis Research Center, Faculty of Medicine, Baqiyatallah University of Medical Sciences, Tehran, IR-Iran
| | | | - Hamidreza Karimi-Sari
- Students' Research Committee, Baqiyatallah University of Medical Sciences, Tehran, IR-Iran.
| | - Hamid Yazdanpanah
- Atherosclerosis Research Center, Faculty of Medicine, Baqiyatallah University of Medical Sciences, Tehran, IR-Iran
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Rechenmacher SJ, Fang JC. Bridging Anticoagulation: Primum Non Nocere. J Am Coll Cardiol 2016; 66:1392-403. [PMID: 26383727 DOI: 10.1016/j.jacc.2015.08.002] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 08/03/2015] [Indexed: 12/17/2022]
Abstract
Chronic oral anticoagulation frequently requires interruption for various reasons and durations. Whether or not to bridge with heparin or other anticoagulants is a common clinical dilemma. The evidence to inform decision making is limited, making current guidelines equivocal and imprecise. Moreover, indications for anticoagulation interruption may be unclear. New observational studies and a recent large randomized trial have noted significant perioperative or periprocedural bleeding rates without reduction in thromboembolism when bridging is employed. Such bleeding may also increase morbidity and mortality. In light of these findings, physician preferences for routine bridging anticoagulation during chronic anticoagulation interruptions may be too aggressive. More randomized trials, such as PERIOP2 (A Double Blind Randomized Control Trial of Post-Operative Low Molecular Weight Heparin Bridging Therapy Versus Placebo Bridging Therapy for Patients Who Are at High Risk for Arterial Thromboembolism), will help guide periprocedural management of anticoagulation for indications such as venous thromboembolism and mechanical heart valves. In the meantime, physicians should carefully consider both the need for oral anticoagulation interruption and the practice of routine bridging when anticoagulation interruption is indicated.
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Affiliation(s)
- Stephen J Rechenmacher
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah.
| | - James C Fang
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah
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Management of Antithrombotic Agents in Oral Surgery Maria Martinez and Dimitrios A. Tsakiris. Dent J (Basel) 2015; 3:93-101. [PMID: 29567929 PMCID: PMC5851192 DOI: 10.3390/dj3040093] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 09/13/2015] [Accepted: 09/23/2015] [Indexed: 11/17/2022] Open
Abstract
Systemic anticoagulation with intravenous or oral anticoagulants and antiplatelet agents is an efficient treatment against thromboembolic or cardiovascular disease. Invasive dental procedures or oral surgery might be associated with bleeding complications if carried out under anticoagulants. Patients on vitamin K antagonists, new direct anticoagulants or antiplatelet agents having dental interventions with low-risk for bleeding do not need interruption of anticoagulation. In case of bleeding complications local hemostatic measures, such as local surgical sutures, fibrin glue, local antifibrinolytic treatment with tranexamic acid, or e-aminocaproic acid suffice to stop bleeding. In patients with high risk of bleeding an individual assessment of the benefit/risk ratio of interrupting anticoagulation should be carried out. Bridging the long-term anticoagulation with short-term anticoagulants should be planned according to national or international guidelines. The introduction of the newer direct oral anticoagulants having more flexible pharmacokinetic properties has facilitated bridging, allowing short-term interruption without increasing the risk of relapsing thrombotic or cardiovascular events.
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Erden İ, Çakcak Erden E, Aksu T, Gölcük ŞE, Turan B, Erkol A, Akçakoyun M, Sayın T. Comparison of uninterrupted warfarin and bridging therapy using low-molecular weight heparin with respect to the severity of bleeding after dental extractions in patients with prosthetic valves. Anatol J Cardiol 2015; 16:467-473. [PMID: 26645263 PMCID: PMC5331392 DOI: 10.5152/anatoljcardiol.2015.6130] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective: The management of anticoagulated patients with warfarin during dental extraction is an intricate issue. We carefully designed the current study so that the amount of bleeding was measured with objective methods and the data from the same patient in different dental extraction appointments could be compared, eliminating the bleeding diathesis differences of patients. Methods: This prospective and controlled study was conducted in 36 adult patients with prosthetic valve requiring multiple tooth extractions. The first dental extraction was performed without the discontinuation of warfarin therapy, and the second procedure was performed with a discontinuation of warfarin and bridging with low-molecular weight heparin (LMWH). The two dental extraction protocols in the same patient group were compared. The total amount of bleeding was calculated as the difference between the weights of gauze swabs used before and after the tamponade; the number of gauze swabs used for bleeding control in the first 48 h was recorded. Result: The median number of used gauze swabs was 2.5 (IQR: 1–5) and 3.0 (IQR: 2–7) in the first and second dental extraction procedures, respectively. The median bleeding time was 50.0 (IQR: 20–100) in the first procedure compared with 60.0 (IQR: 40–140) min in the second procedure. The mean amounts of bleeding were 2194±1418 mg in the first dental extraction procedure and 2950±1694 mg in the second dental extraction procedure. The median number of used gauze swabs, the median bleeding time, and the mean amount of bleeding were statistically higher in the second dental extraction procedure (p<0.001). Conclusion: Continued warfarin treatment at the time of dental extractions reduces the total amount of bleeding compared with bridging therapy in patients with prosthetic valves.
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Affiliation(s)
- İsmail Erden
- Department of Cardiology, Kocaeli Derince Training and Research Hospital; Kocaeli-Turkey.
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Bajkin BV, Vujkov SB, Milekic BR, Vuckovic BA. Risk factors for bleeding after oral surgery in patients who continued using oral anticoagulant therapy. J Am Dent Assoc 2015; 146:375-81. [DOI: 10.1016/j.adaj.2015.01.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 01/15/2015] [Accepted: 01/18/2015] [Indexed: 01/24/2023]
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Jimson S, Amaldhas J, Jimson S, Kannan I, Parthiban J. Assessment of bleeding during minor oral surgical procedures and extraction in patients on anticoagulant therapy. J Pharm Bioallied Sci 2015; 7:S134-7. [PMID: 26015691 PMCID: PMC4439651 DOI: 10.4103/0975-7406.155862] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 10/31/2014] [Accepted: 11/09/2014] [Indexed: 11/21/2022] Open
Abstract
Introduction: The risk of postoperative hemorrhage from oral surgical procedures has been a concern in the treatment of patients who are receiving long-term anticoagulation therapy. A study undertaken in our institution to address questions about the amount and severity of bleeding associated with minor outpatient oral surgery procedures by assessing bleeding in patients who did not alter their anticoagulant regimen. Subjects and Methods: Eighty-three patients receiving long-term anticoagulant therapy visited Department of Oral and Maxillofacial Surgery from May 2010 to October 2011 for extractions and minor oral surgical procedures. Each patient was required to undergo preoperative assessment of prothrombin time (PT) and measurement of the international normalized ratio. Fifty-six patients with preoperative PT values within the therapeutic range 3–4 were included in the study. The patients’ age ranged between 30 and 75 years. Application of surgispon was done following the procedure. Extraction of teeth performed with minimal trauma to the surrounding tissues, the socket margins sutured, and sutures removed after 5 days. Results: There was no significant incidence of prolonged or excessive hemorrhage and wound infection and the healing process was normal.
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Affiliation(s)
- S Jimson
- Department of Oral and Maxillofacial Surgery, Bharath University, Tagore Dental College and Hospital, Chennai, Tamil Nadu, India
| | - Julius Amaldhas
- Department of Biochemistry, Sree Balaji Dental College and Hospital, Chennai, Tamil Nadu, India
| | - Sudha Jimson
- Department of Oral and Maxillofacial Pathology, Bharath University, Sree Balaji Dental College and Hospital, Chennai, Tamil Nadu, India
| | - I Kannan
- Department of Microbiology Tagore Dental College and Hospital, Chennai, Tamil Nadu, India
| | - J Parthiban
- Department of Oral and Maxillofacial Surgery, Tagore Dental College and Hospital, Chennai, Tamil Nadu, India
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Sporbeck B, Bechara FG, Häfner HM, Koenen W, Kolk A, Koscielny J, Meissner M, Pokrywka A, Schirmer S, Strömer K, Löser C, Nast A. S3-Leitlinie zum Umgang mit Antikoagulation bei Operationen an der Haut. J Dtsch Dermatol Ges 2015. [DOI: 10.1111/ddg.12576_suppl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Birte Sporbeck
- Division of Evidence Based Medicine, Charité - Universitätsmedizin Berlin
| | | | | | | | - Andreas Kolk
- Klinik und Poliklinik für Mund-, Kiefer- und Gesichtschirurgie, Klinikum rechts der Isar, Technische Universität München
| | - Jürgen Koscielny
- Institut für Transfusionsmedizin, Charité - Universitätsmedizin Berlin
| | - Markus Meissner
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Frankfurt
| | - Anna Pokrywka
- Klinik für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin
| | - Steffen Schirmer
- Klinik für Plastische, Wiederherstellungs- und Ästhetische Chirurgie - Handchirurgie, Klinikum Bielefeld Mitte
| | - Klaus Strömer
- Niedergelassene Dermatologe, Gemeinschaftspraxis Dr. Strömer / Deden, Mönchengladbach
| | - Christoph Löser
- Hautklinik, Hauttumorzentrum, Klinikum der Stadt Ludwigshafen am Rhein gGmbH
| | - Alexander Nast
- Division of Evidence Based Medicine, Charité - Universitätsmedizin Berlin
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Sporbeck B, Georges Bechara F, Häfner HM, Koenen W, Kolk A, Koscielny J, Meissner M, Pokrywka A, Schirmer S, Strömer K, Löser C, Nast A. S3 guidelines for the management of anticoagulation in cutaneous surgery. J Dtsch Dermatol Ges 2015; 13:346-56. [PMID: 25819254 DOI: 10.1111/ddg.12576] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND An increasing number of patients are being treated with anticoagulants and platelet inhibitors. Whenever surgical procedures of the skin are required, questions arise regarding the perioperative management of anticoagulation. METHODS Development of S3 guidelines following the requirements of the Association of Scientific Medical Societies, systematic literature search and analysis, use of GRADE methodology, structured consensus conference using a nominal group process. RESULTS During cutaneous surgery, treatment with acetylsalicylic acid (ASA) should be continued if medically necessary. In procedures with a higher risk of bleeding and a positive bleeding history, INR should be determined preoperatively. Surgical procedures of the skin with a higher risk of bleeding should not be performed if the INR is above therapeutic range. Bridging from vitamin K antagonists (VKA) to heparin should not be performed just because of the surgery of the skin. As to direct-acting oral anticoagulants, the last dose should be taken 24 h preoperatively. CONCLUSIONS The recommendations issued by the German guidelines group are mostly in line with recommendations provided by other guidelines. The American ìChest-Guidelineì recommends continuing VKAs and acetylsalicylic acid during minor dermatologic procedures. In their guidelines, the German College of General Practitioners and Family Physicians considers an INR of 2 to be adequate in surgical procedures on the skin.
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Affiliation(s)
- Birte Sporbeck
- Division of Evidence Based Medicine, Charité - Universitätsmedizin Berlin
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Dental surgery in anticoagulated patients—stop the interruption. Oral Surg Oral Med Oral Pathol Oral Radiol 2015; 119:136-57. [DOI: 10.1016/j.oooo.2014.10.011] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 09/06/2014] [Accepted: 10/15/2014] [Indexed: 01/12/2023]
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Iwabuchi H, Imai Y, Asanami S, Shirakawa M, Yamane GY, Ogiuchi H, Kurashina K, Miyata M, Nakao H, Imai H. Evaluation of postextraction bleeding incidence to compare patients receiving and not receiving warfarin therapy: a cross-sectional, multicentre, observational study. BMJ Open 2014; 4:e005777. [PMID: 25510886 PMCID: PMC4267073 DOI: 10.1136/bmjopen-2014-005777] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES We investigated incidence and risk factors for postextraction bleeding in patients receiving warfarin and those not receiving anticoagulation therapy. DESIGN Cross-sectional, multicentre, observational study. SETTING 26 hospitals where an oral surgeon is available. PARTICIPANTS Data on 2817 teeth (from 496 patients receiving warfarin, 2321 patients not receiving warfarin; mean age (SD): 62.2 (17.6)) extracted between 1 November 2008 and 31 March 2010, were collected. Warfarin-receiving patients were eligible when prothrombin time-international normalised ratio (PT-INR) measured within 7 days prior to the extraction was less than 3.0. INTERVENTIONS Simple dental extraction was performed, and incidence of postextraction bleeding and comorbidities were recorded. PRIMARY AND SECONDARY OUTCOME MEASURES Postextraction bleeding not controlled by basic haemostasis procedure was clinically significant. RESULTS Bleeding events were reported for 35 (7.1%) and 49 (2.1%) teeth, of which 18 (3.6%) and 9 (0.4%) teeth were considered clinically significant, in warfarin and non-warfarin groups, respectively, the difference between which was 3.24% (CI 1.58% to 4.90%). The incidence rates by patients were 2.77% and 0.39%, in warfarin and non-warfarin groups, respectively (incidence difference 2.38%, CI 0.65% to 4/10%). Univariate analyses showed that age (OR 0.197, p=0.001), PT-INR (OR 3.635, p=0.003), mandibular foramen conduction anaesthesia (OR 4.854, p=0.050) and formation of abnormal granulation tissue in extraction socket (OR 2.900, p=0.031) significantly correlate with bleeding incidence. Multivariate analysis revealed that age (OR 0.126, p=0.001), antiplatelet drugs (OR 0.100, p=0.049), PT-INR (OR 7.797, p=0.001) and history of acute inflammation at extraction site (OR 3.722, p=0.037) were significant risk factors for postextraction bleeding. CONCLUSIONS Our results suggest that there is slight but significant increase in the incidences of postextraction bleeding in patients receiving warfarin. Although absolute incidence was low in both groups, the bleeding risk is not negligible.
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Affiliation(s)
- Hiroshi Iwabuchi
- Department of Oral and Maxillofacial Surgery, Kanagawa Dental University, Yokosuka, Kanagawa, Japan
| | - Yutaka Imai
- Department of Oral & Maxillofacial Surgery, Dokkyo Medical University School of Medicine, Shimotsuga-gun, Tochigi, Japan
| | - Soichiro Asanami
- Department of Dentistry and Implant Center, Sanno Hospital, Minato-ku, Tokyo, Japan
| | | | | | - Hideki Ogiuchi
- Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Kenji Kurashina
- Oral & Dental Center, Aizawa Hospital, Matsumoto, Nagano, Japan
| | - Masaru Miyata
- Department of Dentistry and Oral Surgery, Ishikawa Prefectural Central Hospital, Kanazawa, Ishikawa, Japan
| | - Hiroyuki Nakao
- Department of Epidemiology, National Institute of Public Health of Japan, Wako, Saitama, Japan
| | - Hirohisa Imai
- Department of Epidemiology, National Institute of Public Health of Japan, Wako, Saitama, Japan
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[Retrospective study on bleeding and thromboembolic complications related to tooth extraction, in 93 patients usually treated by antithrombotic therapy]. ACTA ACUST UNITED AC 2014; 116:5-11. [PMID: 25458596 DOI: 10.1016/j.revsto.2014.10.004] [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: 02/18/2014] [Revised: 06/03/2014] [Accepted: 10/06/2014] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Tooth extraction for patients treated by AVK and/or platelet aggregation inhibitor is performed according to local habits rather than to a consensus. We had for objective to assess hemorrhagic and thromboembolic risks for patients for whom treatment with AVK and/or platelet aggregation inhibitor was modified before tooth extraction. MATERIALS AND METHODS Ninety-three patient files were examined retrospectively. The following data was collected: epidemiological data, ASA score, nature and changes of antithrombotic therapy, preoperative INR, number teeth extracted, postoperative complications (bleeding and thromboembolic events). RESULTS Thirty-seven patients were treated with oral anticoagulants, 41 by a platelet aggregation inhibitor, 10 by double platelet aggregation inhibitor therapy, and 5 by an AVK-platelet aggregation inhibitor combination. At D0, the mean INR was decreased to 1.4, 4 patients with high thromboembolic risk had received heparin relay treatment; the treatment was stopped for 9 of the 56 patients on monotherapy with antiplatelet therapy, 4 were switched from clopidogrel to lysine acetylate; clopidogrel was stopped for 7 patients under combination therapy. Seven hundred and twenty-six avulsions (mean 8.1 per patient) were performed, 41 patients presented with mild/moderate bleeding, easily resolved. A patient presented with delayed hemorrhage at D6 (AVK overdose). No thromboembolic complication was reported. DISCUSSION The modification of antithrombotic treatment, as for surgery at high risk of bleeding, seems to limit the risk of bleeding without increasing thromboembolic risk.
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van Veen JJ, Makris M. Management of peri-operative anti-thrombotic therapy. Anaesthesia 2014; 70 Suppl 1:58-67, e21-3. [DOI: 10.1111/anae.12900] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2014] [Indexed: 01/08/2023]
Affiliation(s)
- J. J. van Veen
- Department of Haematology, Sheffield Haemophilia and Thrombosis; Royal Hallamshire Hospital; Sheffield UK
| | - M. Makris
- Department of Haematology, Sheffield Haemophilia and Thrombosis; Royal Hallamshire Hospital; Sheffield UK
- Department of Cardiovascular Science; Royal Hallamshire Hospital; Sheffield UK
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