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Augustin P, Andrei S, Iung B, Para M, Matthews P, de Tymowski C, Ajzenberg N, Montravers P. Thromboembolic events after major bleeding events in patients with mechanical heart valves: a 13-year analysis. J Thromb Thrombolysis 2024; 57:767-774. [PMID: 38556579 DOI: 10.1007/s11239-024-02964-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2024] [Indexed: 04/02/2024]
Abstract
Anticoagulation in patients with mechanical heart valves (MHV) is associated with a risk of major bleeding episodes (MBE). In case of MBE, anticoagulant interruption is advocated. However, there is lack of data regarding the thrombo-embolic events (TE) risk associated with anticoagulant interruption. The main objective of the study was to evaluate the rate and risk factors of 6-months of TEs in patients with MHV experiencing MBE. This observational study was conducted over a 13-year period. Adult patients with a MHV presenting with a MBE were included. The main study endpoint was 6-month TEs, defined by clinical TEs or an echocardiographic documented thrombosis, occurring during an ICU stay or within 6-months. Thromboembolic events were recorded at ICU discharge, and 6 months after discharge. Seventy-nine MBEs were analysed, the rate of TEs at 6-months was 19% CI [11-29%]. The only difference of presentation and management between 6-month TEs and free-TE patients was the time without effective anticoagulation (TWA). The Receiver Operator Characteristic curve identified the value of 122 h of TWA as a cut-off. The multivariate analysis identified early bleeding recurrences (OR 3.62, 95% CI [1.07-12.25], p = 0.039), and TWA longer than 122 h (OR 4.24, 95% CI [1.24-14.5], p = 0.021), as independent risk factors for 6-month TEs. A higher rate of TE was associated with anticoagulation interruption longer than 5 days and early bleeding recurrences. However, the management should still be personalized and discussed for each case given the heterogeneity of causes of MBE and possibilities of haemostatic procedures.
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Affiliation(s)
- Pascal Augustin
- Department of Anesthesiology and Critical Care, Groupe Hospitalier Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, 46 Rue Henri Huchard, Paris, 75018, France.
| | - Stefan Andrei
- Department of Anesthesiology and Critical Care, Groupe Hospitalier Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, 46 Rue Henri Huchard, Paris, 75018, France
- Group of Applied Mathematics and Computational Biology, CNRS UMR 8542, Paris, France
| | - Bernard Iung
- Department of Cardiology, Assistance Publique Hôpitaux de Paris, Groupe Hospitalier Bichat Claude Bernard, University of Paris, Paris, France
| | - Marylou Para
- Department of Cardiovascular Surgery and Transplantation, Groupe Hospitalier Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, Paris, France
- Laboratory of Vascular Translational Science, University of Paris, INSERM UMR 1148, Paris, France
| | - Peter Matthews
- Centre de Recherche sur l'Inflammation, University of Paris, INSERM UMR 1149, CNRS ERL8252, Paris, France
| | - Christian de Tymowski
- Department of Anesthesiology and Critical Care, Groupe Hospitalier Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, 46 Rue Henri Huchard, Paris, 75018, France
- Division of Critical Care Services, Northwick Park and St Marks Hospital, London, UK
| | - Nadine Ajzenberg
- Laboratory of Vascular Translational Science, University of Paris, INSERM UMR 1148, Paris, France
- Department of Hematology, Groupe Hospitalier Bichat Claude Bernard, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Philippe Montravers
- Department of Anesthesiology and Critical Care, Groupe Hospitalier Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, 46 Rue Henri Huchard, Paris, 75018, France
- Physiopathology and Epidemiology of respiratory diseases, University of Paris, INSERM UMR1152, Paris, France
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De Simone B, Chouillard E, Podda M, Pararas N, de Carvalho Duarte G, Fugazzola P, Birindelli A, Coccolini F, Polistena A, Sibilla MG, Kruger V, Fraga GP, Montori G, Russo E, Pintar T, Ansaloni L, Avenia N, Di Saverio S, Leppäniemi A, Lauretta A, Sartelli M, Puzziello A, Carcoforo P, Agnoletti V, Bissoni L, Isik A, Kluger Y, Moore EE, Romeo OM, Abu-Zidan FM, Beka SG, Weber DG, Tan ECTH, Paolillo C, Cui Y, Kim F, Picetti E, Di Carlo I, Toro A, Sganga G, Sganga F, Testini M, Di Meo G, Kirkpatrick AW, Marzi I, déAngelis N, Kelly MD, Wani I, Sakakushev B, Bala M, Bonavina L, Galante JM, Shelat VG, Cobianchi L, Mas FD, Pikoulis M, Damaskos D, Coimbra R, Dhesi J, Hoffman MR, Stahel PF, Maier RV, Litvin A, Latifi R, Biffl WL, Catena F. The 2023 WSES guidelines on the management of trauma in elderly and frail patients. World J Emerg Surg 2024; 19:18. [PMID: 38816766 PMCID: PMC11140935 DOI: 10.1186/s13017-024-00537-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 02/26/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures. METHODS Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023. RESULTS The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared. CONCLUSIONS The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.
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Affiliation(s)
- Belinda De Simone
- Department of Emergency Minimally Invasive Surgery, Academic Hospital of Villeneuve St Georges, Villeneuve St Georges, France.
- Department of General Minimally Invasive Surgery, Infermi Hospital, AUSL Romagna, Rimini, Italy.
- General Surgery Department, American Hospital of Paris, Paris, France.
| | - Elie Chouillard
- General Surgery Department, American Hospital of Paris, Paris, France
| | - Mauro Podda
- Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy
| | - Nikolaos Pararas
- 3rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | | | - Paola Fugazzola
- Unit of General Surgery I, IRCCS San Matteo Hospital of Pavia, University of Pavia, Pavia, Italy
| | | | | | - Andrea Polistena
- Department of Surgery, Policlinico Umberto I Roma, Sapienza University, Rome, Italy
| | - Maria Grazia Sibilla
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Vitor Kruger
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Giulia Montori
- Unit of General and Emergency Surgery, Vittorio Veneto Hospital, Via C. Forlanini 71, 31029, Vittorio Veneto, TV, Italy
| | - Emanuele Russo
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Tadeja Pintar
- UMC Ljubljana and Medical Faculty Ljubljana, Ljubljana, Slovenia
| | - Luca Ansaloni
- New Zealand Blood Service, Christchurch, New Zealand
| | - Nicola Avenia
- Endocrine Surgical Unit - University of Perugia, Terni, Italy
| | - Salomone Di Saverio
- General Surgery Unit, Madonna del Soccorso Hospital, AST Ascoli Piceno, San Benedetto del Tronto, Italy
| | - Ari Leppäniemi
- Division of Emergency Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Andrea Lauretta
- Department of Surgical Oncology, Centro Di Riferimento Oncologico Di Aviano IRCCS, Aviano, Italy
| | - Massimo Sartelli
- Department of General Surgery, Macerata Hospital, Macerata, Italy
| | - Alessandro Puzziello
- Dipartimento di Medicina, Chirurgia e Odontoiatria, Campus Universitario di Baronissi (SA) - Università di Salerno, AOU San Giovanni di Dio e Ruggi di Aragona, Salerno, Italy
| | - Paolo Carcoforo
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Vanni Agnoletti
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Luca Bissoni
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Arda Isik
- Istanbul Medeniyet University, Istanbul, Turkey
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
| | - Oreste Marco Romeo
- Bronson Methodist Hospital/Western Michigan University, Kalamazoo, MI, USA
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al‑Ain, United Arab Emirates
| | | | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital and The University of Western Australia, Perth, Australia
| | - Edward C T H Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ciro Paolillo
- Emergency Department, Ospedale Civile Maggiore, Verona, Italy
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Fernando Kim
- University of Colorado Anschutz Medical Campus, Denver, CO, 80246, USA
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Adriana Toro
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Gabriele Sganga
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Federica Sganga
- Department of Geriatrics, Ospedale Sant'Anna, Ferrara, Italy
| | - Mario Testini
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Giovanna Di Meo
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Andrew W Kirkpatrick
- Departments of Surgery and Critical Care Medicine, University of Calgary, Foothills Medical Centre, Calgary, AB, Canada
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Nicola déAngelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | | | - Imtiaz Wani
- Department of Surgery, Government Gousia Hospital, DHS, Srinagar, India
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Miklosh Bala
- Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Luigi Bonavina
- Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Joseph M Galante
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California Davis, Sacramento, CA, USA
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Novena, Singapore
| | - Lorenzo Cobianchi
- Unit of General Surgery I, IRCCS San Matteo Hospital of Pavia, University of Pavia, Pavia, Italy
- Collegium Medicum, University of Social Sciences, Łodz, Poland
| | - Francesca Dal Mas
- Department of Management, Ca' Foscari University of Venice, Venice, Italy
- Collegium Medicum, University of Social Sciences, Łodz, Poland
| | - Manos Pikoulis
- Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy
| | | | - Raul Coimbra
- Riverside University Health System Medical Center, Riverside, CA, USA
| | - Jugdeep Dhesi
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Melissa Red Hoffman
- Department of Surgery, University of North Carolina, Surgical Palliative Care Society, Asheville, NC, USA
| | - Philip F Stahel
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Ronald V Maier
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Andrey Litvin
- Department of Surgical Diseases No. 3, Gomel State Medical University, University Clinic, Gomel, Belarus
| | - Rifat Latifi
- University of Arizona, Tucson, AZ, USA
- Abrazo Health West Campus, Goodyear, Tucson, AZ, USA
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Fausto Catena
- Department of General and Emergency Surgery, Bufalini Hospital-Level 1 Trauma Center, AUSL Romagna, Cesena, Italy
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Bajolle F, Derridj N, Bitan J, Grazioli A, Pallet N, Lasne D, Bonnet D. Risk factors for serious adverse events related to vitamin K antagonists in children with congenital or acquired heart disease: a prospective cohort study. Thromb Res 2023; 232:93-103. [PMID: 37976734 DOI: 10.1016/j.thromres.2023.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 10/23/2023] [Accepted: 10/25/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVES To assess the occurrence of thrombosis and major bleeding in children with congenital or acquired heart disease (CAHD) treated with VKA and to identify risk factors for these serious adverse events (SAE). STUDY DESIGN All children enrolled in our VKA dedicated educational program between 2008 and 2022 were prospectively included. The time in therapeutic range (TTR) was calculated to evaluate the stability of anticoagulation. Statistical analysis included Cox proportional hazard models. RESULTS We included 405 patients. Median follow-up was 18.7 (9.3-49.4) months. The median TTR was 83.1 % (74.4 %-95.3 %). No deaths occurred because of bleeding or thrombotic events. The incidences of thrombotic and major bleeding events were 0.9 % (CI95 % [0.1-1.8]) and 2.3 % (CI95 % [0.9-3.8]) per patient year, respectively. At 1 and 5 years, 98.3 % (CI95 % [96.2 %-99.2 %]) and 88.7 % (CI95 % [81.9 % 93.1 %]) of patients were free of any SAE, respectively. Although the mechanical mitral valve (MMV) was associated to major bleeding events (HR = 3.1 CI95 % [1.2-8.2], p = 0.02) in univariate analysis, only recurrent minor bleeding events (HR = 4.3 CI95 % [1.6-11.7], p < 0.01) and global TTR under 70 % (HR = 4.7 CI95 % [1.5-15.1], p < 0.01) were independent risk factors in multivariable analysis. In multivariable analysis, giant coronary aneurysms after Kawasaki disease (HR = 7.8 [1.9-32.0], p = 0.005) was the only risk factor for thrombotic events. CONCLUSION Overall, VKA therapy appears to be safe in children with CAHD. Suboptimal TTR, regardless of the indication for VKA initiation, was associated with bleeding events.
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Affiliation(s)
- Fanny Bajolle
- M3C-Paediatric Cardiology center, Hôpital universitaire Necker Enfants-malades, AP-HP, Université de Paris, Paris, France
| | - Neil Derridj
- M3C-Paediatric Cardiology center, Hôpital universitaire Necker Enfants-malades, AP-HP, Université de Paris, Paris, France.
| | - Joan Bitan
- Hematology Laboratory, Hôpital universitaire Necker Enfants-Malades, AP-HP, Université de Paris, Paris, France
| | - Aurelie Grazioli
- M3C-Paediatric Cardiology center, Hôpital universitaire Necker Enfants-malades, AP-HP, Université de Paris, Paris, France
| | - Nicolas Pallet
- Department of Clinical Chemistry, Hôpital Européen Georges Pompidou, AP-HP, Université de Paris, Paris, France
| | - Dominique Lasne
- Hematology Laboratory, Hôpital universitaire Necker Enfants-Malades, AP-HP, Université de Paris, Paris, France
| | - Damien Bonnet
- M3C-Paediatric Cardiology center, Hôpital universitaire Necker Enfants-malades, AP-HP, Université de Paris, Paris, France
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Martin AC, Benamouzig R, Gouin-Thibault I, Schmidt J. Management of Gastrointestinal Bleeding and Resumption of Oral Anticoagulant Therapy in Patients with Atrial Fibrillation: A Multidisciplinary Discussion. Am J Cardiovasc Drugs 2023:10.1007/s40256-023-00582-9. [PMID: 37145342 DOI: 10.1007/s40256-023-00582-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2023] [Indexed: 05/06/2023]
Abstract
Direct oral anticoagulants (DOACs) are recommended for the prevention of thromboembolism in patients with atrial fibrillation (AF), and are now preferred over vitamin K antagonists due to their beneficial efficacy and safety profile. However, all oral anticoagulants carry a risk of gastrointestinal (GI) bleeding. Although the risk is well documented and acute bleeding well codified, there is limited high-quality evidence and no guidelines to guide physicians on the optimal management of anticoagulation after a GI bleeding event. The aim of this review is to provide a multidisciplinary critical discussion of the optimal management of GI bleeding in patients with AF receiving oral anticoagulants to help physicians provide individualized treatment for each patient and optimize outcomes. It is important to perform endoscopy when a patient presents with bleeding manifestations or hemodynamic instability to determine the bleed location and severity of bleeding and then perform initial resuscitation. Administration of all anticoagulants and antiplatelets should be stopped and bleeding allowed to resolve with time; however, anticoagulant reversal should be considered for patients who have life-threatening bleeding or when the bleeding is not controlled by the initial resuscitation. Anticoagulation needs to be timely resumed considering that bleeding risk outweighs thrombotic risk when anticoagulation is resumed early after the bleeding event. To prevent further bleeding, physicians should prescribe anticoagulant therapy with the lowest risk of GI bleeding, avoid medications with GI toxicity, and consider the effect of concomitant medications on potentiating the bleeding risk.
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Affiliation(s)
- Anne-Céline Martin
- Advanced Heart Failure Unit, AP-HP, Cardiology Department, European Hospital Georges Pompidou, Paris, France.
- INSERM UMRS_1140, Innovative Therapies in Haemostasis, Université Paris Cité, 75006, Paris, France.
| | - Robert Benamouzig
- Service de Gastroentérologie, Hôpital Avicenne, AP-HP, Université Paris-Nord-La Sorbonne, Bobigny, France
| | - Isabelle Gouin-Thibault
- Laboratory of Hematology, IRSET-INSERM UMRS 1085, Rennes University Hospital, Rennes, France
| | - Jeannot Schmidt
- LaPSCo, Physiological and Psychosocial Stress, CNRS, Université Clermont Auvergne, Clermont-Ferrand, France
- Emergency Department, CHU Clermont-Ferrand, University Hospital Gabriel Montpied, Clermont-Ferrand, France
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Kietaibl S, Ahmed A, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, De Robertis E, Faraoni D, Filipescu DC, Fries D, Godier A, Haas T, Jacob M, Lancé MD, Llau JV, Meier J, Molnar Z, Mora L, Rahe-Meyer N, Samama CM, Scarlatescu E, Schlimp C, Wikkelsø AJ, Zacharowski K. Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022. Eur J Anaesthesiol 2023; 40:226-304. [PMID: 36855941 DOI: 10.1097/eja.0000000000001803] [Citation(s) in RCA: 60] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesiology & Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University Vienna, Austria (SK), Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS Trust (AAh), Department of Cardiovascular Sciences, University of Leicester, UK (AAh), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AAf), Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark (AAf), Department of Anaesthesiology & Critical Care, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble-Alpes University Hospital, Grenoble, France (PA), Department of Anaesthesiology & Intensive Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania (GB), Division of Anaesthesia, Analgesia, and Intensive Care - Department of Medicine and Surgery, University of Perugia, Italy (EDR), Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA (DFa), University of Medicine and Pharmacy Carol Davila, Department of Anaesthesiology & Intensive Care, Emergency Institute for Cardiovascular Disease, Bucharest, Romania (DCF), Department of Anaesthesia and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria (DFr), Department of Anaesthesiology & Critical Care, APHP, Université Paris Cité, Paris, France (AG), Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida, USA (TH), Department of Anaesthesiology, Intensive Care and Pain Medicine, St.-Elisabeth-Hospital Straubing, Straubing, Germany (MJ), Department of Anaesthesiology, Medical College East Africa, The Aga Khan University, Nairobi, Kenya (MDL), Department of Anaesthesiology & Post-Surgical Intensive Care, University Hospital Doctor Peset, Valencia, Spain (JVL), Department of Anaesthesiology & Intensive Care, Johannes Kepler University, Linz, Austria (JM), Department of Anesthesiology & Intensive Care, Semmelweis University, Budapest, Hungary (ZM), Department of Anaesthesiology & Post-Surgical Intensive Care, University Trauma Hospital Vall d'Hebron, Barcelona, Spain (LM), Department of Anaesthesiology & Intensive Care, Franziskus Hospital, Bielefeld, Germany (NRM), Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP. Centre - Université Paris Cité - Cochin Hospital, Paris, France (CMS), Department of Anaesthesiology and Intensive Care, Fundeni Clinical Institute, Bucharest and University of Medicine and Pharmacy Carol Davila, Bucharest, Romania (ES), Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Linz and Ludwig Boltzmann-Institute for Traumatology, The Research Centre in Co-operation with AUVA, Vienna, Austria (CS), Department of Anaesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark (AW) and Department of Anaesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany (KZ)
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6
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Teissandier D, Moustafa F, Denaives A, Lebecque B, Blondonnet R, Pereira B, Monfoulet LE, Sinegre T, Schmidt J, Lebreton A. Thrombin generation in real life bleeding patients on oral anticoagulants reversed (or not) with (activated) prothrombin complex concentrate. Thromb Res 2023; 223:184-193. [PMID: 36764085 DOI: 10.1016/j.thromres.2023.01.022] [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: 10/18/2022] [Revised: 01/18/2023] [Accepted: 01/21/2023] [Indexed: 01/31/2023]
Abstract
BACKGROUND Bleeding during oral anticoagulant therapy is currently codified by expert guidelines. Monitoring of coagulation during bleeding events is challenging. Our study sought to assess thrombin generation assay (TGA) in direct oral anticoagulant-treated patients without bleeding (WB), bleeding without reversal therapy (BR-), and bleeding with reversal therapy (BR+). METHODS We conducted a prospective, monocentric study from June 2015 to June 2018. For all bleeding groups, TGA was evaluated using platelet-poor plasma collected upon arrival at emergency (T0), and 30 min (T1), 6 h (T2) and 24 h (T3) after reversal therapy (if indicated) following activation by tissue factor 5 pM and phospholipids. RESULTS Overall, 292 patients participated, including 91 BR+, 94 BR-, and 107 WB patients. At T0, vitamin K antagonist reversed (VKA-BR+) patients experienced a significant decrease in TGA parameters (ETP and peak) compared with VKA without bleeding (VKA-WB). Compared with healthy controls, VKA-BR+ patients reversed by four-factor prothrombin complex concentrate (4F-PCC) displayed comparable TGA 's ETP and peak at T1, T2, and T3, whereas direct anti-Xa BR+ patients reversed by 4F-PCC or activated prothrombin complex concentrate (aPCC) reached thrombin generation parameters that exceeded normal range at T2 and T3. CONCLUSIONS In VKA-treated patients reversed by 4F-PCC, TGA parameters were normalized, whereas in rivaroxaban or apixaban-treated patients reversed by 4F-PCC or aPCC, TGA parameters exceeded normal range. Further studies are needed to compare the efficacy and safety of a different dose of reversal therapy and the impact on coagulation parameters.
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Affiliation(s)
- Dorian Teissandier
- Emergency Department, University Hospital of Clermont Ferrand, 63000 Clermont-Ferrand, France; Université Clermont Auvergne, INRAE, UNH, F-63000 Clermont-Ferrand, France.
| | - Farès Moustafa
- Emergency Department, University Hospital of Clermont Ferrand, 63000 Clermont-Ferrand, France; Université Clermont Auvergne, INRAE, UNH, F-63000 Clermont-Ferrand, France
| | - Amélie Denaives
- Hematology Department, University Hospital of Clermont Ferrand, 63000 Clermont-Ferrand, France
| | - Benjamin Lebecque
- Hematology Department, University Hospital of Clermont Ferrand, 63000 Clermont-Ferrand, France
| | - Raiko Blondonnet
- Intensive Care Unit, University Hospital of Clermont Ferrand, 63000 Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics Unit, the Clinical Research and Innovation Direction, University Hospital of Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | | | - Thomas Sinegre
- Université Clermont Auvergne, INRAE, UNH, F-63000 Clermont-Ferrand, France; Hematology Department, University Hospital of Clermont Ferrand, 63000 Clermont-Ferrand, France
| | - Jeannot Schmidt
- Emergency Department, University Hospital of Clermont Ferrand, 63000 Clermont-Ferrand, France
| | - Aurélien Lebreton
- Université Clermont Auvergne, INRAE, UNH, F-63000 Clermont-Ferrand, France; Hematology Department, University Hospital of Clermont Ferrand, 63000 Clermont-Ferrand, France
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7
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Bouget J, Jouhanny A, Soulat L, Oger E. Ground-level falls among nonagenarians: the impact of pre-injury antithrombotic therapy. Intern Emerg Med 2022; 17:1309-1319. [PMID: 35112277 DOI: 10.1007/s11739-021-02914-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 12/16/2021] [Indexed: 12/21/2022]
Abstract
Among nonagenarians admitted to our emergency department (ED) for ground-level falls, we assessed the impact of pre-injury antithrombotic (AT) treatment on the post-traumatic consequences, and identified risk factors for 1-month mortality. All eligible patients were consecutively included over an 18-month period. Head trauma was attested by reliable medical history, witnesses or recent external signs. Patient characteristics, post-traumatic consequences and outcomes were compared across patients with and without AT. Risk factors for 1-month mortality were assessed using multivariate logistic regression analyses. 1014 consecutive nonagenarians were analysed, 675 (66.6%) with AT and 339 (33.4%) without. Head trauma (n = 429, 42.3%) was significantly more frequent among patients with AT (49.2 vs 28.6%, p < 0.001). Intracranial hemorrhage (ICH, n = 43, 4.2%), mostly subdural hematomas (58%), were more frequently found among patients with AT (p < 0.015). At least one fracture was diagnosed for 23.9% of the population, mostly hip fractures, without any significant association with AT. At 1 month, 103 patients (10.2%) had died. The independent risk factors for 1-month mortality were: ICH associated with head trauma (OR = 5.9, 95% CI 2.5-14), Glasgow coma score ≤ 12 at admission (OR = 10; 95% CI 2.2-46), atrial fibrillation (OR = 2.2, 95% CI 1.4-3.4) and age ≥ 95 years (OR = 1.6, 95% CI 1.0-2.5). Our results support accurate and regular assessment of the benefit/risk ratio for antithrombotic treatment among elderly people at high risk for falls.
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Affiliation(s)
- Jacques Bouget
- Emergency Department, University Hospital, 35033, Rennes, France.
- University of Rennes, CHU Rennes, EA 7449 (Pharmacoepidemiology and Health Services Research) REPERES, University Hospital, F-35043, Rennes, France.
| | - Alexia Jouhanny
- Emergency Department, University Hospital, 35033, Rennes, France
| | - Louis Soulat
- Emergency Department, University Hospital, 35033, Rennes, France
| | - Emmanuel Oger
- University of Rennes, CHU Rennes, EA 7449 (Pharmacoepidemiology and Health Services Research) REPERES, University Hospital, F-35043, Rennes, France
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8
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Barletta JF, Erstad BL. Dosing Medications for Coagulopathy Reversal in Patients with Extreme Obesity. J Emerg Med 2022; 63:541-550. [PMID: 35906122 DOI: 10.1016/j.jemermed.2022.04.036] [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: 02/17/2022] [Revised: 03/22/2022] [Accepted: 04/23/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND The reversal of anticoagulant or antiplatelet medications is a priority in the management of patients with severe injury with the goal of minimizing further bleeding without thrombotic complications. There are few studies, however, evaluating the dosing of reversal agents in the setting of trauma specific to patients with extreme obesity. Nevertheless, clinicians must still make decisions, balancing concerns of ongoing bleeding with excessive thrombosis. OBJECTIVES We describe the literature pertaining to dosing of medications used for the reversal of both drug-induced and trauma-related coagulopathy with the intent of providing a framework for clinicians to make dosing decisions in this challenging population. DISCUSSION Obesity is known to impact both the volume of distribution and the clearance of medications, but these changes are not usually linear with size nor are they uniform across drugs. Current strategies for dosing reversal agents in obesity include a capped dose (e.g., prothrombin complex concentrates), fixed dosages (e.g., andexanet alfa, idarucizumab, and tranexamic acid), and weight-based dosing (e.g., desmopressin). Extreme obesity, however, was not highly prevalent in the studies that have validated these dosing strategies. In fact, many of the clinical studies fail to report the average weight of the patients included. CONCLUSION Future studies should make efforts to increase reporting of patients with obesity included in clinical trials along with results stratified by weight class. In the meantime, doses listed in product labels should be used. Desmopressin should be dosed using either ideal body weight or a dose-capping strategy.
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Affiliation(s)
- Jeffrey F Barletta
- Department of Pharmacy Practice, College of Pharmacy, Midwestern University, Glendale
| | - Brian L Erstad
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, Arizona
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Hofer S, Schlimp CJ, Casu S, Grouzi E. Management of Coagulopathy in Bleeding Patients. J Clin Med 2021; 11:jcm11010001. [PMID: 35011742 PMCID: PMC8745606 DOI: 10.3390/jcm11010001] [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: 10/29/2021] [Revised: 12/10/2021] [Accepted: 12/14/2021] [Indexed: 02/06/2023] Open
Abstract
Early recognition of coagulopathy is necessary for its prompt correction and successful management. Novel approaches, such as point-of-care testing (POC) and administration of coagulation factor concentrates (CFCs), aim to tailor the haemostatic therapy to each patient and thus reduce the risks of over- or under-transfusion. CFCs are an effective alternative to ratio-based transfusion therapies for the correction of different types of coagulopathies. In case of major bleeding or urgent surgery in patients treated with vitamin K antagonist anticoagulants, prothrombin complex concentrate (PCC) can effectively reverse the effects of the anticoagulant drug. Evidence for PCC effectiveness in the treatment of direct oral anticoagulants-associated bleeding is also increasing and PCC is recommended in guidelines as an alternative to specific reversal agents. In trauma-induced coagulopathy, fibrinogen concentrate is the preferred first-line treatment for hypofibrinogenaemia. Goal-directed coagulation management algorithms based on POC results provide guidance on how to adjust the treatment to the needs of the patient. When POC is not available, concentrate-based management can be guided by other parameters, such as blood gas analysis, thus providing an important alternative. Overall, tailored haemostatic therapies offer a more targeted approach to increase the concentration of coagulation factors in bleeding patients than traditional transfusion protocols.
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Affiliation(s)
- Stefan Hofer
- Department of Anaesthesiology, Westpfalz-Klinikum Kaiserslautern, 67655 Kaiserlautern, Germany
- Correspondence: ; Tel.: +49-631-203-1030
| | - Christoph J. Schlimp
- Department of Anaesthesiology and Intensive Care, AUVA Trauma Hospital Linz, 4010 Linz, Austria;
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Center, 1200 Vienna, Austria
| | - Sebastian Casu
- Emergency Department, Asklepios Hospital Wandsbek, 22043 Hamburg, Germany;
| | - Elisavet Grouzi
- Transfusion Service and Clinical Hemostasis, Saint Savvas Oncology Hospital, 115 22 Athens, Greece;
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10
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Abdoellakhan RA, Khorsand N, Ter Avest E, Lameijer H, Faber LM, Ypma PF, Nieuwenhuizen L, Veeger NJGM, Meijer K. Fixed Versus Variable Dosing of Prothrombin Complex Concentrate for Bleeding Complications of Vitamin K Antagonists-The PROPER3 Randomized Clinical Trial. Ann Emerg Med 2021; 79:20-30. [PMID: 34535300 DOI: 10.1016/j.annemergmed.2021.06.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 06/07/2021] [Accepted: 06/17/2021] [Indexed: 11/01/2022]
Abstract
STUDY OBJECTIVE To determine if a fixed dose of 1000 IU of 4-factor prothrombin complex concentrate (4F-PCC) is as effective as traditional variable dosing based on body weight and international normalized ratio (INR) for reversal of vitamin K antagonist (VKA) anticoagulation. METHODS In this open-label, multicenter, randomized clinical trial, patients with nonintracranial bleeds requiring VKA reversal with 4F-PCC were allocated to either a 1,000-IU fixed dose of 4F-PCC or the variable dose. The primary outcome was the proportion of patients with effective hemostasis according to the International Society of Thrombosis and Haemostasis definition. The design was noninferiority with a lower 95% confidence interval of no more than -6%. When estimating sample size, we assumed that fixed dosing would be 4% superior. RESULTS From October 2015 until January 2020, 199 of 310 intended patients were included before study termination due to decreasing enrollment rates. Of the 199 patients, 159 were allowed in the per-protocol analysis. Effective hemostasis was achieved in 87.3% (n=69 of 79) in fixed compared to 89.9% (n=71 of 79) in the variable dosing cohort (risk difference 2.5%, 95% confidence interval -13.3 to 7.9%, P=.27). Median door-to-needle times were 109 minutes (range 16 to 796) in fixed and 142 (17 to 1076) for the variable dose (P=.027). INR less than 2.0 at 60 minutes after 4F-PCC infusion was reached in 91.2% versus 91.7% (P=1.0). CONCLUSION The large majority of patients had good clinical outcome after 4F-PCC use; however, noninferiority of the fixed dose could not be demonstrated because the design assumed the fixed dose would be 4% superior. Door-to-needle time was shortened with the fixed dose, and INR reduction was similar in both dosing regimens.
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Affiliation(s)
- Rahat A Abdoellakhan
- Department of Haematology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
| | | | - Ewoud Ter Avest
- Department of Emergency Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Heleen Lameijer
- Department of Emergency Medicine, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - Laura M Faber
- Department of Haematology, Rode Kruis Ziekenhuis, Beverwijk, the Netherlands
| | - Paula F Ypma
- Department of Haematology, Hagaziekenhuis, The Hague, the Netherlands
| | | | - Nic J G M Veeger
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Karina Meijer
- Department of Haematology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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11
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Zemouri A, Lin F, Billuart O, Sacco E, Emmerich J, Priollet P, Yannoutsos A. Prevalence and management of antivitamin K overdose in a hospital setting. JOURNAL DE MEDECINE VASCULAIRE 2021; 46:175-181. [PMID: 34238512 DOI: 10.1016/j.jdmv.2021.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 05/21/2021] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Vitamin K antagonist (VKA) related adverse events are the first cause for iatrogenic events in France, particularly due to the narrow therapeutic margin. The risk of bleeding increases significantly when the INR level is ≥5. The main objective of this study was to assess the prevalence of VKA overdose in a hospital setting (at D2 of hospital entry) and to evaluate physicians' adherence to clinical practice guidelines for the management of VKA overdose according to French National Authority for Health recommendations. METHODS This single-center retrospective observational study consisted in querying the computerized database of a Parisian hospital on 21275INR determinations (3995 patients, 6813 hospital stays) performed between 2013 and 2018. RESULTS An INR level ≥5 was noted during 350 (6%) of the hospital stays, in 331 patients (of whom 57% were women). The mean age of the patient population with an INR≥5 was 81.1 years. Infection, heart failure and renal failure were the most frequent acute medical conditions for hospital admission. Twenty-three patients (7%) had a bleeding complication, 11 of which were major bleeding complications. Older age was associated with the severity of bleeding complications. Fifteen in-hospital deaths (4%) were reported, not related to bleeding events. The management of VKA overdose did not comply with the recommendations in 43% of cases, in particular for the highest INRs (50% of noncompliance for an INR>6.4). Non-compliance with recommendations for VKA overdose was related to: the delay until the INR was checked (44% of cases); the indication for prescribing vitamin K (34% of cases); the dose or route of administration of vitamin K therapy (19% of cases); and the interruption or not of VKA therapy (12% of cases). CONCLUSION The management of VKA overdose in a hospital setting remains non-compliant with the recommendations in almost half of the cases, mainly due to the delayed INR control and inappropriate management of vitamin K therapy. Computerized alert system would be helpful for personalized patient management and improved pharmacovigilance to prevent iatrogenic VKA events.
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Affiliation(s)
- A Zemouri
- Vascular medicine department, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - F Lin
- Medical Information Department, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - O Billuart
- Medical Information Department, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - E Sacco
- Clinical Research Center, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - J Emmerich
- Vascular medicine department, Groupe Hospitalier Paris Saint-Joseph, Paris, France; Inserm UMR 1153-CRESS, Paris, France
| | - P Priollet
- Vascular medicine department, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - A Yannoutsos
- Vascular medicine department, Groupe Hospitalier Paris Saint-Joseph, Paris, France; Inserm UMR 1153-CRESS, Paris, France.
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12
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2020 ACC/AHA guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2021; 162:e183-e353. [PMID: 33972115 DOI: 10.1016/j.jtcvs.2021.04.002] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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13
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 143:e72-e227. [PMID: 33332150 DOI: 10.1161/cir.0000000000000923] [Citation(s) in RCA: 531] [Impact Index Per Article: 177.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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14
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 77:e25-e197. [PMID: 33342586 DOI: 10.1016/j.jacc.2020.11.018] [Citation(s) in RCA: 780] [Impact Index Per Article: 260.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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15
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Bouget J, Huet MC, Roy PM, Viglino D, Lacut K, Pavageau L, Oger E. Acute, major muscular hematoma associated with antithrombotic agents: A multicenter real-world cohort. Thromb Res 2020; 199:54-58. [PMID: 33429124 DOI: 10.1016/j.thromres.2020.12.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 12/17/2020] [Accepted: 12/18/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is little data on major muscular hematomas and the little there is has mainly focused on patients exposed to oral anticoagulants. OBJECTIVE To describe the clinical characteristics, management and outcomes of patients admitted to emergency department (ED) for major muscular hematoma associated with an antithrombotic agent, and to identify predictors of in-hospital mortality. PATIENTS AND METHODS Over a three-year period, all consecutive cases of adult patients admitted to the ED of 5 tertiary care hospitals for major muscular hematoma while exposed to an antithrombotic agent were prospectively collected and medically validated. Clinical and biological data, therapeutic management of the bleeding event, and in-hospital mortality were collected from the medical records and compared across five groups of hematoma locations. Potential confounders were taken in account using a multivariate binomial regression model. RESULTS Three hundred and seventy-five patients were included (mean age = 81.4 years): 271 were exposed to vitamin K antagonists, 58 to parenteral anticoagulants (heparin, LMWH, fondaparinux), 33 to antiplatelets, and 13 to direct oral anticoagulants. The muscular hematomas were located in the lower limbs (n = 198), the rectus sheath (n = 71), the iliopsoas (n = 45), the upper limbs (n = 33), or elsewhere (n = 28). Reversal therapy was prescribed for 48.5% of patients, red cell transfusions for 63.6%, surgery for 12.3% and embolization for 3.5%. For 84% of patients, hospitalization was required, with a median length of stay of 10 days. Overall, in-hospital mortality was 8.5%. Reversal therapy, the need for intensive care and mortality were significantly more frequent among patients with iliopsoas hematomas. The independent predictors of in-hospital mortality were: decrease in mean arterial pressure (RR = 1.84), decrease in hemoglobin level (RR = 1.37) and the iliopsoas location (RR = 3.06). CONCLUSION Frail elderly patients with major muscular hematomas linked to antithrombotic agents risk substantial morbidity and in-hospital mortality. The iliopsoas location was the most life-threatening bleeding site. Close observation of this population is warranted to ensure better outcomes.
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Affiliation(s)
- Jacques Bouget
- Univ Rennes, CHU Rennes, EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, F 35043 Rennes, France
| | | | - Pierre-Marie Roy
- Emergency Department, Centre Hospitalier Universitaire, Institut MITOVASC, Université d'Angers, Angers, France; F-CRIN INNOVTE, France
| | - Damien Viglino
- Emergency Department, Grenoble-Alpes University Hospital, F 38043 Grenoble, France
| | - Karine Lacut
- CIC 1412, Université de Bretagne Loire, Université de Brest, INSERM CIC 1412, CHRU de Brest, F 29200 Brest, France
| | - Laure Pavageau
- Emergency Department, University hospital, F 44093 Nantes, France
| | - Emmanuel Oger
- Univ Rennes, CHU Rennes, EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, F 35043 Rennes, France.
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16
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Izumi C, Eishi K, Ashihara K, Arita T, Otsuji Y, Kunihara T, Komiya T, Shibata T, Seo Y, Daimon M, Takanashi S, Tanaka H, Nakatani S, Ninami H, Nishi H, Hayashida K, Yaku H, Yamaguchi J, Yamamoto K, Watanabe H, Abe Y, Amaki M, Amano M, Obase K, Tabata M, Miura T, Miyake M, Murata M, Watanabe N, Akasaka T, Okita Y, Kimura T, Sawa Y, Yoshida K. JCS/JSCS/JATS/JSVS 2020 Guidelines on the Management of Valvular Heart Disease. Circ J 2020; 84:2037-2119. [DOI: 10.1253/circj.cj-20-0135] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kiyoyuki Eishi
- Division of Cardiovascular Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | - Kyomi Ashihara
- Department of Cardiology, Tokyo Women’s Medical University Hospital
| | - Takeshi Arita
- Division of Cardiovascular Medicine Heart & Neuro-Vascular Center, Fukuoka Wajiro
| | - Yutaka Otsuji
- Department of Cardiology, Hospital of University of Occupational and Environmental Health
| | - Takashi Kunihara
- Department of Cardiac Surgery, The Jikei University School of Medicine
| | - Tatsuhiko Komiya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital
| | - Toshihiko Shibata
- Department of Cardiovascular Surgery, Osaka City University Postgraduate of Medicine
| | - Yoshihiro Seo
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences
| | - Masao Daimon
- Department of Clinical Laboratory/Cardiology, The University of Tokyo Hospital
| | | | | | - Satoshi Nakatani
- Division of Health Sciences, Osaka University Graduate School of Medicine
| | - Hiroshi Ninami
- Department of Cardiac Surgery, Tokyo Women’s Medical University
| | - Hiroyuki Nishi
- Department of Cardiovascular Surgery, Osaka General Medical Center
| | | | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | | | - Kazuhiro Yamamoto
- Division of Cardiovascular Medicine, Endocrinology and Metabolism, Faculty of Medicine, Tottori University
| | | | - Yukio Abe
- Department of Cardiology, Osaka City General Hospital
| | - Makoto Amaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Masashi Amano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kikuko Obase
- Division of Cardiovascular Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | - Minoru Tabata
- Department of Cardiovascular Surgery, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Takashi Miura
- Division of Cardiovascular Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | | | - Mitsushige Murata
- Department of Laboratory Medicine, Tokai University Hachioji Hospital
| | - Nozomi Watanabe
- Department of Cardiology, Miyazaki Medical Association Hospital
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Yutaka Okita
- Department of Cardiovascular Surgery, Takatsuki Hospital
| | - Takeshi Kimura
- Department of Cardiology, Kyoto University Graduate School of Medicine
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Kiyoshi Yoshida
- Department of Cardiology, Sakakibara Heart Institute of Okayama
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17
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Moustafa F, Dopeux L, Mulliez A, Boirie Y, Morand C, Gentes E, Farigon N, Richard D, Lebreton A, Teissandier D, Dutheil F, Schmidt J. Severe undernutrition increases bleeding risk on vitamin-K antagonists. Clin Nutr 2020; 40:2237-2243. [PMID: 33077273 DOI: 10.1016/j.clnu.2020.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 09/25/2020] [Accepted: 10/01/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Hemorrhage occurs in 7-10% of patients treated with vitamin K antagonist (VKA), with major bleeding in 1-3%. Impact of nutritional status on the bleeding risk of patients on anticoagulants is still poorly documented. Our study aimed to analyze the link between the nutritional status of patients on VKA and the occurrence of hemorrhagic events. We also analyzed micronutrients status. METHODS A case-control, monocentric, and prospective study was conducted from August 2012 to October 2015. The case patients were those presenting with major bleeding and control patients those without any bleeding under VKA treatment. RESULTS Overall, 294 patients under VKA treatment were paired according to age, gender, and index normalized ratio (INR). Out of these, 98 (33.3%) had major bleeding and 196 (66.7%) did not have any bleeding. Additionally, more than two-thirds of patients displayed undernutrition, which was more prevalent in bleeding than non-bleeding patients (OR = 1.85, CI95%: 1.07-3.21). There was a higher bleeding risk for those with severe undernutrition (OR = 2.66, CI95%: 1.58-4.46), with no difference found concerning moderate undernutrition. Bleeding patients had lower plasma-zinc concentrations than non-bleeding patients (9.4 ± 3.6 vs. 10.5 ± 3.7 μmol/L, p = 0.003); among them, there was a higher rate of patients with plasma zinc under 5 μmol/L (9% vs. 2%, p < 0.001). CONCLUSION Patients with undernutrition on VKA exhibit a significantly higher bleeding risk, which increases three-fold in case of severe undernutrition. The evaluation of nutritional status provides additional, valuable prognosis information prior to initiating VKA therapy. CLINICALTRIALS. GOV NUMBER NCT01742871.
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Affiliation(s)
- Farès Moustafa
- Emergency Department, Clermont-Ferrand University Hospital, Clermont-Ferrand, France; Université Clermont Auvergne, Clermont-Ferrand, France.
| | - Loïc Dopeux
- Emergency Department, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Aurelien Mulliez
- Biostatistics Unit, DRCI, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Yves Boirie
- Service de Nutrition Clinique, CHU Clermont-Ferrand, Unité de Nutrition Humaine, INRA, Université Clermont Auvergne, 63003, Clermont-Ferrand, France; Université Clermont-Auvergne, Unité de Nutrition, CRNH, Clermont-Ferrand, France
| | - Christine Morand
- Université Clermont Auvergne, INRAE, UNH, Unité de Nutrition Humaine, Clermont-Ferrand, France
| | - Elodie Gentes
- Service de Nutrition Clinique, CHU Clermont-Ferrand, Unité de Nutrition Humaine, INRA, Université Clermont Auvergne, 63003, Clermont-Ferrand, France; Université Clermont-Auvergne, Unité de Nutrition, CRNH, Clermont-Ferrand, France
| | - Nicolas Farigon
- Service de Nutrition Clinique, CHU Clermont-Ferrand, Unité de Nutrition Humaine, INRA, Université Clermont Auvergne, 63003, Clermont-Ferrand, France
| | - Damien Richard
- Université Clermont Auvergne, CHU Clermont-Ferrand, Laboratoire de Pharmacologie et Toxicologie, Clermont-Ferrand, France
| | - Aurélien Lebreton
- Université Clermont Auvergne, INRAE, UNH, Unité de Nutrition Humaine, Clermont-Ferrand, France; Service d'Hématologie Biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France; Centre de Ressources et Compétences des Maladies Hémorragiques Constitutionnelles, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Dorian Teissandier
- Emergency Department, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Frederic Dutheil
- Emergency Department, Clermont-Ferrand University Hospital, Clermont-Ferrand, France; Université Clermont Auvergne, Clermont-Ferrand, France; School of Exercise Science, Australian Catholic University, Melbourne, VIC, Australia; UMR CNRS 6024, "Physiological and Psychosocial Stress" Team, LAPSCO, Clermont-Ferrand, France
| | - Jeannot Schmidt
- Emergency Department, Clermont-Ferrand University Hospital, Clermont-Ferrand, France; Université Clermont Auvergne, Clermont-Ferrand, France
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18
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Bouget J, Viglino D, Yvetot Q, Oger E. Major gastrointestinal bleeding and antithrombotics: Characteristics and management. World J Gastroenterol 2020; 26:5463-5473. [PMID: 33024397 PMCID: PMC7520611 DOI: 10.3748/wjg.v26.i36.5463] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/30/2020] [Accepted: 08/29/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND There are few reports on major gastrointestinal (GI) bleeding among patients receiving an antithrombotic.
AIM To describe clinical characteristics, bleeding locations, management and in-hospital mortality related to these events.
METHODS Over a three-year period, we prospectively identified 1080 consecutive adult patients admitted in two tertiary care hospitals between January 1, 2013 and December 31, 2015 for major GI bleeding while receiving an antithrombotic. The bleeding events were medically validated. Clinical characteristics, causative lesions, management and fatalities were described. The distribution of antithrombotics prescribed was compared across the bleeding lesions identified.
RESULTS Of 576 patients had symptoms of upper GI bleeding and 504 symptoms of lower GI bleeding. No cause was identified for 383 (35.5%) patients. Gastro-duodenal ulcer was the first causative lesion in the upper tract (209 out of 408) and colonic diverticulum the first causative lesion in the lower tract (120 out of 289). There was a larger proportion of direct oral anticoagulant use among patients with lower GI than among those with upper GI lesion locations (P = 0.03). There was an independent association between gastro-duodenal ulcer and antithrombotic use (P = 0.03), taking account of confounders and proton pump inhibitor co-prescription. Pair wise comparisons pointed to a difference between vitamin K antagonist, direct oral anticoagulants, and antiplatelet agents in monotherapy vs dual antiplatelet agents.
CONCLUSION We showed a higher rate of bleeding lesion identification and suggested a different pattern of antithrombotic exposure between upper and lower GI lesion locations and between gastro-duodenal ulcer and other identified upper GI causes of bleeding. Management was similar across antithrombotics and in-hospital mortality was low (5.95%).
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Affiliation(s)
- Jacques Bouget
- EA 7449 REPERES, Pharmacoepidemiology and Health Services Research, Univ Rennes, Rennes 35000, France
| | - Damien Viglino
- Emergency Department and Mobile Intensive Care Unit-HP2 Laboratory INSERM U1042, University Grenoble Alps, La Tronche 38700, France
| | | | - Emmanuel Oger
- EA 7449 REPERES, Université de Rennes 1, Rennes 35000, France
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Erdoes G, Koster A, Ortmann E, Meesters MI, Bolliger D, Baryshnikova E, Martinez Lopez De Arroyabe B, Ahmed A, Lance MD, Ranucci M, von Heymann C, Agarwal S, Ravn HB. A European consensus statement on the use of four-factor prothrombin complex concentrate for cardiac and non-cardiac surgical patients. Anaesthesia 2020; 76:381-392. [PMID: 32681570 DOI: 10.1111/anae.15181] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2020] [Indexed: 02/06/2023]
Abstract
Modern four-factor prothrombin complex concentrate was designed originally for rapid targeted replacement of the coagulation factors II, VII, IX and X. Dosing strategies for the approved indication of vitamin K antagonist-related bleeding vary greatly. They include INR and bodyweight-related protocols as well as fixed dose regimens. Particularly in the massively bleeding trauma and cardiac surgery patient, four-factor prothrombin complex concentrate is used increasingly for haemostatic resuscitation. Members of the Transfusion and Haemostasis Subcommittee of the European Association of Cardiothoracic Anaesthesiology performed a systematic literature review on four-factor prothrombin complex concentrate. The available evidence has been summarised for dosing, efficacy, drug safety and monitoring strategies in different scenarios. Whereas there is evidence for the efficacy of four-factor prothrombin concentrate for a variety of bleeding scenarios, convincing safety data are clearly missing. In the massively bleeding patient with coagulopathy, our group recommends the administration of an initial bolus of 25 IU.kg-1 . This applies for: the acute reversal of vitamin K antagonist therapy; haemostatic resuscitation, particularly in trauma; and the reversal of direct oral anticoagulants when no specific antidote is available. In patients with a high risk for thromboembolic complications, e.g. cardiac surgery, the administration of an initial half-dose bolus (12.5 IU.kg-1 ) should be considered. A second bolus may be indicated if coagulopathy and microvascular bleeding persists and other reasons for bleeding are largely ruled out. Tissue-factor-activated, factor VII-dependent and heparin insensitive point-of-care tests may be used for peri-operative monitoring and guiding of prothrombin complex concentrate therapy.
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Affiliation(s)
- G Erdoes
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - A Koster
- Institute for Anaesthesiology, Heart and Diabetes Centre NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - E Ortmann
- Department of Anaesthesia, Kerckhoff Heart and Lung Centre, Bad Nauheim, Germany
| | - M I Meesters
- Department of Anaesthesiology, University Medical Centre Utrecht, The Netherlands
| | - D Bolliger
- Department of Anaesthesia, Prehospital Emergency Medicine, and Pain Therapy, University Hospital Basel, Switzerland
| | - E Baryshnikova
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | | | - A Ahmed
- Department of Anaesthesia, University Hospitals of Leicester NHS Trust, UK.,Department of Cardiovascular Sciences, University of Leicester, UK
| | - M D Lance
- Hamad Medical Corporation, HMC, Anaesthesiology, ICU and Peri-operative Medicine, Doha, Qatar
| | - M Ranucci
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - C von Heymann
- Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - S Agarwal
- Department of Anaesthesia, Manchester University Hospitals, Manchester, UK
| | - H B Ravn
- Department of Cardiothoracic Anaesthesiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
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20
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Mellado M, Trujillo-Santos J, Bikdeli B, Jiménez D, Núñez MJ, Ellis M, Marchena PJ, Vela JR, Clara A, Moustafa F, Monreal M. Vena cava filters in patients presenting with major bleeding during anticoagulation for venous thromboembolism. Intern Emerg Med 2019; 14:1101-1112. [PMID: 31054013 DOI: 10.1007/s11739-019-02077-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 03/20/2019] [Indexed: 12/28/2022]
Abstract
The association between inferior vena cava filter (IVC) use and outcome in patients presenting with major bleeding during anticoagulation for venous thromboembolism (VTE) has not been thoroughly investigated. We used the RIETE registry to compare the 30-day outcomes (death, major re-bleeding or VTE recurrences) in VTE patients who bled during the first 3 months of therapy, regarding the insertion of an IVC filter. A propensity score matched (PSM) analysis was performed to adjust for potential confounders. From January 2001 to September 2016, 1065 VTE patients had major bleeding during the first 3 months of anticoagulation (gastrointestinal 370; intracranial 124). Of these, 122 patients (11%) received an IVC filter. Patients receiving a filter restarted anticoagulation later (median, 4 vs. 2 days) and at lower doses (95 ± 52 IU/kg/day vs. 104 ± 55 of low-molecular-weight heparin) than those not receiving a filter. During the first 30 days after bleeding (after excluding 246 patients who died within the first 24 h), 283 patients (27%) died, 63 (5.9%) had non-fatal re-bleeding and 19 (1.8%) had recurrent pulmonary embolism (PE). In PSM analysis, patients receiving an IVC filter (n = 122) had a lower risk for all-cause death (HR 0.49; 95% CI 0.31-0.77) or fatal bleeding (HR 0.16; 95% CI 0.07-0.49) and a similar risk for re-bleeding (HR 0.55; 95% CI 0.23-1.40) or PE recurrences (HR 1.57; 95% CI 0.38-6.36) than those not receiving a filter (n = 429). In VTE patients experiencing major bleeding during the first 3 months, use of an IVC filter was associated with reduced mortality rates.Clinical Trial Registration NCT02832245.
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Affiliation(s)
- Meritxell Mellado
- Department of Angiology and Vascular Surgery, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Javier Trujillo-Santos
- Department of Internal Medicine, Hospital General Universitario de Santa Lucía, Murcia, Universidad Católica de Murcia (UCAM), Murcia, Spain
| | - Behnood Bikdeli
- Division of Cardiology, Department of Medicine, Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY, USA
- Yale/YNHH Center for Outcomes Research and Evaluation (CORE), New Haven, CT, USA
- Cardiovascular Research Foundation (CRF), New York, NY, USA
| | - David Jiménez
- Respiratory Department, Hospital Universitario Ramón Y Cajal, IRYCIS, Madrid, Spain
| | - Manuel Jesús Núñez
- Department of Internal Medicine, Complejo Hospitalario de Pontevedra, Pontevedra, Spain
| | - Martin Ellis
- Department of Haematology, Meir Hospital, Kfar Saba, Israel
| | - Pablo Javier Marchena
- Department of Internal Medicine and Emergency, Parc Sanitari Sant Joan de Deu-Hospital General, Barcelona, Spain
| | - Jerónimo Ramón Vela
- Department of Internal Medicine, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Albert Clara
- Department of Angiology and Vascular Surgery, Hospital del Mar, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Farès Moustafa
- Department of Emergency, Clermont-Ferrand University Hospital, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trias I Pujol, Universidad Autónoma de Barcelona, Carretera del Canyet s.n., Badalona, 08916, Barcelona, Spain.
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21
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Vigué B, Samama CM. Prise en charge hémostatique des hémorragies cérébrales sous anticoagulants oraux. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2019-0113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
L’hématome intracrânien spontané a un pronostic clinique sévère. Le devenir des patients dépend de l’efficacité de la prise en charge initiale. L’importance du saignement, le volume de l’hématome et son évolution sont les facteurs principaux qui contrôlent mortalité et morbidité. Les traitements anticoagulants oraux, antivitamines K (AVK) et anticoagulants oraux directs (AOD), favorisent l’expansion de l’hématome. La correction rapide de l’hémostase permet le contrôle partiel de l’hématome. Alors que la réversion des AVK par les concentrés de complexe prothrombinique (CCP) a fait l’objet de recommandations bien diffusées, l’attitude thérapeutique reste peu codifiée avec les AOD, alliant l’utilisation de l’idarucizumab pour le dabigatran et des CCP pour les anti-Xa qui n’ont, pour l’instant, pas d’antidote.
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22
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Spiliopoulos S, Festas G, Theodosis A, Palialexis K, Reppas L, Konstantos C, Brountzos E. Incidence and endovascular treatment of severe spontaneous non-cerebral bleeding: a single-institution experience. Eur Radiol 2019; 29:3296-3307. [PMID: 30519935 DOI: 10.1007/s00330-018-5869-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 10/16/2018] [Accepted: 10/29/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To investigate the incidence and endovascular treatment of severe spontaneous non-cerebral hemorrhage (SSNCH) in a high-volume, tertiary university hospital. METHODS All patients diagnosed with SSNCH between January 2016 and June 2017 were retrospectively analyzed. Endovascular treatment (group EVT) was offered only in patients demonstrating active bleeding at CT angiography (CTA). In cases without active bleeding at CTA, conservative management was decided (group CM). Outcome measures included the incidence of SSNCH, 6-month rebleeding, and survival rates in the two groups as well as EVT technical success and related complications. RESULTS Within the 18-month period, 44 SSNCH cases were identified, resulting in an annual incidence of 29.3 cases. In 37/44 cases (84.1%), bleeding was attributed to the antithrombotic therapy. In total, 19/44 patients underwent EVT (43.2%), and 25/44 patients (56.8%) were managed conservatively. Two patients who were initially treated conservatively finally underwent EVT due to rebleeding (7.4%). The technical success of EVT was 100%, while rebleeding occurred in 1 case (5.2%) following lumbar artery embolization and was successfully re-embolized. According to the Kaplan-Meier analysis, the 1-, 3-, and 6-month survival rates were 68.4%, 63.2%, and 42.1% for group EVT and 87.5%, 75.0%, and 58.3% for group CM, respectively. There were no EVT-related complications. CONCLUSIONS The annual incidence of SSNCH in our institution is substantial. EVT resulted in uncomplicated, high bleeding control rates. The mortality rate was similarly high following either EVT or conservative treatment and was mainly attributed to severe comorbidities. KEY POINTS • This study demonstrates that the incidence of severe spontaneous non-cerebral hemorrhage (SSNCH) in our institution is substantial. • Endovascular treatment was offered only in patients with clinical signs of ongoing hemorrhage and active bleeding at CT angiography and resulted in effective and uncomplicated, minimal invasive hemostasis, in a population with severe comorbidities. • This is the first study to evaluate the outcomes of both endovascular hemostasis and conservative management. Rebleeding following either conservative or endovascular treatment was minimal.
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Affiliation(s)
- Stavros Spiliopoulos
- 2nd Department of Radiology, Division of Interventional Radiology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
| | - Georgios Festas
- 2nd Department of Radiology, Division of Interventional Radiology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Antonios Theodosis
- 2nd Department of Radiology, Division of Interventional Radiology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Palialexis
- 2nd Department of Radiology, Division of Interventional Radiology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Lazaros Reppas
- 2nd Department of Radiology, Division of Interventional Radiology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Chysostomos Konstantos
- 2nd Department of Radiology, Division of Interventional Radiology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Elias Brountzos
- 2nd Department of Radiology, Division of Interventional Radiology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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23
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Bouget J, Balusson F, Scailteux LM, Maignan M, Roy PM, L'her E, Pavageau L, Nowak E. Major bleeding with antithrombotic agents: a 2012-2015 study using the French nationwide Health Insurance database linked to emergency department records within five areas - rationale and design of SACHA study. Fundam Clin Pharmacol 2019; 33:443-462. [PMID: 30537335 DOI: 10.1111/fcp.12444] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 11/27/2018] [Accepted: 12/06/2018] [Indexed: 12/29/2022]
Abstract
Bleeding represents the most recognized and feared complications of antithrombotic drugs including oral anticoagulants. Previous studies showed inconsistent results on the safety profile. Among explanations, bleeding definition could vary and classification bias exists related to the lack of medical evaluation. To quantify the risk of major haemorrhagic event and event-free survival associated with antithrombotic drugs (vitamin K antagonist [VKA], non-VKA anticoagulant [NOAC], antiplatelet agent, parenteral anticoagulant) in 2012-2015, we linked the French nationwide Health Insurance database (SNIIRAM) with a local 'emergency database' (clinical and biological data collected in clinical records). In the VKA-NOAC comparison, a Cox regression analysis will be used to estimate the hazard ratio of major haemorrhagic event adjusted on gender, modified HAS-BLED score and comorbidities. A distinction on the type of major haemorrhagic event (intracranial, gastrointestinal and other haemorrhagic events) was made. We present here the study protocol and the database linkage results. Using six linkage keys, among 3 837 557 hospital visits identified in SNIIRAM, 5264 have been matched with a major haemorrhagic event identified in the 'emergency database', thus clinically confirmed. The 1090 unmatched haemorrhagic events could be explained by the fact that patients were not extracted in the SNIIRAM database (patients living in accommodation establishment with internal use of pharmacy, military people with specific insurance…). We showed the value of SNIIRAM enrichment with a clinical database, a necessary step to categorize haemorrhagic events by a clinically relevant definition and medical validation; it will allow to estimate more accuracy each type of haemorrhagic event.
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Affiliation(s)
- Jacques Bouget
- Univ Rennes, REPERES [Pharmacoepidemiology and Heath Services Research] - EA 7449, Univ Rennes, Rennes, F-35000, France.,Emergency Department, University hospital, Rennes, F-35033, France
| | - Frédéric Balusson
- Univ Rennes, REPERES [Pharmacoepidemiology and Heath Services Research] - EA 7449, Univ Rennes, Rennes, F-35000, France
| | - Lucie-Marie Scailteux
- Univ Rennes, REPERES [Pharmacoepidemiology and Heath Services Research] - EA 7449, Univ Rennes, Rennes, F-35000, France.,Pharmacovigilance, Pharmacoepidemiology and drug information center, Rennes, F-35033, France
| | - Maxime Maignan
- Emergency Department, University Hospital, Grenoble, F-38043, France
| | - Pierre-Marie Roy
- Emergency Department, University hospital, Angers, F-49033, France
| | - Erwan L'her
- Emergency Department, University hospital, Brest, F-29609, France
| | - Laure Pavageau
- Emergency Department, University hospital, Nantes, F-44093, France
| | - Emmanuel Nowak
- CHU de Brest, Brest, F-29200, France.,Inserm CIC 1412, IFR 148, Université de Brest, Brest, F-29200, France
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24
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Alfeky H, McArthur P, Helmy Y. Salvaging Digital Replantation and Revascularisation: Efficiency of Heparin Solution Subcutaneous Injection. Surg Res Pract 2018; 2018:1601738. [PMID: 30584577 PMCID: PMC6280226 DOI: 10.1155/2018/1601738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 09/04/2018] [Accepted: 10/31/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Distal digital replantation and revascularisation remains one of the demanding microsurgical procedures due to the difficulty of vascular anastomosis. Venous congestion is the most commonly encountered problem after replantation due to the difficulty of venous anastomosis in traumatic injuries. Heparin, among other drugs, is commonly used to facilitate venous drainage and prevent thrombosis. However, systemic heparin can be contraindicated in some patients. The senior author has experience of subcutaneous heparin injection for venous congestion in thirteen patients. METHODS An amount of 1 ml of calcium heparin (25,000 U) was mixed in 2.4 ml of normal saline making a solution that has 1000 U per 0.1 ml. 1000 U (0.1 ml) of the solution was injected directly into the congested replanted digits. This was repeated twice daily until venous congestion improved. RESULTS All the congested replanted digits survived without systemic side effects. There were no local side effects of the treatment. The PT and APTT have shown slight increase but they remained within the normal range. Haemoglobin levels have dropped slightly but no patients were at any risk of developing anaemia or needed blood transfusion. CONCLUSIONS Subcutaneous heparin injections can salvage the replanted digits when venous congestion is a warning flag for replantation failure. It is safe and very efficient in patients where systemic heparin cannot be administered. However, this article shows the results in only thirteen patients which is a small number to show the efficacy, safety, and side effects.
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Affiliation(s)
- Haz Alfeky
- Consultant Plastic Surgeon, Plastic Surgery Department, University Hospital Coventry and Warwickshire, Coventry, UK
| | - Paul McArthur
- Consultant Plastic Surgery, Whiston Hospital, Liverpool, UK
| | - Yasser Helmy
- Professor of Plastic Surgery, Alazhar University Hospitals, Cairo, Egypt
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25
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Galliazzo S, Donadini MP, Ageno W. Antidotes for the direct oral anticoagulants: What news? Thromb Res 2018; 164 Suppl 1:S119-S123. [PMID: 29703468 DOI: 10.1016/j.thromres.2018.01.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 01/02/2018] [Accepted: 01/03/2018] [Indexed: 01/06/2023]
Abstract
The direct oral anticoagulants (DOACs) are recommended as the first-choice anticoagulants for both stroke prevention in patients with non-valvular atrial fibrillation and the treatment and secondary prevention of venous thromboembolism. DOACs cause bleeding, albeit less than warfarin. Most bleeding complications can be controlled by general reversal strategies and supportive care. However, in case of life-threatening bleeding, or when urgent invasive procedures are needed, a more rapid and thorough reversal may be required. Idarucizumab, andexanet alfa and ciraparantag have been developed as reversal agents for the DOACs. To date idarucizumab is the only approved antidote and is specific for dabigatran. Andexanet alfa, a reversal agent for the factor Xa inhibitors, is still under investigation, but its approval by regulatory agencies is expected soon. Ciraparantag, a universal antidote, is in an earlier stage of development. Based on the results of clinical trials to date, these compounds appear to be breakthrough for urgent and emergency reversal. When administered at fixed doses, they ensured a rapid, efficient and safe restoration of haemostasis. From a practical perspective, all hospitals should develop local protocols to ensure safe and efficient clinical implementation of reversal strategies. Post-marketing studies will be essential to assess the evolution of management strategies and to confirm the safety and effectiveness of these agents.
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Affiliation(s)
- S Galliazzo
- Research Center on Thromboembolic Diseases and Antithrombotic Drugs, Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - M P Donadini
- Research Center on Thromboembolic Diseases and Antithrombotic Drugs, Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - W Ageno
- Research Center on Thromboembolic Diseases and Antithrombotic Drugs, Department of Medicine and Surgery, University of Insubria, Varese, Italy.
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26
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Moustafa F, Stehouwer A, Kamphuisen P, Sahuquillo JC, Sampériz Á, Alfonso M, Pace F, Suriñach JM, Blanco-Molina Á, Mismetti P, Monreal M. Management and outcome of major bleeding in patients receiving vitamin K antagonists for venous thromboembolism. Thromb Res 2018; 171:74-80. [PMID: 30265883 DOI: 10.1016/j.thromres.2018.09.049] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 09/12/2018] [Accepted: 09/15/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND The optimal management of major bleeding in patients receiving vitamin K antagonists (VKA) for venous thromboembolism (VTE) is unclear. METHODS We used the RIETE (Registro Informatizado Enfermedad TromboEmbólica) registry to assess the management and 30-day outcomes after major bleeding in patients receiving VKA for VTE. RESULTS From January 2013 to December 2017, 267 of 18,416 patients (1.4%) receiving long-term VKA for VTE had a major bleeding (in the gastrointestinal tract 78, intracranial 72, hematoma 50, genitourinary 20, other 47). Overall, 151 patients (57%) received blood transfusion; 110 (41%) vitamin K; 37 (14%) fresh frozen plasma; 29 (11%) pro-haemostatic agents and 20 (7.5%) a vena cava filter. During the first 30 days, 59 patients (22%) died (41 died of bleeding) and 13 (4.9%) had a thrombosis. On multivariable analysis, patients with intracranial bleeding (hazard ratio [HR]: 4.58; 95%CI: 2.40-8.72) and those with renal insufficiency at baseline (HR: 2.73; 95%CI: 1.45-5.15) had an increased mortality risk, whereas those receiving vitamin K had a lower risk (HR: 0.47; 0.24-0.92). On the other hand, patients receiving fresh frozen plasma were at increased risk for thrombotic events (HR: 4.22; 95%CI: 1.25-14.3). CONCLUSIONS Major bleeding in VTE patients receiving VKA carries a high mortality rate. Intracranial bleeding and renal insufficiency increased the risk. Fresh frozen plasma seems to increase this risk for recurrent VTE.
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Affiliation(s)
- Farès Moustafa
- Department of Emergency, Clermont-Ferrand University Hospital, Clermont-Ferrand, France.
| | - Alexander Stehouwer
- University of Groningen, University Medical Center Groningen, Department of Internal Medicine, Division of Vascular Medicine, Groningen, Netherlands.
| | - Pieter Kamphuisen
- Department of Internal Medicine, Tergooi Hilversum, Netherlands and Department of Vascular Medicine, University Medical Center Groningen, Groningen, Netherlands.
| | | | - Ángel Sampériz
- Department of Internal Medicine, Hospital Reina Sofía, Tudela, Navarra, Spain.
| | - María Alfonso
- Department of Pneumonology, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Federica Pace
- Department of Medicina d'Urgenza, Ospedale San Camilo, Rome, Italy.
| | | | | | - Patrick Mismetti
- Thrombosis Research Group, Université de Saint-Etienne, Jean Monnet, Inserm, Service de Médecine Interne et Thérapeutique, Hôpital Nord, Saint-Etienne, France.
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol de Badalona, Barcelona, Universidad Católica de Murcia, Spain.
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27
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Albaladejo P, Pernod G, Godier A, de Maistre E, Rosencher N, Mas JL, Fontana P, Samama CM, Steib A, Schlumberger S, Marret E, Roullet S, Susen S, Madi-Jebara S, Nguyen P, Schved JF, Bonhomme F, Sié P. Management of bleeding and emergency invasive procedures in patients on dabigatran: Updated guidelines from the French Working Group on Perioperative Haemostasis (GIHP) – September 2016. Anaesth Crit Care Pain Med 2018; 37:391-399. [DOI: 10.1016/j.accpm.2018.04.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 04/17/2018] [Accepted: 04/18/2018] [Indexed: 11/25/2022]
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28
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Abstract
The recent emergence of 'non-VKA' oral anticoagulants may have led to some forgetting that vitamin K antagonists (VKA) are by far the most widely prescribed oral anticoagulants worldwide. Consequently, we decided to summarize the information available on them. This paper presents the problems facing emergency physicians confronted with patients on VKAs in 10 points, from pharmacological data to emergency management. Vitamin K antagonists remain preferable in many situations including in the elderly, in patients with extreme body weights, severe chronic kidney or liver disease or valvular heart disease, and in patients taking VKAs with well-controlled international normalized ratios (INRs). Given the way VKAs work, a stable anticoagulant state can only be achieved at the earliest 5 days after starting therapy. The induction phase of VKA treatment is associated with the highest risk of bleeding; validated algorithms based on INR values have to be followed. VKA asymptomatic overdoses and 'non-severe' hemorrhage are managed by omitting a dose or stopping treatment plus administering vitamin K depending on the INR. Major bleeding is managed using a VKA reversal strategy. A prothrombin complex concentrate infusion plus vitamin K is preferred to rapidly achieve an INR of up to 1.5 and maintain a normal coagulation profile. The INR must be measured 30 min after the infusion. Before an invasive procedure, if an INR of less than 1.5 (<1.3 in neurosurgery) is required, it can be achieved by combining prothrombin complex concentrate and vitamin K. A well-codified strategy is essential for managing patients requiring emergency invasive procedures or presenting bleeding complications.
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Kataruka A, Renner E, Barnes GD. Evaluating the role of clinical pharmacists in pre-procedural anticoagulation management. Hosp Pract (1995) 2017; 46:16-21. [PMID: 29283294 DOI: 10.1080/21548331.2018.1420346] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES While physicians are typically responsible for managing perioperative warfarin, clinic pharmacists may improve pre-procedural decision-making. We assessed the impact of pharmacist-driven care for chronic warfarin-treated patients undergoing outpatient right heart catheterization (RHC). METHODS 200 warfarin patients who underwent RHC between January 2012 and September 2015 were analyzed. Pharmacist-care (n = 79) was compared to the usual care model (n = 121). The primary outcome was a composite of (1) documentation of anticoagulation plan, (2) holding warfarin at least 5 days prior to procedure, (3) guideline-congruent low molecular weight heparin (LMWH) bridging, and (4) correct LMWH dosing if bridging deemed necessary. Chi-squared test performed to assess the role of pharmacist. A multivariable logistic regression analysis was performed to the composite endpoint, adjusted for the month of procedure. RESULTS Compared to the usual care model, pharmacist-driven care (OR 4.69, 95% CI 1.73-12.71, p = 0.002) and date of the procedure (OR 1.06/month, 95% CI 1.01-1.10, p = 0.011) were independently associated with the primary composite outcome. Of the individual outcome components, pharmacist-driven care was only associated with documentation (96.2% vs. 67.8%, OR 9.19, 95% CI 2.19-38.62, p = 0.002). Remaining components including hold warfarin for at least 5 days, appropriate bridging and correct LMWH dosing were not significantly associated with pharmacist-care. CONCLUSIONS Pharmacist-care is associated with better guideline-based anticoagulation management, but this was primarily driven by improved documentation. The impact of pharmacist managed peri-procedural anticoagulation on clinical outcomes remains unknown.
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Affiliation(s)
- Akash Kataruka
- a Department of Internal Medicine , Michigan Medicine , Ann Arbor , MI , USA
| | - Elizabeth Renner
- b Department of Pharmacy Services , Michigan Medicine , Ann Arbor , MI , USA
| | - Geoffrey D Barnes
- c Frankel Cardiovascular Center , Michigan Medicine , Ann Arbor , MI , USA
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Chai-Adisaksopha C, Hillis C, Siegal DM, Movilla R, Heddle N, Crowther M, Iorio A. Prothrombin complex concentrates versus fresh frozen plasma for warfarin reversal A systematic review and meta-analysis. Thromb Haemost 2017; 116:879-890. [DOI: 10.1160/th16-04-0266] [Citation(s) in RCA: 118] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 06/22/2016] [Indexed: 01/02/2023]
Abstract
SummaryUrgent reversal of warfarin is required for patients who experience major bleeding or require urgent surgery. Treatment options include the combination of vitamin K and coagulation factor replacement with either prothrombin complex concentrate (PCC) or fresh frozen plasma (FFP). However, the optimal reversal strategy is unclear based on clinically relevant outcomes. We searched in MEDLINE, EMBASE and Cochrane library to December 2015. Thirteen studies (5 randomised studies and 8 observational studies) were included. PCC use was associated with a significant reduction in all-cause mortality compared to FFP (OR= 0.56, 95 % CI; 0.37–0.84, p=0.006). A higher proportion of patients receiving PCC achieved haemostasis compared to those receiving FFP, but this was not statistically significant (OR 2.00, 95 % CI; 0.85–4.68). PCC use was more likely to achieve normalisation of international normalised ratio (INR) (OR 10.80, 95 % CI; 6.12–19.07) and resulted in a shorter time to INR correction (mean difference –6.50 hours, 95 %CI; –9.75 to –3.24). Red blood cell transfusion was not statistically different between the two groups (OR 0.88, 95 % CI: 0.53–1.43). Patients receiving PCC had a lower risk of post-transfusion volume overload compared to FFP (OR 0.27, 95 % CI; 0.13–0.58). There was no statistically significant difference in the risk of thromboembolism following administration of PCC or FFP (OR 0.91, 95 % CI; 0.44–1.89). In conclusion, as compared to FFP, the use of PCC for warfarin reversal was associated with a significant reduction in all-cause mortality, more rapid INR reduction, and less volume overload without an increased risk of thromboembolic events.Supplementary Material to this article is available online at www.thrombosis-online.com.
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Baumgartner H, Falk V, Bax JJ, De Bonis M, Hamm C, Holm PJ, Iung B, Lancellotti P, Lansac E, Rodriguez Muñoz D, Rosenhek R, Sjögren J, Tornos Mas P, Vahanian A, Walther T, Wendler O, Windecker S, Zamorano JL. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J 2017; 38:2739-2791. [PMID: 28886619 DOI: 10.1093/eurheartj/ehx391] [Citation(s) in RCA: 4213] [Impact Index Per Article: 601.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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Falk V, Baumgartner H, Bax JJ, De Bonis M, Hamm C, Holm PJ, Iung B, Lancellotti P, Lansac E, Muñoz DR, Rosenhek R, Sjögren J, Tornos Mas P, Vahanian A, Walther T, Wendler O, Windecker S, Zamorano JL, Roffi M, Alfieri O, Agewall S, Ahlsson A, Barbato E, Bueno H, Collet JP, Coman IM, Czerny M, Delgado V, Fitzsimons D, Folliguet T, Gaemperli O, Habib G, Harringer W, Haude M, Hindricks G, Katus HA, Knuuti J, Kolh P, Leclercq C, McDonagh TA, Piepoli MF, Pierard LA, Ponikowski P, Rosano GM, Ruschitzka F, Shlyakhto E, Simpson IA, Sousa-Uva M, Stepinska J, Tarantini G, Tchétché D, Aboyans V. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur J Cardiothorac Surg 2017; 52:616-664. [DOI: 10.1093/ejcts/ezx324] [Citation(s) in RCA: 429] [Impact Index Per Article: 61.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Sahai T, Tavares MF, Sweeney JD. Rapid response to intravenous vitamin K may obviate the need to transfuse prothrombin complex concentrates. Transfusion 2017; 57:1885-1890. [DOI: 10.1111/trf.14166] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 04/13/2017] [Accepted: 04/17/2017] [Indexed: 12/16/2022]
Affiliation(s)
- Tanmay Sahai
- Roger Williams Hospital; Providence Rhode Island
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Ozawa S, Nelson T. Clinical Application of Prothrombin Complex Concentrate in Blood Management in Patients. Crit Care Nurse 2017; 37:49-56. [PMID: 28365649 DOI: 10.4037/ccn2017333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Management of patients receiving anticoagulants is a major factor in achieving better outcomes. Anticoagulant therapy may need to be discontinued or rapidly reversed before urgent surgery or invasive procedures. In these situations, treatment with concentrated vitamin K, fresh frozen plasma, and/or clotting factors can achieve more rapid anticoagulant reversal than can drug discontinuation alone. Activated prothrombin complex concentrate is used to treat hemophiliac patients with acquired factor VIII inhibitors. Nonactivated prothrombin complex concentrates are used for anticoagulant reversal. The concentrates are effective within minutes of dosing, providing a nearly immediate decrease in the international normalized ratio. The concentrates are lyophilized powders that can be quickly reconstituted, do not require ABO blood typing before use, and contain 25 times the concentration of vitamin K-dependent clotting factors compared with fresh frozen plasma. Studies suggest that the concentrates are associated with better clinical end points than is fresh frozen plasma.
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Affiliation(s)
- Sherri Ozawa
- Sherri Ozawa is the clinical director, Institute for Patient Blood Management and Bloodless Medicine and Surgery, Englewood Hospital and Medical Center, Englewood, NJ, and the executive director of the Society for the Advancement of Blood Management. .,Tiffany Nelson is the clinical director, patient blood management, and the transfusion safety officer for the Florida Hospital System, Orlando, Florida.
| | - Tiffany Nelson
- Sherri Ozawa is the clinical director, Institute for Patient Blood Management and Bloodless Medicine and Surgery, Englewood Hospital and Medical Center, Englewood, NJ, and the executive director of the Society for the Advancement of Blood Management.,Tiffany Nelson is the clinical director, patient blood management, and the transfusion safety officer for the Florida Hospital System, Orlando, Florida
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Incidence des hémorragies intracrâniennes retardées à 24h chez les patients traités par anticoagulants et victimes d’un traumatisme crânien. ANNALES FRANCAISES DE MEDECINE D URGENCE 2017. [DOI: 10.1007/s13341-017-0720-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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37
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Anaemia as an independent key risk factor for major haemorrhage in patients treated with vitamin K antagonists: Results of the SCORE prospective cohort. Thromb Res 2017; 151:83-88. [PMID: 28109541 DOI: 10.1016/j.thromres.2016.10.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 09/26/2016] [Accepted: 10/26/2016] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Risk scores for the prediction of haemorrhage are poorly predictive of major bleeding. The aim of this study was to refine the estimation of bleeding risk by identifying one or several parameters of prognostic significance among these algorithms. MATERIALS AND METHODS The SCORE study was a prospective, multicentre cohort study conducted in France in 2009-2010. Patients were eligible if they had received vitamin K antagonist (VKA) for any therapeutic indication for at least 3months. The primary outcome was the occurrence of major bleeding at 1-year follow-up. RESULTS In total, 962 patients were included in this study and evaluated at 1year. The incidence of major bleeding at 1-year follow-up (Kaplan-Meier method) was 2.9% [95% confidence interval (CI) 1.9-4.2]. The rate of major bleeding was 8.2% (95 CI 3.4-16.2) per year in patients classified as high risk by at least four scores. In a multivariate Cox analysis, of the risk factors for the different scores, only anaemia <100g/l at inclusion was strongly associated with risk of major bleeding (hazard ratio 6.1, 95% CI 2.7-13.8, P<0.0001). Through an induction tree analysis performed to identify a common parameter in the majority of scores, anaemia was found to be the main predictor of correct classification as high risk by at least four scores (55% of patients classified as high risk by at least four scores vs 3.3% in the absence of anaemia). CONCLUSION Anaemia with haemoglobin <100g/l is the most important predictor of high risk of bleeding in patients treated with VKA.
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Sayhan MB, Salt Ö, Demir AM. Prothrombin Complex Concentrates in Life-Threatening Bleeding. Balkan Med J 2016; 33:712-713. [PMID: 27994932 DOI: 10.5152/balkanmedj.2016.151625] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 02/19/2016] [Indexed: 11/22/2022] Open
Affiliation(s)
- Mustafa Burak Sayhan
- Department of Emergency Medicine, Trakya University School of Medicine, Edirne, Turkey
| | - Ömer Salt
- Department of Emergency Medicine, Trakya University School of Medicine, Edirne, Turkey
| | - Ahmet Muzaffer Demir
- Department of Internal Medicine/Hematology, Trakya University University School of Medicine, Edirne, Turkey
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The critical care management of spontaneous intracranial hemorrhage: a contemporary review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:272. [PMID: 27640182 PMCID: PMC5027096 DOI: 10.1186/s13054-016-1432-0] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Spontaneous intracerebral hemorrhage (ICH), defined as nontraumatic bleeding into the brain parenchyma, is the second most common subtype of stroke, with 5.3 million cases and over 3 million deaths reported worldwide in 2010. Case fatality is extremely high (reaching approximately 60 % at 1 year post event). Only 20 % of patients who survive are independent within 6 months. Factors such as chronic hypertension, cerebral amyloid angiopathy, and anticoagulation are commonly associated with ICH. Chronic arterial hypertension represents the major risk factor for bleeding. The incidence of hypertension-related ICH is decreasing in some regions due to improvements in the treatment of chronic hypertension. Anticoagulant-related ICH (vitamin K antagonists and the newer oral anticoagulant drugs) represents an increasing cause of ICH, currently accounting for more than 15 % of all cases. Although questions regarding the optimal medical and surgical management of ICH still remain, recent clinical trials examining hemostatic therapy, blood pressure control, and hematoma evacuation have advanced our understanding of ICH management. Timely and aggressive management in the acute phase may mitigate secondary brain injury. The initial management should include: initial medical stabilization; rapid, accurate neuroimaging to establish the diagnosis and elucidate an etiology; standardized neurologic assessment to determine baseline severity; prevention of hematoma expansion (blood pressure management and reversal of coagulopathy); consideration of early surgical intervention; and prevention of secondary brain injury. This review aims to provide a clinical approach for the practicing clinician.
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Ghadimi K, Levy JH, Welsby IJ. Prothrombin Complex Concentrates for Bleeding in the Perioperative Setting. Anesth Analg 2016; 122:1287-300. [PMID: 26983050 DOI: 10.1213/ane.0000000000001188] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Prothrombin complex concentrates (PCCs) contain vitamin K-dependent clotting factors (II, VII, IX, and X) and are marketed as 3 or 4 factor-PCC formulations depending on the concentrations of factor VII. PCCs rapidly restore deficient coagulation factor concentrations to achieve hemostasis, but like with all procoagulants, the effect is balanced against thromboembolic risk. The latter is dependent on both the dose of PCCs and the individual patient prothrombotic predisposition. PCCs are approved by the US Food and Drug Administration for the reversal of vitamin K antagonists in the setting of coagulopathy or bleeding and, therefore, can be administered when urgent surgery is required in patients taking warfarin. However, there is growing experience with the off-label use of PCCs to treat patients with surgical coagulopathic bleeding. Despite their increasing use, there are limited prospective data related to the safety, efficacy, and dosing of PCCs for this indication. PCC administration in the perioperative setting may be tailored to the individual patient based on the laboratory and clinical variables, including point-of-care coagulation testing, to balance hemostatic benefits while minimizing the prothrombotic risk. Importantly, in patients with perioperative bleeding, other considerations should include treating additional sources of coagulopathy such as hypofibrinogenemia, thrombocytopenia, and platelet disorders or surgical sources of bleeding. Thromboembolic risk from excessive PCC dosing may be present well into the postoperative period after hemostasis is achieved owing to the relatively long half-life of prothrombin (factor II, 60-72 hours). The integration of PCCs into comprehensive perioperative coagulation treatment algorithms for refractory bleeding is increasingly reported, but further studies are needed to better evaluate the safe and effective administration of these factor concentrates.
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Affiliation(s)
- Kamrouz Ghadimi
- From the Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
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41
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Moustafa F, Saint-Denis J, Laporte S, Mismetti P, Schmidt J. Comparison of blood coagulation factors between patients with gastrointestinal or intracranial bleeding under vitamin K antagonists. Eur J Intern Med 2016; 33:e22-4. [PMID: 27209417 DOI: 10.1016/j.ejim.2016.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 04/29/2016] [Accepted: 05/02/2016] [Indexed: 11/27/2022]
Affiliation(s)
- F Moustafa
- Service des Urgences Adultes, CHU Gabriel Montpied, Clermont-Ferrand, France.
| | - J Saint-Denis
- Service des Urgences Adultes, CHU Gabriel Montpied, Clermont-Ferrand, France; Université d'Auvergne, Clermont-I, UFR de Médecine, Clermont-Ferrand, France
| | - S Laporte
- EA3065, Université Jean Monnet, Saint-Etienne, France; Unité de Recherche Clinique, Innovation, et Pharmacologie, Centre hospitalo-universitaire de Saint-Etienne, Hôpital Nord, Saint-Etienne, France
| | - P Mismetti
- EA3065, Université Jean Monnet, Saint-Etienne, France; Unité de Recherche Clinique, Innovation, et Pharmacologie, Centre hospitalo-universitaire de Saint-Etienne, Hôpital Nord, Saint-Etienne, France; Service de Médecine interne et Thérapeutique, Centre hospitalo-universitaire de Saint-Etienne, Hôpital Nord, Saint-Etienne, France
| | - J Schmidt
- Service des Urgences Adultes, CHU Gabriel Montpied, Clermont-Ferrand, France; Université d'Auvergne, Clermont-I, UFR de Médecine, Clermont-Ferrand, France
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42
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Charbonneau H, Pathak A, Albenque JP, Misrai V. Greenlight™ photovaporization of the prostate in patients under rivaroxaban: Lesson learned after the first cases. Prog Urol 2016; 26:273-5. [PMID: 26970929 DOI: 10.1016/j.purol.2016.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Accepted: 02/06/2016] [Indexed: 11/16/2022]
Affiliation(s)
- H Charbonneau
- EA 4564 "Modélisation de l'agression tissulaire et nociceptive", université Paul-Sabatier, 31000 Toulouse, France; Pôle anesthésie-réanimation, CHU Purpan, place du Dr-Baylac, 31059 Toulouse cedex 9, France.
| | - A Pathak
- Department of cardiovascular medicine, clinique Pasteur, 31300 Toulouse, France
| | - J-P Albenque
- Department of cardiovascular medicine, clinique Pasteur, 31300 Toulouse, France
| | - V Misrai
- Department of urology, clinique Pasteur, 31300 Toulouse, France
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43
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Ghadimi K, Dombrowski KE, Levy JH, Welsby IJ. Andexanet alfa for the reversal of Factor Xa inhibitor related anticoagulation. Expert Rev Hematol 2016; 9:115-22. [DOI: 10.1586/17474086.2016.1135046] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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44
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Llitjos JF, Daviaud F, Grimaldi D, Legriel S, Georges JL, Guerot E, Bedos JP, Fagon JY, Charpentier J, Mira JP. Ilio-psoas hematoma in the intensive care unit: a multicentric study. Ann Intensive Care 2016; 6:8. [PMID: 26782681 PMCID: PMC4717128 DOI: 10.1186/s13613-016-0106-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Accepted: 01/04/2016] [Indexed: 02/06/2023] Open
Abstract
Background
Clinical features and outcomes of patients with spontaneous ilio-psoas hematoma (IPH) in intensive care units (ICUs) are poorly documented. The objectives of this study were to determine epidemiological, clinical, biological and management characteristics of ICU patients with IPH. Methods
We conducted a retrospective multicentric study in three French ICUs from January 2006 to December 2014. We included IPH diagnosed both at admission and during ICU stay. Surgery and embolization were available 24 h a day for each center, and therapeutic decisions were undertaken after pluridisciplinary discussion. All IPHs were diagnosed using CT scan. Results During this period, we identified 3.01 cases/1000 admissions. The mortality rate of the 77 included patients was 30 %. In multivariate analysis, we observed that mortality was independently associated with SAPS II (OR 1.1, 95 % CI [1.013–1.195], p = 0.02) and with the presence of hemorrhagic shock (OR 67.1, 95 % CI [2.6–1691], p = 0.01). We found IPH was related to anticoagulation therapy in 56 cases (72 %), with guideline-concordant reversal performed in 33 % of patients. We did not found any association between anticoagulant therapy type and outcome. Conclusion We found IPH is an infrequent disease, with a high mortality rate of 30 %, mostly related to anticoagulation therapy and usually affecting the elderly. Management of anticoagulation-related IPH includes a high rate of no reversal of 38 %.
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Affiliation(s)
- J F Llitjos
- Medical Intensive Care Unit, Cochin Hospital, Groupe Hospitalier Cochin Broca Hôtel-Dieu, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France. .,Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, 15 rue de l'Ecole de Médecine, 75006, Paris, France.
| | - F Daviaud
- Medical Intensive Care Unit, Cochin Hospital, Groupe Hospitalier Cochin Broca Hôtel-Dieu, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France.,Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, 15 rue de l'Ecole de Médecine, 75006, Paris, France
| | - D Grimaldi
- Medical Intensive Care Unit, Cochin Hospital, Groupe Hospitalier Cochin Broca Hôtel-Dieu, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France.,Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, 15 rue de l'Ecole de Médecine, 75006, Paris, France
| | - S Legriel
- Intensive Care Unit, Hôpital de Versailles - Site André Mignot, 177 rue de Versailles, 78150, Le Chesnay Cedex, France
| | - J L Georges
- Cardiology, Hôpital de Versailles - Site André Mignot, 177 rue de Versailles, 78150, Le Chesnay Cedex, France
| | - E Guerot
- Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, 15 rue de l'Ecole de Médecine, 75006, Paris, France.,Medical Intensive Care Unit, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - J P Bedos
- Intensive Care Unit, Hôpital de Versailles - Site André Mignot, 177 rue de Versailles, 78150, Le Chesnay Cedex, France
| | - J Y Fagon
- Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, 15 rue de l'Ecole de Médecine, 75006, Paris, France.,Medical Intensive Care Unit, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - J Charpentier
- Medical Intensive Care Unit, Cochin Hospital, Groupe Hospitalier Cochin Broca Hôtel-Dieu, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France.,Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, 15 rue de l'Ecole de Médecine, 75006, Paris, France
| | - J P Mira
- Medical Intensive Care Unit, Cochin Hospital, Groupe Hospitalier Cochin Broca Hôtel-Dieu, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France.,Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, 15 rue de l'Ecole de Médecine, 75006, Paris, France
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Sartori MT, Prandoni P. How to effectively manage the event of bleeding complications when using anticoagulants. Expert Rev Hematol 2015; 9:37-50. [DOI: 10.1586/17474086.2016.1112733] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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46
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Milling TJ, Refaai MA, Goldstein JN, Schneider A, Omert L, Harman A, Lee ML, Sarode R. Thromboembolic Events After Vitamin K Antagonist Reversal With 4-Factor Prothrombin Complex Concentrate: Exploratory Analyses of Two Randomized, Plasma-Controlled Studies. Ann Emerg Med 2015; 67:96-105.e5. [PMID: 26094105 PMCID: PMC6537597 DOI: 10.1016/j.annemergmed.2015.04.036] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 04/16/2015] [Accepted: 04/27/2015] [Indexed: 10/25/2022]
Abstract
STUDY OBJECTIVE We evaluated thromboembolic events after vitamin K antagonist reversal in post hoc analyses of pooled data from 2 randomized trials comparing 4-factor prothrombin complex concentrate (4F-PCC) (Beriplex/Kcentra) with plasma. METHODS Unblinded investigators identified thromboembolic events, using standardized terms (such as "myocardial infarction," "deep vein thrombosis," "pulmonary embolism," and "ischemic stroke"). A blinded safety adjudication board reviewed serious thromboembolic events, as well as those referred by an independent unblinded data and safety monitoring board. We descriptively compared thromboembolic event and patient characteristics between treatment groups and included detailed patient-level outcome descriptions. We did not power the trials to assess safety. RESULTS We enrolled 388 patients (4F-PCC: n=191; plasma: n=197) in the trials. Thromboembolic events occurred in 14 of 191 patients (7.3%) in the 4F-PCC group and 14 of 197 (7.1%) in the plasma group (risk difference 0.2%; 95% confidence interval -5.5% to 6.0%). Investigators reported serious thromboembolic events in 16 patients (4F-PCC: n=8; plasma: n=8); the data and safety monitoring board referred 2 additional myocardial ischemia events (plasma group) to the safety adjudication board for review. The safety adjudication board judged serious thromboembolic events in 10 patients (4F-PCC: n=4; plasma: n=6) as possibly treatment related. There were 8 vascular thromboembolic events in the 4F-PCC group versus 4 in the plasma group, and 1 versus 6 cardiac events, respectively. Among patients with thromboembolic events, 3 deaths occurred in each treatment group. All-cause mortality for the pooled population was 13 per group. We observed no relationship between thromboembolic event occurrence and factor levels transiently above the upper limit of normal; there were no notable differences in median factor or proteins C and S levels up to 24 hours postinfusion start in patients with and without thromboembolic events. CONCLUSION The incidence of thromboembolic events after vitamin K antagonist reversal with 4F-PCC or plasma was similar and independent of coagulation factor levels; small differences in the number of thromboembolic event subtypes were observed between treatment groups.
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Affiliation(s)
- Truman J Milling
- Seton/UT Southwestern Clinical Research Institute of Austin, University Medical Center at Brackenridge, Dell Children's Medical Center, Austin, TX.
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Godier A, Gouin-Thibault I, Rosencher N, Albaladejo P. [Management of direct oral anticoagulants for invasive procedures]. ACTA ACUST UNITED AC 2015; 40:173-81. [PMID: 25778841 DOI: 10.1016/j.jmv.2015.02.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2014] [Accepted: 01/08/2015] [Indexed: 12/16/2022]
Abstract
Three new Direct Oral Anticoagulants (DOACs), rivaroxaban, apixaban and dabigatran etexilate are available on the French market. Management of DOAC-induced bleeding risk remains challenging. For elective procedures with high hemorrhagic risk, a last DOAC intake five days before procedure ensures complete elimination in all patients. Heparin bridging therapy should be proposed only to patients at high thrombotic risk. For elective procedures with low hemorrhagic risk, the DOAC intake of the night before procedure should be omitted. For urgent procedures with high bleeding risk, DOAC plasmatic concentration can be helpful: concentration lower than 30 ng/mL should enable performing the procedure; a high concentration is associated with a higher bleeding risk, especially if higher than 400 ng/mL. In case of massive bleeding, no antidote is approved yet; activated prothrombin concentrates or non-activated 4-factors prothrombin concentrates could be considered.
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Affiliation(s)
- A Godier
- Service d'anesthésie-réanimation, fondation ophtalmologique Adolphe-de-Rothschild, 25, rue Manin, 75019 Paris, France; Inserm UMR-S1140, université Paris-Descartes, Sorbonne Paris-Cité, 75006 Paris, France.
| | - I Gouin-Thibault
- Inserm UMR-S1140, université Paris-Descartes, Sorbonne Paris-Cité, 75006 Paris, France; Laboratoire d'hématologie, groupe hospitalier Cochin-Hôtel-Dieu, AP-HP, 75014 Paris, France
| | - N Rosencher
- Service d'anesthésie-réanimation, groupe hospitalier Cochin-Hôtel-Dieu, AP-HP, 75014 Paris, France
| | - P Albaladejo
- Pôle d'anesthésie-réanimation, CHU de Grenoble, 38000 Grenoble, France
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Morotti A, Frascisco MF. Emergency management of major bleeding in a case of maxillofacial trauma and anticoagulation: utility of prothrombin complex concentrates in the shock room. Hematol Rep 2015; 7:5656. [PMID: 25852847 PMCID: PMC4378204 DOI: 10.4081/hr.2015.5656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2014] [Accepted: 02/18/2015] [Indexed: 01/21/2023] Open
Abstract
Life-threatening bleeding in anticoagulation with Warfarin is an emergency challenging issue. Several approaches are available to treat bleeding in either over-anticoagulation or proper-anticoagulation, including vitamin K, fresh frozen plasma and prothrombin complex concentrates (PCC) administration. In coexisting trauma-induced bleeding and anticoagulation, reversal of anticoagulation must be a rapid and highly effective procedure. Furthermore the appropriate treatment must be directly available in each shock rooms to guarantee the rapid management of the emergency. PCC require a simple storage, rapid accessibility, fast administration procedures and high effectiveness. Here we report the utility of PCC in management of a craniofacial trauma in proper-anticoagulation.
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Affiliation(s)
- Alessandro Morotti
- Department of Internal Medicine, San Luigi Hospital, University of Turin , Italy
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Martin AC, Gouin-Thibault I, Siguret V, Mordohay A, Samama CM, Gaussem P, Le Bonniec B, Godier A. Multimodal assessment of non-specific hemostatic agents for apixaban reversal. J Thromb Haemost 2015; 13:426-36. [PMID: 25630710 DOI: 10.1111/jth.12830] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 12/07/2014] [Indexed: 08/31/2023]
Abstract
BACKGROUND Non-specific hemostatic agents, namely activated prothrombin complex concentrate (aPCC), PCC and recombinant activated factor (F) VII (rFVIIa), can be used, off-label, to reverse the effects of FXa inhibitors in the rare cases of severe hemorrhages, as no approved specific antidote is available. We have evaluated the ability of aPCC, PCC and rFVIIa to reverse apixaban. METHODS Healthy volunteer whole blood was spiked with therapeutic or supra-therapeutic apixaban concentrations and two doses of aPCC, PCC or rFVIIa. Tests performed included a turbidimetry assay for fibrin polymerization kinetics analysis, scanning electron microscopy for fibrin network structure observation, thrombin generation assay (TGA), thromboelastometry, prothrombin time and activated partial thromboplastin time. RESULTS aPCC generated a dense clot constituting thin and branched fibers similar to those of a control without apixaban, increased fibrin polymerization velocity and improved quantitative (endogenous thrombin potential and peak height) as well as latency (clotting and lag times) parameters. Adding PCC also improved the fibrin and increased quantitative parameters, but fibrin polymerization kinetics and latency parameters were not corrected. Finally, rFVIIa improved latency parameters but failed to restore the fibrin network structure, fibrin polymerization velocity and quantitative parameters. CONCLUSION aPCC was more effective than PCC or rFVIIa in reversing in vitro the effects of apixaban. aPCC rapidly triggered the development of an apparently normal fibrin network and corrected latency and quantitative parameters, whereas PCC or rFVIIa had only a partial effect.
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Affiliation(s)
- A-C Martin
- Faculté de Pharmacie, Inserm UMR-S1140, Paris, France; Sorbonne Paris Cité, Université Paris Descartes, Paris, France; Service de Cardiologie, Hôpital du Val de Grâce, Paris, France
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Gutermann IK, Niggemeier V, Zimmerli LU, Holzer BM, Battegay E, Scharl M. Gastrointestinal bleeding and anticoagulant or antiplatelet drugs: systematic search for clinical practice guidelines. Medicine (Baltimore) 2015; 94:e377. [PMID: 25569664 PMCID: PMC4602853 DOI: 10.1097/md.0000000000000377] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Gastrointestinal (GI) bleeding is a frequently encountered and very serious problem in emergency room patients who are currently being treated with anticoagulant or antiplatelet medications. There is, however, a lack of clinical practice guidelines about how to respond to these situations. The goal of this study was to find published articles that contain specific information about how to safely adjust anticoagulant and antiplatelet therapy when GI bleeding occurs.The investigators initiated a global search on the PubMed and Google websites for published information about GI bleeding in the presence of anticoagulant or antiplatelet therapy. After eliminating duplicate entries, the medical articles that remained were screened to narrow the sets of articles to those that met specific criteria. Articles that most closely matched study criteria were analyzed in detail and compared to determine how many actual guidelines exist and are useful.We could provide only minimal information about appropriate therapeutic strategies because no articles provided sufficient specific advice about how to respond to situations involving acute GI bleeding and concurrent use of anticoagulant or antiplatelet drugs. Only 4 articles provided enough detail to be of any use in an emergency situation.Clinical practice guidelines and also clinical trials for GI hemorrhaging should be expanded to state in which situations the use of anticoagulant or antiplatelet drugs should be suspended and the medications should later be resumed, and they should state the level of risk for any particular action.
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Affiliation(s)
- Irit Kaye Gutermann
- From the Division of Internal Medicine (IKG, VN, LUZ, BMH, EB, MS); Center of Competence Multimorbidity (LUZ, BMH, EB); The University Research Priority Program "Dynamics of Healthy Aging" (EB); Zurich Center for Integrative Human Physiology (EB, MS); and Division of Gastroenterology and Hepatology (MS), University Hospital Zurich, Zurich, Switzerland
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