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He W, Tang P. Management of perioperative anticoagulation in patients with mechanical heart valve replacement undergoing laparoscopic cholecystectomy: a case report of postoperative cerebral embolism. Front Surg 2024; 11:1404436. [PMID: 39233766 PMCID: PMC11371760 DOI: 10.3389/fsurg.2024.1404436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 08/08/2024] [Indexed: 09/06/2024] Open
Abstract
Patients with mechanical heart valve replacement require lifelong anticoagulation therapy, and additional surgeries can pose a risk of bleeding and thromboembolic events due to the need for perioperative anticoagulation management. Here, we present a case report of a patient who underwent laparoscopic cholecystectomy (LC) and endoscopic retrograde cholangiopancreatography (ERCP) after mechanical heart valve replacement and experienced postoperative cerebral embolism. The management of perioperative anticoagulation in these patients is discussed, including strategies for minimizing the risks of bleeding and thromboembolic events during and after surgery.
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Affiliation(s)
- Wei He
- Department of Ophthalmology, Sichuan Taikang Hospital, Chengdu, China
| | - Panli Tang
- Department of Cardiothoracic Surgery, Sichuan Taikang Hospital, Chengdu, China
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2
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Ghule P, Panic J, Malone DC. Risk of bleeding with concomitant use of oral anticoagulants and aspirin: A systematic review and meta-analysis. Am J Health Syst Pharm 2024; 81:494-508. [PMID: 38263263 DOI: 10.1093/ajhp/zxae010] [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: 01/19/2024] [Indexed: 01/25/2024] Open
Abstract
PURPOSE Oral anticoagulants (OACs) and aspirin can trigger bleeding events when used alone or in combination. The purpose of this study was to compare the risk of any type of bleeding in individuals exposed to a combination of OAC and aspirin with the risk in those taking an OAC or aspirin alone. METHODS MEDLINE and Web of Science were queried in January 2021 for eligible articles. Studies were included if they were either randomized controlled trials (RCTs) or observational studies and evaluated the number of any bleeding events in two groups, one with exposure to both OAC and aspirin and one with exposure to OAC alone or aspirin alone. Pooled odds ratios were calculated using a random-effects model. RESULTS Forty-two studies were included. In an analysis of 15 RCTs and 19 observational studies evaluating OAC plus aspirin versus OAC alone, a significant difference in the risk of bleeding was observed in the combination groups, with an odds ratio [OR] of, 1.36 (95% CI, 1.15-1.59) for RCTs and an OR of 1.42 (95% CI-, 1.09-1.87) for observational studies. When OAC plus aspirin was compared to aspirin alone, a higher rate of bleeding was found in the combination group (OR, 2.36; 95%CI, 1.91-2.92) in the analysis of 15 RCTs, but no significant difference was found among 10 observational studies (OR, 1.93; 95% Cl, 0.99-3.75). CONCLUSION The risk of any type of bleeding was significantly increased among patients taking aspirin plus OAC compared to those taking OAC alone in both RCTs and observational studies. Evaluation of RCTs comparing OAC plus aspirin to aspirin alone suggests increased bleeding risk as well.
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Affiliation(s)
- Priyanka Ghule
- College of Pharmacy, University of Utah, Salt Lake City, UH, USA
| | - Jennifer Panic
- Froedtert and the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Daniel C Malone
- College of Pharmacy, University of Utah, Salt Lake City, UH, USA
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Li T, Chen L, Peng M, Song G, Wang C, Peng Q, Tan S. Pregnancy outcomes in Chinese women with mechanical heart valves receiving warfarin treatment throughout pregnancy: 14-year experience. Thromb Res 2024; 236:22-29. [PMID: 38387300 DOI: 10.1016/j.thromres.2024.02.016] [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: 11/14/2023] [Revised: 02/11/2024] [Accepted: 02/14/2024] [Indexed: 02/24/2024]
Abstract
OBJECTIVE The purpose was to evaluate pregnancy outcomes and risk factors associated with fetal complications in Chinese pregnant women with mechanical heart valves (MHVs) taking low-dose warfarin, aiming to fill in the research gap of this area. METHODS Between June 2010 and Aug 2023, 122 patients with MHVs who had 151 pregnancies and received warfarin throughout pregnancy were included. We compared them with 302 paired pregnancies without warfarin treatment. Binary logistic regression analyses were performed to explore risk predictors of fetal complications. RESULTS Pregnancy loss rate was 37.1 % in women taking warfarin, compared to only 4.6 % for those without warfarin exposure in pregnancy (RR = 8.00, 95 % CI: 4.61-13.90). In pregnant women with MHVs, there were 34 spontaneous abortions, 22 stillbirths and 1 neonatal malformation. In the first, second and third pregnant trimesters of women with MHVs, fetal complication incidences were 19.2 %, 9.9 % and 8.0 %, respectively. 86.0 % of fetal complications occurred in women taking a warfarin dose ≤5 mg/d, accounting for 94.0 % of the total population. The newborns' birth weight, gestational age and 1-minute Apgar score were significantly lower in pregnancies treated with warfarin compared to those without warfarin exposure. Only 2.0 % of postpartum hemorrhage and no thrombosis or maternal mortality data were collected in pregnant women on warfarin in this study. CONCLUSION Most Chinese pregnant women take a warfarin daily dose ≤5 mg and they might have only around 60 % chance of giving birth to a live baby without maternal complications.
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Affiliation(s)
- Tianyu Li
- Department of Pharmacy, Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Institute of Clinical Pharmacy, Central South University, Changsha, Hunan 410011, China
| | - Lei Chen
- Department of Pharmacy, Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Institute of Clinical Pharmacy, Central South University, Changsha, Hunan 410011, China
| | - Mei Peng
- Department of Gynaecology and Obstetrics, Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Guobao Song
- Department of Cardiovascular Surgery, Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Chunyan Wang
- Department of Pharmacy, Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Institute of Clinical Pharmacy, Central South University, Changsha, Hunan 410011, China
| | - Qiyun Peng
- Department of Pharmacy, Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Institute of Clinical Pharmacy, Central South University, Changsha, Hunan 410011, China
| | - Shenglan Tan
- Department of Pharmacy, Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Institute of Clinical Pharmacy, Central South University, Changsha, Hunan 410011, China.
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Antithrombotic treatment for valve protheses: Which drug, which dose, and when? Prog Cardiovasc Dis 2022; 72:4-14. [DOI: 10.1016/j.pcad.2022.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 05/29/2022] [Indexed: 11/20/2022]
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Huckaby LV, Seese LM, Gleason TG, Sultan I, Wang Y, Thoma F, Kilic A. Outcomes related to anticoagulation management for mechanical valve replacements. J Thorac Dis 2021; 13:2874-2884. [PMID: 34164179 PMCID: PMC8182532 DOI: 10.21037/jtd-20-2562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background This study evaluates anticoagulation management and its impact on longitudinal clinical outcomes in patients undergoing mechanical valve replacement. Methods Patients undergoing mechanical mitral valve replacement (MVR) or aortic valve replacement (AVR) from 2010–2018 at a single center were included. Patients were stratified into therapeutic and non-therapeutic anticoagulation groups based on the median percentage of international normalized ratio (INR) values within the reference range (2.0–3.0 for AVR, 2.5–3.5 for MVR) during the first post-operative year. Using Cox regression analysis, comorbidity-adjusted survival and freedom from adverse events were compared. Results Six hundred and fifty-one patients underwent mechanical valve replacement (166 MVR, 485 AVR). Comorbidity-adjusted survival was similar in the MVR and AVR cohorts (P=0.23). There was a median of 27 [interquartile range (IQR): 14–42] INRs drawn per patient in the first post-operative year. The median percentage of INRs within the reference values during the first post-operative year was 42.85% (IQR: 30.77–53.95%), with the majority of non-therapeutic INRs being subtherapeutic (34.51%; n=6,864). There were no significant differences in adjusted survival between the therapeutic and non-therapeutic groups [hazard ratio (HR): 1.12, P=0.73]. Within the first post-operative year, there were no significant differences in stroke, major bleeding, peripheral non-stroke arterial thromboembolism, and readmission for intravenous heparin in the therapeutic and non-therapeutic groups. Conclusions Taking into account relevant comorbidities and valve type, patients with a larger proportion of non-therapeutic INRs during the first post-operative year demonstrated no difference in longitudinal clinical outcomes. Further research into more standardized INR monitoring and potentially expanded INR target ranges for patients undergoing mechanical valve replacement is warranted.
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Affiliation(s)
- Lauren V Huckaby
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Laura M Seese
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Thomas G Gleason
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Yisi Wang
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Floyd Thoma
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Arman Kilic
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Wang M, Zeraatkar D, Obeda M, Lee M, Garcia C, Nguyen L, Agarwal A, Al-Shalabi F, Benipal H, Ahmad A, Abbas M, Vidug K, Holbrook A. Drug-drug Interactions with Warfarin: A Systematic Review and Meta-analysis. Br J Clin Pharmacol 2021; 87:4051-4100. [PMID: 33769581 DOI: 10.1111/bcp.14833] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 03/07/2021] [Accepted: 03/10/2021] [Indexed: 12/13/2022] Open
Abstract
AIM The objective of this paper is to systematically review the literature on drug-drug interactions with warfarin, with a focus on patient-important clinical outcomes. METHODS MEDLINE, EMBASE, and the International Pharmaceutical Abstract (IPA) databases were searched from January 2004 to August 2019. We included studies describing drug-drug interactions between warfarin and other drugs. Screening and data extraction were conducted independently and in duplicate. We synthesized pooled odds ratios (OR) with 95% confidence intervals (CIs), comparing warfarin plus another medication to warfarin alone. We assessed the risk of bias at the study level and evaluated the overall certainty of evidence using GRADE. RESULTS Of 42,013 citations identified, a total of 72 studies reporting on 3,735,775 patients were considered eligible, including 11 randomized clinical trials and 61 observational studies. Increased risk of clinically relevant bleeding when added to warfarin therapy was observed for antiplatelet (AP) regimens (OR=1.74; 95% CI 1.56, 1.94), many antimicrobials (OR=1.63; 95% CI 1.45, 1.83), NSAIDs including COX-2 NSAIDs (OR=1.83; 95% CI 1.29, 2.59), SSRIs (OR=1.62; 95% CI 1.42, 1.85), mirtazapine (OR=1.75; 95% CI 1.30, 2.36), loop diuretics (OR=1.92; 95% CI 1.29, 2.86), and others. We found a protective effect of proton pump inhibitors (PPIs) against warfarin-related gastrointestinal (GI) bleedings (OR=0.69; 95% CI 0.64, 0.73). No significant effect on thromboembolic events or mortality of any drug group used with warfarin was found, including single or dual AP regimens. CONCLUSIONS This review found low to moderate certainty evidence supporting the interaction between warfarin and a small group of medications, which result in increased bleeding risk. PPIs are associated with reduced hospitalization for upper GI bleeding for patients taking warfarin. Further studies are required to better understand drug-drug interactions leading to thromboembolic outcomes or death.
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Affiliation(s)
- Mei Wang
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main Street West, Hamilton, L8S 4K1, Ontario, Canada.,Clinical Pharmacology & Toxicology, Research Institute, St Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, L8N 4A6, Ontario, Canada
| | - Dena Zeraatkar
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main Street West, Hamilton, L8S 4K1, Ontario, Canada
| | - Michael Obeda
- Department of Family Medicine, Queen's University, 220 Bagot St, Kingston, K7L 3G2, Ontario, Canada
| | - Munil Lee
- Schulich School of Medicine and Dentistry, Western University, London, N6A 3K7, Ontario, Canada
| | - Cristian Garcia
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main Street West, Hamilton, L8S 4K1, Ontario, Canada
| | - Laura Nguyen
- Faculty of Medicine, University of Ottawa, 451 Smyth Rd, Ottawa, K1H 8M5, Ontario, Canada
| | - Arnav Agarwal
- Department of Medicine, University of Toronto, 27 King's College Circle, Toronto, M5S 1A, Ontario, Canada
| | - Farah Al-Shalabi
- Clinical Pharmacology & Toxicology, Research Institute, St Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, L8N 4A6, Ontario, Canada
| | - Harsukh Benipal
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main Street West, Hamilton, L8S 4K1, Ontario, Canada
| | - Afreen Ahmad
- Bachelor Health Sciences Program, Faculty of Health Sciences, McMaster University, 1280 Main Street West, Hamilton, L8S 4K1, Ontario, Canada
| | - Momina Abbas
- Bachelor Arts & Science Program, Faculty of Arts & Science, McMaster University, 1280 Main Street West, Hamilton, L8S 4K1, Ontario, Canada
| | - Kristina Vidug
- Clinical Pharmacology & Toxicology, Research Institute, St Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, L8N 4A6, Ontario, Canada
| | - Anne Holbrook
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main Street West, Hamilton, L8S 4K1, Ontario, Canada.,Clinical Pharmacology & Toxicology, Research Institute, St Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, L8N 4A6, Ontario, Canada.,Division of Clinical Pharmacology & Toxicology, Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, L8S 4K1, Ontario, Canada
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Aikins J, Koomson A, Ladele M, Al-Nusair L, Ahmed A, Ashry A, Harky A. Anticoagulation and antiplatelet therapy in patients with prosthetic heart valves. J Card Surg 2020; 35:3521-3529. [PMID: 32939828 DOI: 10.1111/jocs.15034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 09/05/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND The choice of antithrombotic therapy, anticoagulants or antiplatelets, after prosthetic heart valve replacement or repair, remains a disputed topic in the literature. Antithrombotic therapies are used after heart valve intervention to reduce the rates of thromboembolic events, therefore improving patient outcomes. Different interventions may require different therapeutic regimens to achieve the most efficacious clinical outcome for patients. METHODS AND DISCUSSION This review aims to summarize and critique the available literature concerning therapeutic agents used for bioprosthetic and mechanical valves as well as for valve repair, so as to assist clinicians and researchers in making decisions with regard to their patients and research endeavors.
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Affiliation(s)
- Joel Aikins
- Imperial College School of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Abeku Koomson
- Imperial College School of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Mofolaoluwami Ladele
- Imperial College School of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Lana Al-Nusair
- Imperial College School of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Amna Ahmed
- Imperial College School of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Amr Ashry
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK.,Department of Cardiothoracic Surgery, Assiut University Hospital, Assiut, Egypt
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK.,Department of Integrative Biology, Faculty of Life Science, University of Liverpool, Liverpool, UK.,Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, Liverpool, UK
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8
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Warfarin pharmacogenetics in patients with heart valve replacement. GENE REPORTS 2020. [DOI: 10.1016/j.genrep.2020.100769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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9
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ACC/AHA Versus ESC Guidelines on Prosthetic Heart Valve Management. J Am Coll Cardiol 2019; 73:1707-1718. [DOI: 10.1016/j.jacc.2019.01.038] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 01/17/2019] [Accepted: 01/21/2019] [Indexed: 11/15/2022]
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10
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Lip GYH, Collet JP, Caterina RD, Fauchier L, Lane DA, Larsen TB, Marin F, Morais J, Narasimhan C, Olshansky B, Pierard L, Potpara T, Sarrafzadegan N, Sliwa K, Varela G, Vilahur G, Weiss T, Boriani G, Rocca B, Gorenek B, Savelieva I, Sticherling C, Kudaiberdieva G, Chao TF, Violi F, Nair M, Zimerman L, Piccini J, Storey R, Halvorsen S, Gorog D, Rubboli A, Chin A, Scott-Millar R. Antithrombotic therapy in atrial fibrillation associated with valvular heart disease: a joint consensus document from the European Heart Rhythm Association (EHRA) and European Society of Cardiology Working Group on Thrombosis, endorsed by the ESC Working Group on Valvular Heart Disease, Cardiac Arrhythmia Society of Southern Africa (CASSA), Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), South African Heart (SA Heart) Association and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE). Europace 2017; 19:1757-1758. [DOI: 10.1093/europace/eux240] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 06/20/2017] [Indexed: 01/08/2023] Open
Affiliation(s)
- Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Denmark (Chair, representing EHRA)
| | - Jean Philippe Collet
- Sorbonne Université Paris 6, ACTION Study Group, Institut De Cardiologie, Groupe Hôpital Pitié-Salpetrière (APHP), INSERM UMRS 1166, Paris, France
| | | | - Laurent Fauchier
- Centre Hospitalier Universitaire Trousseau et Faculté de Medicinde, Université François Rabelais, Tours, France
| | - Deirdre A Lane
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom; and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Torben B Larsen
- Thrombosis Research Unit,Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | | | - Joao Morais
- Department of Cardiology, Leiria Hospital Centre, Leiria, Portugal
| | | | | | - Luc Pierard
- Department of Cardiology, University Hospital Sart-Tilman, Liege, Belgium
| | - Tatjana Potpara
- School of Medicine, Belgrade University; Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
| | - Nizal Sarrafzadegan
- Isfahan Cardiovascular Research Center (WHO Collaborating Center), Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran and School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Karen Sliwa
- Hatter Institute for Cardiovascular Research in Africa, Faculty of Health Sciences, University of Cape Town, South Africa; and Mary McKillop Institute, ACU, Melbourne, Australia
| | - Gonzalo Varela
- Servicio de Electrofisiología, Centro Cardiovascular Casa de Galicia, Hidalgos, Uruguay
| | - Gemma Vilahur
- Cardiovascular Science Institute - ICCC, IIB-Sant Pau, CiberCV, Hospital de Sant Pau, Barcelona, Spain
| | - Thomas Weiss
- Medical Department For Cardiology and Intensive Care, Wilhelminenhospital, and Medical Faculty Sigmund Freud University, Vienna, Austria
| | - Giuseppe Boriani
- Cardiology Department, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Bianca Rocca
- Institute of Pharmacology, Catholic University School of Medicine, Rome, Italy (Co-Chair, representing ESC Working Group on Thrombosis)
| | - Bulent Gorenek
- Eskisehir Osmangazi University, Eskisehir, Turkey (Reviewer Coordinator)
| | - Irina Savelieva
- Molecular and Clinical Sciences Institute, St George's University of London, London, UK
| | | | | | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, and Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan (APHRS reviewer)
| | | | - Mohan Nair
- Department of Cardiology, Max Super Specialty Hospital, New Delhi, India
| | - Leandro Zimerman
- Hospital de Cl쭩cas de Porto Alegre, Federal University of Rio Grande do Sul, Brasil (SOLAECE reviewer)
| | - Jonathan Piccini
- Duke University Medical Center, Duke Clinical Research Institute, Durham, USA (HRS reviewer)
| | - Robert Storey
- Department of Cardiovascular Sciences, University of Sheffield, Sheffield, UK
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway
| | - Diana Gorog
- National Heart and Lung Institute, Imperial College, London, and Postgraduate Medicine, University of Hertfordshire, Hertfordshire, UK
| | - Andrea Rubboli
- Ospedale Maggiore, Division of Cardiology, Bologna, Italy (Working Group of Thrombosis reviewer)
| | - Ashley Chin
- Electrophysiology and Pacing, Groote Schuur Hospital, University of Cape Town, South Africa (CASSA reviewer)
| | - Robert Scott-Millar
- Department of Medicine, Division of Cardiology, University of Cape Town, South Africa (SAHeart reviewer)
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Jaffer IH, Whitlock RP. Rebuttal to: choice of prosthetic valve in a developing country. HEART ASIA 2016; 8:73. [PMID: 27326238 DOI: 10.1136/heartasia-2016-010734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/17/2016] [Indexed: 11/03/2022]
Affiliation(s)
- Iqbal H Jaffer
- Thrombosisand Atherosclerosis Research Institute, Hamilton, Ontario, Canada; Division of Cardiac Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Richard P Whitlock
- Division of Cardiac Surgery, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada
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12
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Toeg H, Boodhwani M. Review of anticoagulation options for mechanical valve prosthesis. Interv Cardiol 2015. [DOI: 10.2217/ica.15.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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13
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Di Nisio M, Peinemann F, Porreca E, Rutjes AWS. Primary prophylaxis for venous thromboembolism in patients undergoing cardiac or thoracic surgery. Cochrane Database Syst Rev 2015; 2015:CD009658. [PMID: 26091835 PMCID: PMC11024391 DOI: 10.1002/14651858.cd009658.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Cardiac and thoracic surgery are associated with an increased risk of venous thromboembolism (VTE). The safety and efficacy of primary thromboprophylaxis in patients undergoing these types of surgery is uncertain. OBJECTIVES To assess the effects of primary thromboprophylaxis on the incidence of symptomatic VTE and major bleeding in patients undergoing cardiac or thoracic surgery. SEARCH METHODS The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched May 2014) and CENTRAL (2014, Issue 4). The authors searched the reference lists of relevant studies, conference proceedings, and clinical trial registries. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs comparing any oral or parenteral anticoagulant or mechanical intervention to no intervention or placebo, or comparing two different anticoagulants. DATA COLLECTION AND ANALYSIS We extracted data on methodological quality, participant characteristics, interventions, and outcomes including symptomatic VTE and major bleeding as the primary effectiveness and safety outcomes, respectively. MAIN RESULTS We identified 12 RCTs and one quasi-RCT (6923 participants), six for cardiac surgery (3359 participants) and seven for thoracic surgery (3564 participants). No study evaluated fondaparinux, the new oral direct thrombin, direct factor Xa inhibitors, or caval filters. All studies had major study design flaws and most lacked a placebo or no treatment control group. We typically graded the quality of the overall body of evidence for the various outcomes and comparisons as low, due to imprecise estimates of effect and risk of bias. We could not pool data because of the different comparisons and the lack of data. In cardiac surgery, 71 symptomatic VTEs occurred in 3040 participants from four studies. In a study of 2551 participants, representing 85% of the review population in cardiac surgery, the combination of unfractionated heparin with pneumatic compression stockings was associated with a 61% reduction of symptomatic VTE compared to unfractionated heparin alone (1.5% versus 4.0%; risk ratio (RR) 0.39; 95% confidence interval (CI) 0.23 to 0.64). Major bleeding was only reported in one study, which found a higher incidence with vitamin K antagonists compared to platelet inhibitors (11.3% versus 1.6%, RR 7.06; 95% CI 1.64 to 30.40). In thoracic surgery, 15 symptomatic VTEs occurred in 2890 participants from six studies. In the largest study evaluating unfractionated heparin versus an inactive control the rates of symptomatic VTE were 0.7% versus 0%, respectively, giving a RR of 6.71 (95% CI 0.40 to 112.65). There was insufficient evidence to determine if there was a difference in the risk of major bleeding from two studies evaluating fixed-dose versus weight-adjusted low molecular weight heparin (2.7% versus 8.1%, RR 0.33; 95% CI 0.07 to 1.60) and unfractionated heparin versus low molecular weight heparin (6% and 4%, RR 1.50; 95% CI 0.26 to 8.60). AUTHORS' CONCLUSIONS The evidence regarding the efficacy and safety of thromboprophylaxis in cardiac and thoracic surgery is limited. Data for important outcomes such as pulmonary embolism or major bleeding were often lacking. Given the uncertainties around the benefit-to-risk balance, no conclusions can be drawn and a case-by-case risk evaluation of VTE and bleeding remains preferable.
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Affiliation(s)
- Marcello Di Nisio
- University "G. D'Annunzio" of Chieti‐PescaraDepartment of Medical, Oral and Biotechnological Sciencesvia dei Vestini 31ChietiItaly66013
- Academic Medical CenterDepartment of Vascular MedicineAmsterdamNetherlands
| | - Frank Peinemann
- Children's Hospital, University of ColognePediatric Oncology and HematologyKerpener Str. 62CologneNWGermany50937
| | - Ettore Porreca
- "University G. D'Annunzio" FoundationDepartment of Medicine and Aging; Centre for Aging Sciences (Ce.S.I.), Internal Medicine Unit31 Via dei VestiniChietiChietiItaly66100
| | - Anne WS Rutjes
- University "G. D'Annunzio" of Chieti‐PescaraDepartment of Medical, Oral and Biotechnological Sciencesvia dei Vestini 31ChietiItaly66013
- Fondazione "Università G. D'Annunzio"Centre for Systematic Reviewsvia dei Vestini 31ChietiChietiItaly66100
- University of BernInstitute of Social and Preventive Medicine (ISPM)Finkenhubelweg 11BernBernSwitzerland3012
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Abstract
BACKGROUND Patients with prosthetic heart valves are at increased risk for valve thrombosis and arterial thromboembolism. Oral anticoagulation alone, or the addition of antiplatelet drugs, has been used to minimise this risk. An important issue is the effectiveness and safety of the latter strategy. OBJECTIVES This is an update of our previous review; the goal was to create a valid synthesis of all available, methodologically sound data to further assess the safety and efficacy of combined oral anticoagulant and antiplatelet therapy versus oral anticoagulant monotherapy in patients with prosthetic heart valves. SEARCH METHODS We updated the previous searches from 2003 and 2010 on 16 January 2013 and searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (2012, Issue 12), MEDLINE (OVID, 1946 to January Week 1 2013), and EMBASE (OVID, 1980 to 2013 Week 02). We have also looked at reference lists of individual reports, review articles, meta-analyses, and consensus statements. We included reports published in any language or in abstract form. SELECTION CRITERIA All reports of randomised controlled trials comparing standard-dose oral anticoagulation to standard-dose oral anticoagulation and antiplatelet therapy in patients with one or more prosthetic heart valves. DATA COLLECTION AND ANALYSIS Two review authors independently performed the search strategy, assessed trials for inclusion and study quality, and extracted data. We collected adverse effects information from the trials. MAIN RESULTS One new study has been identified and included in this update. In total, 13 studies involving 4122 participants were included in this review update. Years of publication ranged from 1971 to 2011. Compared with anticoagulation alone, the addition of an antiplatelet agent reduced the risk of thromboembolic events (odds ratio (OR) 0.43, 95% confidence interval (CI) 0.32 to 0.59; P < 0.00001) and total mortality (OR 0.57, 95% CI 0.42 to 0.78; P = 0.0004). Aspirin and dipyridamole reduced these events similarly. The risk of major bleeding was increased when antiplatelet agents were added to oral anticoagulants (OR 1.58, 95% CI 1.14 to 2.18; P = 0.006).For major bleeding, there was no evidence of heterogeneity between aspirin and dipyridamole and in the comparison of trials performed before and after 1990, around the time when anticoagulation standardisation with the international normalised ratio was being implemented. A lower daily dose of aspirin (< 100 mg) may be associated with a lower major bleeding risk than higher doses. AUTHORS' CONCLUSIONS Adding antiplatelet therapy, either dipyridamole or low-dose aspirin, to oral anticoagulation decreases the risk of systemic embolism or death among patients with prosthetic heart valves. The risk of major bleeding is increased with antiplatelet therapy. These results apply to patients with mechanical prosthetic valves or those with biological valves and indicators of high risk such as atrial fibrillation or prior thromboembolic events. The effectiveness and safety of low-dose aspirin (100 mg daily) appears to be similar to higher-dose aspirin and dipyridamole. In general, the quality of the included trials tended to be low, possibly reflecting the era when the majority of the trials were conducted (1970s and 1980s when trial methodology was less advanced).
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