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Yang HG, Kim DK. Concomitant Use of Antiplatelet Agents and Proton-Pump Inhibitors Increases the Risk of Adverse Cardiovascular Events: A Nationwide Population-Based Cohort Study Using Balanced Operational Definitions. J Cardiovasc Dev Dis 2023; 10:264. [PMID: 37367429 DOI: 10.3390/jcdd10060264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/02/2023] [Accepted: 06/16/2023] [Indexed: 06/28/2023] Open
Abstract
Antiplatelet agents are commonly used in combination with proton-pump inhibitors (PPIs) in patients with acute coronary syndrome who are at risk of gastrointestinal hemorrhage. However, studies have reported that PPIs can alter the pharmacokinetics of antiplatelet agents and result in adverse cardiovascular events. We enrolled 311 patients who received antiplatelet therapy with PPIs for >30 days and 1244 matched controls following a 1:4 propensity score matching during the index period. Patients were followed up until death, myocardial infarction, coronary revascularization, or the end of the follow-up period. Patients who used antiplatelet therapy with PPIs were found to be at higher risk of mortality than the controls (adjusted hazard ratio (HR): 1.77; 95% confidence interval (CI): 1.30-2.40). The adjusted HR for patients who used antiplatelet agents with PPIs developing myocardial infarction and coronary revascularization events was 3.52 (95% CI: 1.34-9.22) and 4.74 (95% CI: 2.03-11.05), respectively. Additionally, middle-aged patients or those within 3 years of concomitant use showed a higher risk of myocardial infarction and coronary revascularization. Our findings suggest that antiplatelet therapy combined with PPIs has a higher mortality risk in patients with gastrointestinal bleeding and is associated with an increased risk of myocardial infarction and coronary revascularization.
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Affiliation(s)
- Hee Gyu Yang
- Department of Otorhinolaryngology-Head and Neck Surgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea
| | - Dong-Kyu Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea
- Division of Big Data and Artificial Intelligence, Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea
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Abstract
Valvular heart disease is a major public health issue. The prevalence of valvular heart disease is expected to increase due to an aging population. Valve dysfunction manifests as valve stenosis, regurgitation, or both due to various etiologies. Valve repair and replacement are the main treatment options for severe valve dysfunction. Valve replacement is achieved by using either a mechanical or a bioprosthetic valve. Mechanical valves are more durable but require lifelong anticoagulation with associated complications. Bioprosthetic valves usually require anticoagulation only transiently after implantation but are less durable and degenerate more rapidly. In this article, we discuss antithrombotic regimens in persons after valve operations. We discuss general issues and antithrombotic recommendations for patients undergoing surgical bioprosthetic valve replacement, mechanical valve replacement (including different regimens for different positions and types of mechanical valves), mitral valve repair, and transcatheter aortic valve replacement. In addition, we discuss the antithrombotic management of patients in special circumstances, including patients with mechanical valves who have recurrent bleeding or thrombotic events, patients with mechanical valves undergoing surgery, and pregnant women with mechanical valves.
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Bristow P, Sargent J, Luis Fuentes V, Brockman D. Outcome of bioprosthetic valve replacement in dogs with tricuspid valve dysplasia. J Small Anim Pract 2017; 58:205-210. [DOI: 10.1111/jsap.12630] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 10/17/2016] [Accepted: 10/25/2016] [Indexed: 10/20/2022]
Affiliation(s)
- P. Bristow
- Department of Veterinary Clinical Sciences; Royal Veterinary College, Hatfield, Herts AL9 7TA; UK
| | - J. Sargent
- Department of Veterinary Clinical Sciences; Royal Veterinary College, Hatfield, Herts AL9 7TA; UK
| | - V. Luis Fuentes
- Department of Veterinary Clinical Sciences; Royal Veterinary College, Hatfield, Herts AL9 7TA; UK
| | - D. Brockman
- Department of Veterinary Clinical Sciences; Royal Veterinary College, Hatfield, Herts AL9 7TA; UK
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Hwang TW, Kim SO, Lee SY, Kim SH, Choi EY, Jang SI, Park SJ, Kwon HW, Lim HB, Lee CH, Choi ES. Impact of postoperative duration of Aspirin use on longevity of bioprosthetic pulmonary valve in patients who underwent congenital heart disease repair. KOREAN JOURNAL OF PEDIATRICS 2016; 59:446-450. [PMID: 27895692 PMCID: PMC5118504 DOI: 10.3345/kjp.2016.59.11.446] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Revised: 09/06/2016] [Accepted: 09/12/2016] [Indexed: 11/27/2022]
Abstract
Purpose Generally, aspirin is used as a protective agent against thrombogenic phenomenon after pulmonary valve replacement (PVR) using a bioprosthetic valve. However, the appropriate duration of aspirin use is unclear. We analyzed the impact of postoperative duration of aspirin use on the longevity of bioprosthetic pulmonary valves in patients who underwent repair for congenital heart diseases. Methods We retrospectively reviewed the clinical data of 137 patients who underwent PVR using a bioprosthetic valve between January 2000 and December 2003. Among these patients, 89 were included in our study and divided into groups I (≤12 months) and II (>12 months) according to duration of aspirin use. We analyzed echocardiographic data from 9 to 11 years after PVR. Pulmonary vale stenosis and regurgitation were classified as mild, moderate, or severe. Results The 89 patients consisted of 53 males and 36 females. Their mean age was 14.3±8.9 years (range, 2.6–48 years) and body weight was 37.6±14.7 kg (range, 14–72 kg). The postoperative duration of aspirin use was 7.3±2.9 months in group I and 32.8±28.4 months in group II. However, no significant difference in sex ratio, age, body weight, type of bioprosthetic valve, and number of early redo-PVRs. In the comparison of echocardiographic data about 10 years later, no significant difference in pulmonary valve function was found. The overall freedom rate from redo-PVR at 10 years showed no significant difference (P=0.498). Conclusion Our results indicated no benefit from long-term aspirin medication (>6 months) in patients who underwent PVR with a bioprosthetic valve.
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Affiliation(s)
- Tae-Woong Hwang
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea
| | - Sung-Ook Kim
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea
| | - Sang-Yun Lee
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea
| | - Seong-Ho Kim
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea
| | - Eun-Young Choi
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea
| | - So-Ick Jang
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea
| | - Su-Jin Park
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea
| | - Hye-Won Kwon
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea
| | - Hyo-Bin Lim
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea
| | - Chang-Ha Lee
- Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Bucheon, Korea
| | - Eun-Seok Choi
- Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Bucheon, Korea
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Abstract
PURPOSE OF REVIEW The efficacy of anticoagulation for valvular prostheses is the result of a delicate balance between the risk of thromboembolic (TE) events and bleeding. Here, we review data on anticoagulation for valve prostheses with a focus on clinical trials that address key unanswered questions. RECENT FINDINGS There are several unanswered questions in the field of prosthetic valve anticoagulation, including: optimal TE prophylaxis in the short term for bioprostheses, optimal TE prophylaxis following transcatheter aortic valve implantation, the safety and efficacy of lower levels of anticoagulation with the bileaflet mechanical prosthesis, the role of aspirin for patients with mechanical prostheses, and the management of anticoagulation for mechanical valves in pregnancy. Other areas of study include the role, if any, of nonwarfarin oral anticoagulants for prosthetic TE prophylaxis as well as self-INR monitoring. Finally, we briefly mention studies of newer anticoagulants, such as novel vitamin K antagonists and antisense oligonucleotides, that are on the horizon. SUMMARY Optimal antithrombotic management is a key issue for patients with valvular prostheses, and the publication of recent trials has provided much-needed guidance. We highlight areas of progress, in addition to the major unanswered questions for which well-designed, prospective clinical trials are forthcoming.
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Forsberg P, DeSancho MT. Role of novel anticoagulants for patients with mechanical heart valves. Curr Atheroscler Rep 2015; 16:448. [PMID: 25172513 DOI: 10.1007/s11883-014-0448-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The introduction of the target-specific oral anticoagulants (TSOACs) has led to a major shift in the management of patients at risk for thrombosis. The landscape continues to evolve as the evidence regarding their efficacy and safety in various clinical situations emerges. Antithrombotic therapy for thromboprophylaxis in patients with mechanical heart valves is challenging. To date, the RE-ALIGN trial comparing dabigatran etexilate to warfarin is the only randomized controlled study in this patient population. The higher risk of thromboembolic and bleeding events in the group of patients who received dabigatran compared with warfarin reinforced current guidelines recommending against the use of TSOACs in patients with mechanical heart valves. However, additional studies are needed to find suitable alternatives to vitamin K antagonists in this unique patient population.
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Affiliation(s)
- Peter Forsberg
- Weill Cornell Medical College, Weill Greenberg Pavilion, 1305 York Avenue, 7th Floor Room 51, New York, NY, 10021, USA,
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Rolden HJ, Grutters JP, van der Wilt GJ, Maas AH. Closing the information gap between clinical and postmarketing trials: the case of dabigatran: Table 1. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2015; 1:153-6. [DOI: 10.1093/ehjcvp/pvv020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Sheriff J, Girdhar G, Chiu WC, Jesty J, Slepian MJ, Bluestein D. Comparative efficacy of in vitro and in vivo metabolized aspirin in the DeBakey ventricular assist device. J Thromb Thrombolysis 2015; 37:499-506. [PMID: 24043375 DOI: 10.1007/s11239-013-0997-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Ventricular assist devices (VADs) are implanted in patients with end-stage heart failure to provide both short- and long-term hemodynamic support. Unfortunately, bleeding and thromboembolic complications due to the severely disturbed, dynamic flow conditions generated within these devices require complex, long-term antiplatelet and anticoagulant therapy. While several studies have examined the effectiveness of one such agent, aspirin, under flow conditions, data comparing the efficacy of in vitro and in vivo metabolized aspirin is lacking. Two sets of studies were conducted in vitro with purified human platelets circulating for 30 min in a flow loop containing the DeBakey VAD (MicroMed Cardiovascular, Houston, TX, USA): (a) 20 μM aspirin was added exogenously in vitro to platelets isolated from aspirin-free subjects, and (b) platelets were obtained from donors 2 h (n = 14) and 20 h (n = 13) after ingestion of 1,000 mg aspirin. Near real-time platelet activation state (PAS) was measured with a modified prothrombinase-based assay. Platelets exposed to aspirin in vitro and in vivo (metabolized) showed 28.2 and 25.3 % reduction in platelet activation rate, respectively, compared to untreated controls. Our results demonstrate that in vitro treatment with antiplatelet drugs such as aspirin is as effective as in vivo metabolized aspirin in testing the effect of reducing shear-induced platelet activation in the VAD. Using the PAS assay provides a practical in vitro alternative to in vivo testing of antiplatelet efficacy, as well as for testing the thrombogenic performance of devices during their research and development.
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Affiliation(s)
- Jawaad Sheriff
- Department of Biomedical Engineering, Stony Brook University, T15-090 Health Sciences Center, Stony Brook, NY, 11794-8151, USA
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Combined low-dose aspirin and warfarin anticoagulant therapy of postoperative atrial fibrillation following mechanical heart valve replacement. ACTA ACUST UNITED AC 2014; 34:902-906. [DOI: 10.1007/s11596-014-1371-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 10/18/2014] [Indexed: 10/24/2022]
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Twenty-year single-center experience with the medtronic open pivot mechanical heart valve. Ann Thorac Surg 2014; 97:1306-13. [PMID: 24507942 DOI: 10.1016/j.athoracsur.2013.11.035] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 11/10/2013] [Accepted: 11/18/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND Since May 1992 the Medtronic Open Pivot mechanical heart valve has been implanted routinely at the authors' institution. The study aim was to analyze, retrospectively, the 20-year clinical results of the valve. METHODS Between May 1992 and December 2011 a total of 1,520 valves was inserted into 1,382 consecutive patients (1,012 aortic, 473 mitral, 26 tricuspid, 9 pulmonary). The mean age of the patients was 61±13.2 years. Preoperatively, 65% of the patients were in New York Heart Association (NYHA) class III or greater. Frequent comorbidities included atrial fibrillation (n=419), coronary disease (n=357), and diabetes (n=255). The 99% complete follow-up totaled 10,527 patient-years (range 12 to 244 months). RESULTS Ninety-day mortality was 5.2% (n=73, 8 valve related). Of the 550 total deaths, 240 were cardiac and 56 valve related. Multivariate analysis selected age, NYHA III or greater, concomitant coronary revascularization, and respiratory insufficiency as risk factors for death. Renal failure was considered a risk factor in the aortic and atrial fibrillation in the mitral subgroup. Erratic international normalized ratio (INR), NYHA class III or greater, and non-sinus rhythm were risk factors for thromboembolism; likewise redo operations in the aortic subgroup. Erratic INR and age were risk factors for bleeding as were over-coagulation and coronary revascularization in the aortic subgroup and redo operations and renal failure in mitral patients. CONCLUSIONS This 20-year experience demonstrated excellent clinical outcomes with no structural valve failure. Odds ratio defined aortic patients as the lowest risk for adverse events. By contrast atrial fibrillation and elderly age, in combination with instable anticoagulation, yielded the worst long-term results.
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13
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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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Attia JR, Pearce R. The use, misuse and abuse of dabigatran. Med J Aust 2013; 198:356-7. [PMID: 23581945 DOI: 10.5694/mja12.10729] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Accepted: 10/29/2012] [Indexed: 01/16/2023]
Abstract
The tale of dabigatran sounds some cautionary notes about proper critical appraisal of new randomised controlled trials,care in deciding on the generalisability of results, judicious screening of patients and lessons about the politics around increasingly lucrative drugs. The old lesson of caveat utilitor still holds: let the user beware!
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Affiliation(s)
- John R Attia
- University of Newcastle, Newcastle, NSW, Australia.
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Abstract
Appropriate acute treatment with plasminogen activators (PAs) can significantly increase the probability of minimal or no disability in selected ischemic stroke patients. There is a great deal of evidence showing that intravenous recombinant tissue PAs (rt-PA) infusion accomplishes this goal, recanalization with other PAs has also been demonstrated in the development of this treatment. Recanalization of symptomatic, documented carotid or vertebrobasilar arterial territory occlusions have also been achieved by local intra-arterial PA delivery, although only a single prospective double-blinded randomized placebo-controlled study has been reported. The increase in intracerebral hemorrhage with these agents by either delivery approach underscores the need for careful patient selection, dose-appropriate safety and efficacy, proper clinical trial design, and an understanding of the evolution of cerebral tissue injury due to focal ischemia. Principles underlying the evolution of focal ischemia have been expanded by experience with acute PA intervention. Several questions remain open that concern the manner in which PAs can be applied acutely in ischemic stroke and how injury development can be limited.
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Affiliation(s)
- Gregory J del Zoppo
- Division of Hematology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington 98104, USA.
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Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Barón-Esquivias G, Baumgartner H, Andrew Borger M, Carrel TP, De Bonis M, Evangelista A, Falk V, Iung B, Lancellotti P, Pierard L, Price S, Schäfers HJ, Schuler G, Stepinska J, Swedberg K, Takkenberg J, Von Oppell UO, Windecker S, Zamorano JL, Zembala M, Bax JJ, Baumgartner H, Ceconi C, Dean V, Deaton C, Fagard R, Funck-Brentano C, Hasdai D, Hoes A, Kirchhof P, Knuuti J, Kolh P, McDonagh T, Moulin C, Popescu BA, Reiner Ž, Sechtem U, Anton Sirnes P, Tendera M, Torbicki A, Vahanian A, Windecker S, Popescu BA, Von Segesser L, Badano LP, Bunc M, Claeys MJ, Drinkovic N, Filippatos G, Habib G, Kappetein AP, Kassab R, Lip GY, Moat N, Nickenig G, Otto CM, Pepper J, Piazza N, Pieper PG, Rosenhek R, Shuka N, Schwammenthal E, Schwitter J, Tornos Mas P, Trindade PT, Walther T. Guíade práctica clínica sobre el tratamiento de las valvulopatías (versión 2012). Rev Esp Cardiol (Engl Ed) 2013. [DOI: 10.1016/j.recesp.2012.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Barón-Esquivias G, Baumgartner H, Borger MA, Carrel TP, De Bonis M, Evangelista A, Falk V, Iung B, Lancellotti P, Pierard L, Price S, Schäfers HJ, Schuler G, Stepinska J, Swedberg K, Takkenberg J, Von Oppell UO, Windecker S, Zamorano JL, Zembala M, Bax JJ, Baumgartner H, Ceconi C, Dean V, Deaton C, Fagard R, Funck-Brentano C, Hasdai D, Hoes A, Kirchhof P, Knuuti J, Kolh P, McDonagh T, Moulin C, Popescu BA, Reiner Ž, Sechtem U, Sirnes PA, Tendera M, Torbicki A, Vahanian A, Windecker S, Popescu BA, Von Segesser L, Badano LP, Bunc M, Claeys MJ, Drinkovic N, Filippatos G, Habib G, Kappetein AP, Kassab R, Lip GY, Moat N, Nickenig G, Otto CM, Pepper J, Piazza N, Pieper PG, Rosenhek R, Shuka N, Schwammenthal E, Schwitter J, Mas PT, Trindade PT, Walther T. Guidelines on the management of valvular heart disease (version 2012). Eur J Cardiothorac Surg 2012; 42:S1-44. [DOI: 10.1093/ejcts/ezs455] [Citation(s) in RCA: 1024] [Impact Index Per Article: 85.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Barón-Esquivias G, Baumgartner H, Borger MA, Carrel TP, De Bonis M, Evangelista A, Falk V, Iung B, Lancellotti P, Pierard L, Price S, Schäfers HJ, Schuler G, Stepinska J, Swedberg K, Takkenberg J, Von Oppell UO, Windecker S, Zamorano JL, Zembala M, Baumgartner H, Ceconi C, Dean V, Deaton C, Fagard R, Funck-Brentano C, Hasdai D, Hoes A, Kirchhof P, Knuuti J, Kolh P, McDonagh T, Moulin C, Popescu BA, Reiner Ž, Sechtem U, Sirnes PA, Tendera M, Torbicki A, Vahanian A, Windecker S, Popescu BA, Von Segesser L, Badano LP, Bunc M, Claeys MJ, Drinkovic N, Filippatos G, Habib G, Kappetein AP, Kassab R, Lip GY, Moat N, Nickenig G, Otto CM, Pepper J, Piazza N, Pieper PG, Rosenhek R, Shuka N, Schwammenthal E, Schwitter J, Mas PT, Trindade PT, Walther T. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012; 33:2451-96. [PMID: 22922415 DOI: 10.1093/eurheartj/ehs109] [Citation(s) in RCA: 2620] [Impact Index Per Article: 218.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
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- Service de Cardiologie, Hospital Bichat AP-HP, 46 rue Henri Huchard, 75018 Paris, France.
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Anticoagulation therapy with combined low dose aspirin and warfarin following mechanical heart valve replacement. Thromb Res 2011; 128:e91-4. [DOI: 10.1016/j.thromres.2011.07.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Revised: 06/29/2011] [Accepted: 07/05/2011] [Indexed: 11/23/2022]
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Maciejewski M, Piestrzeniewicz K, Jaszewski R, Bielecka-Dabrowa A, Goch JH. Sources of thromboembolism in patients with correctly functioning mechanical valves: a single-center transesophageal echocardiographic study. Heart Surg Forum 2011; 14:E149-56. [PMID: 21676679 DOI: 10.1532/hsf98.20101048] [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
BACKGROUND In patients with mechanical prostheses (MP), thromboembolism is one of the most serious complications. The study aim was to assess the incidence of sources of thromboembolism in patients with correctly functioning MP with and without a history of thromboembolism. METHODS Two hundred ninety-seven patients with correctly functioning MP were enrolled in this single-center, transesophageal echocardiographic (TEE), retrospective, observational study. Two groups were analyzed: Group A, 183 patients with a history of thromboembolism, and Group B, 114 patients with no history of thromboembolism. RESULTS Definite sources of thromboembolism were revealed in 59% of patients in Group A, and sources of potential thromboembolism were revealed in 13% of patients in Group B (P < .001). Multiple sources of thromboembolism were present in 9% of patients in Group A and 1% of patients in Group B. Localization of sources of thromboembolism included MP ring (59% and 53% of patients in Groups A and B, respectively); left atrium/left atrium appendage (24%/21% and 13%/40% of patients in Groups A and B, respectively); and aorta (12% and 13% of patients in Groups A and B, respectively). Patients with multiple sources of thromboembolism were older (P < .001) and in a higher New York Heart Association (NYHA) class (P = .004). Patients with sources of thromboembolism in the aorta were older than the rest of the group (P < .01). CONCLUSIONS In patients with correctly functioning MP, sources of thromboembolism are observed 4 times more often in case of the positive history of thromboembolism. The most common source of thromboembolism is thrombosis of MP ring. Age and heart failure predispose multiple sources of thromboembolism. One might consider control TEE after mechanical valve implantation, but only in selected group of patients without embolic events but with a higher risk of thromboembolism.
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Affiliation(s)
- Marek Maciejewski
- Clinic of Cardiology, Institute of Cardiology and Cardiac Surgery, Medical University of Lodz, Poland
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Leiria TLL, Lopes RD, Williams JB, Katz JN, Kalil RAK, Alexander JH. Antithrombotic therapies in patients with prosthetic heart valves: guidelines translated for the clinician. J Thromb Thrombolysis 2011; 31:514-22. [PMID: 21327503 PMCID: PMC3699194 DOI: 10.1007/s11239-011-0574-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Patients with prosthetic heart valves require chronic oral anticoagulation. In this clinical scenario, physicians must be mindful of the thromboembolic and bleeding risks related to chronic anticoagulant therapy. Currently, only vitamin K antagonists are approved for this indication. This paper reviews the main heart valve guidelines focusing on the use of oral anticoagulation in these patients.
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Affiliation(s)
- Tiago L. L. Leiria
- Instituto de Cardiologia do Rio Grande do Sul/Fundação Universitária de Cardiologia, Porto Alegre, Brazil
| | - Renato D. Lopes
- Duke Clinical Research Institute, Division of Cardiology, Department of Medicine, Duke University Medical Center, Box 3850, Durham, NC 27710, UK
| | - Judson B. Williams
- Duke Clinical Research Institute, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, UK
| | - Jason N. Katz
- Division of Cardiology & Division of Pulmonary/Critical Care Medicine, University of North Carolina Center for Heart and Vascular Care, Chapel Hill, NC, UK
| | - Renato A. K. Kalil
- Instituto de Cardiologia do Rio Grande do Sul/Fundação Universitária de Cardiologia, Porto Alegre, Brazil. Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | - John H. Alexander
- Duke Clinical Research Institute, Division of Cardiology, Department of Medicine, Duke University Medical Center, Box 3850, Durham, NC 27710, UK
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Zhao HJ, Zheng ZT, Wang ZH, Li SH, Zhang Y, Zhong M, Zhang W. “Triple Therapy” Rather Than “Triple Threat”. Chest 2011; 139:260-270. [DOI: 10.1378/chest.09-3083] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Trzeciak P, Zembala M, Poloński L. Major hemorrhagic and thromboembolic complications in patients with mechanical heart valves receiving oral anticoagulant therapy. Heart Surg Forum 2010; 13:E80-5. [PMID: 20444682 DOI: 10.1532/hsf98.20091097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Patients with mechanical heart valve prostheses are obligated to receive lifelong oral anticoagulant therapy to prevent thromboembolic complications; however, this treatment is associated with an increased risk of bleeding. The aim of this study was to evaluate the frequency of major hemorrhagic and thromboembolic complications in patients with mechanical heart valves who received oral anticoagulant therapy. MATERIALS AND METHODS The analysis involved 225 patients who underwent successful surgery in 2000; the mean (+/-SD) follow-up period was 43.3 +/- 9.2 months. Aortic, mitral, and double valve replacement was performed in 128 (56.7%), 70 (31.1%), and 27 (12.1%) of the patients, respectively. There were 128 men (57.3%), and the mean patient age was 57.9 +/- 18.8 years. The following data were assessed: rate of major hemorrhagic and thromboembolic complications, frequency of international normalized ratio (INR) rate measurements, and percentage of results within the therapeutic range. RESULTS Major hemorrhagic and thromboembolic complications occurred in 25 patients (11.1%). Seventeen patients (7.5%) survived, and 8 (3.6%) died of the complications. Major hemorrhagic and thromboembolic complications occurred in 17 patients (7.6%) and 8 patients (3.6%), respectively. The mean time between sequential measurements was 4.3 +/- 3.0 weeks, and of all the INR values collected, 42.4% were within, 31.3% were below, and 26.3% were above the target ranges. CONCLUSIONS Patients with a mechanical heart valve prosthesis receiving acenocoumarol are susceptible to major hemorrhagic and thromboembolic complications, some of which lead to death. Despite the danger related to these complications, patients receiving anticoagulant therapy still have difficulty achieving INR values within the therapeutic range.
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Affiliation(s)
- Przemysław Trzeciak
- 3rd Department of Cardiology, Silesian Center for Heart Disease, Zabrze, Poland.
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Bover R, Pérez-Gómez F, Maluenda MP, Asenjo S, Pérez-Saldaña R, Igea A, Suárez M, Coleto D, Fernández C. Long-term follow-up of atrial fibrillation patients in the NASPEAF study. Prospective evaluation of different antiplatelet treatments. Rev Esp Cardiol 2010; 62:992-1000. [PMID: 19712620 DOI: 10.1016/s1885-5857(09)73265-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION AND OBJECTIVES In the NASPEAF (National Study for Prevention of Embolism in Atrial Fibrillation) trial, combination therapy with an anticoagulant and an antiplatelet was more effective than anticoagulation alone in patients with atrial fibrillation. We report long-term follow-up in these patients, including prospective evaluation of different antiplatelet therapies. METHODS This analysis included 574 atrial fibrillation patients. Standard anticoagulation (international normalized ratio [INR] 2.0-3.0) was used as control therapy to compare with anticoagulation (INR 1.9-2.5) plus either triflusal at 600 mg/day, triflusal at 300 mg/day or aspirin at 100 mg/day. The primary endpoint was ischemic or hemorrhagic stroke, a systemic or coronary ischemic event, or cardiovascular death. The mean follow-up was 4.92 years. RESULTS Long-term follow-up confirmed that combination therapy with an anticoagulant plus triflusal at 600 mg/day gave significantly better results than anticoagulation alone (hazard ratio [HR]=0.33; 95% confidence interval [CI], 0.14-0.80; P=.014). There was a significantly higher incidence of ischemic events with triflusal at 300 mg/day (P=.031) and of severe bleeding events with aspirin at 100 mg/day (P=.008). The mean INR was similar in the three combination therapy groups. The incidence of severe nongastric bleeding during combination therapy with triflusal was very low (0.3% of patients/year). CONCLUSIONS Long-term follow-up confirmed that combination antithrombotic therapy with triflusal at 600 mg/day gave significantly better results than anticoagulant monotherapy. The results obtained with combination therapy with triflusal at 300 mg/day and with aspirin at 100 mg/day should be considered provisional because the treatment groups were small and treatment was not randomly assigned.
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Affiliation(s)
- Ramón Bover
- Servicio de Cardiología, Hospital Universitario Clínico San Carlos, Madrid, España.
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25
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Antithrombotic effects of naturally derived products on coagulation and platelet function. Methods Mol Biol 2010; 663:229-40. [PMID: 20617421 DOI: 10.1007/978-1-60761-803-4_9] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
To date, there have been few systematic studies of the antiplatelet and/or anticoagulant effects of natural products. According to the Natural Medicines Comprehensive Database, approximately 180 dietary supplements have the potential to interact with warfarin, and more than 120 may interact with aspirin, clopidogrel, and dipyridamole. These include anise and dong quai (anticoagulant effects); omega 3-fatty acids in fish oil, ajoene in garlic, ginger, ginko, and vitamin E (antiplatelet properties); fucus (heparin-like activity); danshen (antithrombin III-like activity and anticoagulant bioavailability); and St. John's Wort and American Ginseng (interference with drug metabolism). Other supplements, such as high doses of vitamin E (vitamin K antagonist activity), alfalfa (high-vitamin K content), and coenzyme Q10 (vitamin K-like activity), may affect blood clotting, which is dependent on vitamin K. Studies are needed to understand the role of various dietary supplements in thrombosis and their interactions with standard anticoagulants and antiplatelet drugs.
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Bover R, Pérez-Gómez F, Maluenda MP, Asenjo S, Pérez-Saldaña R, Igea Á, Suárez M, Coleto D, Fernández C. Seguimiento a largo plazo de enfermos con fibrilación auricular del estudio NASPEAF. Control prospectivo de otros tratamientos antiplaquetarios. Rev Esp Cardiol 2009. [DOI: 10.1016/s0300-8932(09)72097-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Bouganim T, Shapira Y, Sagie A, Vaturi M, Battler A, Kornowski R, Lev EI. Platelet reactivity in patients with a history of obstructive prosthetic valve thrombosis. Am J Cardiol 2009; 103:1760-3. [PMID: 19539089 DOI: 10.1016/j.amjcard.2009.02.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2008] [Revised: 02/10/2009] [Accepted: 02/15/2009] [Indexed: 10/20/2022]
Abstract
One of the most serious complications of mechanical valves is obstructive prosthetic valve thrombosis (OPVT or "stuck valve"). Some patients develop OPVT despite an international normalized ratio (INR) in the therapeutic recommended range. We hypothesized that patients who develop OPVT have hyper-reactive platelets. We, therefore, examined platelet reactivity in patients who developed OPVT, despite a therapeutic or near-therapeutic INR, compared with a matched control group. We compared platelet reactivity between patients who had had an OPVT episode, despite a therapeutic or near-therapeutic INR (n = 18), and a matched group of patients with mechanical valves who did not develop this complication (n = 18) from 1996 to 2007. Platelet reactivity was evaluated by platelet aggregation in response to various agonists, platelet deposition under flow conditions in the Impact-R system, and plasma levels of platelet activation markers (soluble CD40 ligand and P-selectin). In the OPVT group, the average INR during the index episode was 3.1 +/- 1.5, and 44.6 +/- 40 months had elapsed from the index episode to the present study. Both groups were matched for gender, age +/-10 years, valve position and type, active smoking, and diabetes. Patients with an OPVT history had a greater aggregation in response to collagen (p = 0.05), greater platelet deposition in the Impact-R system (p = 0.01), and tended to have higher levels of soluble P-selection and soluble CD40 ligand (p = 0.07) than their control counterparts. In conclusion, patients with a history of OPVT appear to have increased platelet reactivity, which might contribute to an increased risk of thrombotic complications. These patients would, therefore, likely benefit from the addition of antiplatelet therapy to their standard anticoagulant treatment.
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Maribas P. Management of prosthetic heart valve obstruction: Speech for the surgery? Arch Cardiovasc Dis 2009; 102:255-7. [PMID: 19427602 DOI: 10.1016/j.acvd.2009.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Accepted: 03/12/2009] [Indexed: 11/29/2022]
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Callison RC, Adams HP. Use of antiplatelet agents for prevention of ischemic stroke. Neurol Clin 2008; 26:1047-77, ix. [PMID: 19026902 DOI: 10.1016/j.ncl.2008.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Overall management to lower risk for ischemic stroke is multifaceted. Management includes measures to treat risk factors for accelerated atherosclerosis and stroke, antithrombotic therapies to lower the risk for thromboembolism, and surgery to treat a defined arterial or cardiac lesion. Treatment decisions are made on a case-by-case basis, with most patients receiving some combination of medication and recommendations for lifestyle modification. Some patients will also undergo surgical or endovascular interventions. This article discusses antithrombotic treatment for ischemic stroke prevention, placing major emphasis on the indications for and administration of antiplatelet therapy.
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Affiliation(s)
- R Charles Callison
- Division of Cerebrovascular Diseases Department of Neurology, Carver College of Medicine University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA
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30
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Indications of combined vitamin K antagonists and aspirin therapy. J Thromb Thrombolysis 2008; 27:421-9. [PMID: 18516500 DOI: 10.1007/s11239-008-0234-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2008] [Accepted: 05/12/2008] [Indexed: 10/22/2022]
Abstract
Based on their mode of action, it is reasonable to expect that the combination therapy of aspirin and a vitamin K antagonist (VKA) may be more beneficial in preventing (athero) thrombotic complications in high-risk patients for cardiovascular events. However, there is no consensus about additional aspirin use in the most common indications for VKA or the use of VKAs to be added to the most common aspirin indications. The variation in clinical outcomes and bleeding complications suggests that extrapolating from one indication to another may not be appropriate. So far, decisions about the combined use of aspirin and VKA are individualized in the absence of adequate data. Only in patients with mechanical heart valves the benefits and safety of combining aspirin with VKA therapy seems obvious. In patients with peripheral artery disease no beneficial effect was noted for the combination therapy, perhaps with an exception of those with graft failure. For all other clinical situations, this is unclear and should be avoided.
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Salem DN, O'Gara PT, Madias C, Pauker SG. Valvular and Structural Heart Disease. Chest 2008; 133:593S-629S. [DOI: 10.1378/chest.08-0724] [Citation(s) in RCA: 191] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Schulman S, Beyth RJ, Kearon C, Levine MN. Hemorrhagic Complications of Anticoagulant and Thrombolytic Treatment. Chest 2008; 133:257S-298S. [PMID: 18574268 DOI: 10.1378/chest.08-0674] [Citation(s) in RCA: 484] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Sam Schulman
- From the Thrombosis Service, McMaster Clinic, HHS-General Hospital, Hamilton, ON, Canada.
| | - Rebecca J Beyth
- Rehabilitation Outcomes Research Center NF/SG Veterans Health System, Gainesville, FL
| | - Clive Kearon
- McMaster University Clinic, Henderson General Hospital, Hamilton, ON, Canada
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Dunning J, Versteegh M, Fabbri A, Pavie A, Kolh P, Lockowandt U, Nashef SAM. Guideline on antiplatelet and anticoagulation management in cardiac surgery. Eur J Cardiothorac Surg 2008; 34:73-92. [PMID: 18375137 DOI: 10.1016/j.ejcts.2008.02.024] [Citation(s) in RCA: 246] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2007] [Revised: 02/15/2008] [Accepted: 02/19/2008] [Indexed: 01/17/2023] Open
Abstract
This document presents a professional view of evidence-based recommendations around the issues of antiplatelet and anticoagulation management in cardiac surgery. It was prepared by the Audit and Guidelines Committee of the European Association for Cardio-Thoracic Surgery (EACTS). We review the following topics: evidence for aspirin, clopidogrel and warfarin cessation prior to cardiac surgery; perioperative interventions to reduce bleeding including the use of aprotinin and tranexamic acid; the use of thromboelastography to guide blood product usage; protamine reversal of heparin; the use of factor VIIa to control severe bleeding; anticoagulation after mechanical, tissue valve replacement and mitral valve repair; the use of antiplatelets and clopidogrel after cardiac surgery to improve graft patency and reduce thromboembolic complications and thromboprophylaxis in the postoperative period. This guideline is subject to continuous informal review, and when new evidence becomes available. The formal review date will be at 5 years from publication (September 2013).
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Affiliation(s)
- Joel Dunning
- Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
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35
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Emery RW, Emery AM, Raikar GV, Shake JG. Anticoagulation for mechanical heart valves: a role for patient based therapy. J Thromb Thrombolysis 2007; 25:18-25. [DOI: 10.1007/s11239-007-0105-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2007] [Accepted: 08/30/2007] [Indexed: 12/01/2022]
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Acute Thrombosis of a Prosthetic Mitral Valve: A Lesson in Anticoagulation. J Am Soc Echocardiogr 2007; 20:1010.e7-9. [DOI: 10.1016/j.echo.2007.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2006] [Indexed: 10/23/2022]
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Johnson SG, Witt DM, Eddy TR, Delate T. Warfarin and Antiplatelet Combination Use Among Commercially Insured Patients Enrolled in an Anticoagulation Management Service. Chest 2007; 131:1500-7. [PMID: 17494799 DOI: 10.1378/chest.06-2374] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Although warfarin and antiplatelet medications have documented efficacy for prevention of primary and secondary cardiovascular events, the appropriateness of warfarin and antiplatelet combination therapy is not well described in national consensus guidelines. METHODS AND RESULTS Cross-sectional data from 4,557 Kaiser Permanente Colorado members > or = 18 years old who were receiving warfarin anticoagulation therapy were used to quantify the prevalence of warfarin and antiplatelet agent (ie, aspirin, clopidogrel, dipyridamole, and/or dipyridamole/aspirin) combination therapy as of September 30, 2005, and to identify characteristics of patients receiving combination therapy. The prevalence of warfarin and any antiplatelet combination therapy was 385/1,000 (95% confidence interval [CI], 371/1,000 to 399/1,000). The majority of combination therapy was warfarin and aspirin (prevalence, 378/1,000) with a daily dose of aspirin, 81 mg, being the most reported dose (prevalence, 328/1,000). Patients receiving combination therapy were more likely to be male (63.6% vs 46.4%; adjusted odds ratio, 1.5; 95% CI, 1.3 to 1.7) and have a comorbidity of heart failure (29.0% vs 15.6%; adjusted odds ratio, 1.2; 95% CI, 1.1 to 1.5), coronary artery disease (62.4% vs 17.5%; adjusted odds ratio, 7.6; 95% CI, 6.5 to 8.8), and/or stroke/transient ischemic attack (5.2% vs 1.6%; adjusted odds ratio, 3.5; 95% CI, 2.3 to 5.3). CONCLUSION Nearly 4 of 10 patients receiving warfarin management care were receiving warfarin and antiplatelet combination therapy. The findings suggest that this practice is widespread, especially among patients with established cardiovascular disease, and involves a substantially higher number of patients than previously reported. The clinical outcomes associated with this practice require further investigation.
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Affiliation(s)
- Samuel G Johnson
- Kaiser Permanente of Colorado, 16601 E Centretech Pkwy, Aurora, CO 80011, USA.
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Wilson AM, Ardehali R, Brinton TJ, Yeung AC, Vagelos R. Successful removal of a paradoxical coronary embolus using an aspiration catheter. ACTA ACUST UNITED AC 2006; 3:633-6. [PMID: 17063168 DOI: 10.1038/ncpcardio0681] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2006] [Accepted: 04/19/2006] [Indexed: 11/09/2022]
Abstract
BACKGROUND A 28-year-old man presented at hospital with persistent pain in his chest and left arm, a paced rhythm on electrocardiography and elevated levels of cardiac enzymes. He was known to have patent foramen ovale and a dual-chamber pacemaker, which had been implanted following electrophysiological ablation to treat supraventricular tachycardia 3 years previously. The patient did not have a history of cardiovascular risk factors, recent travel, immobilization or clinical features of infection, and he was not taking any medication. INVESTIGATIONS Electrocardiography, cardiac enzyme studies, coronary angiography and transthoracic echocardiography. DIAGNOSIS Acute myocardial infarction, paradoxical coronary embolus and patent foramen ovale. MANAGEMENT Coronary aspiration embolectomy and systemic anticoagulation.
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Affiliation(s)
- Andrew M Wilson
- Interventional Cardiology, Stanford University Medical Center, 300 Pasteur Drive, Stanford, CA 94305, USA.
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Hallas J, Dall M, Andries A, Andersen BS, Aalykke C, Hansen JM, Andersen M, Lassen AT. Use of single and combined antithrombotic therapy and risk of serious upper gastrointestinal bleeding: population based case-control study. BMJ 2006; 333:726. [PMID: 16984924 PMCID: PMC1592384 DOI: 10.1136/bmj.38947.697558.ae] [Citation(s) in RCA: 267] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To assess the risk of serious upper gastrointestinal bleeding associated with the newer antithrombotic agents used alone or in combination with other antithrombotic drugs; to describe the trends in use of antithrombotic drugs in the background population. DESIGN Population based case-control study. SETTING Funen County, Denmark (population 470,000). SUBJECTS 1443 cases of serious upper gastrointestinal bleeding identified during 2000-4; 57,720 age and sex matched controls. MAIN OUTCOME MEASURE Exposure to low dose aspirin, clopidogrel, dipyridamole, vitamin K antagonists, and combined antithrombotic treatment. RESULTS Adjusted odds ratios associating drug use with upper gastrointestinal bleeding were 1.8 (95% confidence interval 1.5 to 2.1) for low dose aspirin, 1.1 (0.6 to 2.1) for clopidogrel, 1.9 (1.3 to 2.8) for dipyridamole, and 1.8 (1.3 to 2.4) for vitamin K antagonists. Corresponding figures for combined use were 7.4 (3.5 to 15) for clopidogrel and aspirin, 5.3 (2.9 to 9.5) for vitamin K antagonists and aspirin, and 2.3 (1.7 to 3.3) for dipyridamole and aspirin. Other combinations were used too infrequently to allow estimation. The number of treatment years needed to produce one excess case varied from 124 for the clopidogrel-aspirin combination to 8800 for clopidogrel alone. During the study period, exposure to combined antithrombotic regimens increased by 425% in the background population. CONCLUSION Antithrombotic treatment is becoming increasingly aggressive. Combined antithrombotic treatment confers particular risk and is associated with high incidence of gastrointestinal bleeding.
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Affiliation(s)
- Jesper Hallas
- Department of Clinical Pharmacology, IST, Syddansk Universitet, 5000 Odense, Denmark.
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Kulik A, Rubens FD, Wells PS, Kearon C, Mesana TG, van Berkom J, Lam BK. Early postoperative anticoagulation after mechanical valve replacement: a systematic review. Ann Thorac Surg 2006; 81:770-81. [PMID: 16427905 DOI: 10.1016/j.athoracsur.2005.07.023] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2005] [Revised: 07/04/2005] [Accepted: 07/06/2005] [Indexed: 10/25/2022]
Abstract
The optimal approach to early postoperative anticoagulation after mechanical valve implantation remains controversial. This review article examines the pathogenesis of thrombus formation and the different strategies for early postoperative anticoagulation. The most commonly reported anticoagulation regimens had the after estimates of early postoperative thromboembolism and hemorrhage: oral anticoagulation alone (0.9%, 3.3%); oral anticoagulation with intravenous unfractionated heparin (1.1%, 7.2%); and oral anticoagulation with low molecular weight heparin (0.6%, 4.8%). Although intravenous heparin may be associated with a higher incidence of hemorrhage, a randomized trial is needed to provide the best evidence regarding early postoperative anticoagulation after mechanical valve implantation. Nearly four decades have passed since the first mechanical prosthetic valves were implanted. Frequent thromboembolic complications with the first mechanical valves led to recommendations of universal anticoagulation for these patients. Since then, several design changes and modifications have been made to improve the longevity, hemodynamics, and thrombogenicity of newer generation mechanical valves. With improved blood flow, less stasis, and less thrombogenic materials, lower rates of thromboembolism have been reported. Despite these advances however, thromboembolism and anticoagulant-related bleeding continue to account for 75% of all complications after mechanical valve replacement. Occurring most commonly within six months after implantation, these complications can adversely affect mortality and quality of life. Furthermore, the threat of their occurrence creates a psychological burden for each patient with a mechanical valve. The need for life-long anticoagulation in patients with mechanical valves is not in dispute, and the perioperative management of anticoagulation during non-cardiac surgery has been reviewed extensively. However, the approach to early postoperative anticoagulation after mechanical valve implantation is still a matter of debate. The optimal intensity and timing of anticoagulation to prevent early thromboembolism after valve replacement surgery without postoperative bleeding complications is unknown. Hence, many anticoagulation protocols have been proposed, but a lack of consensus remains. The objectives of this study were (1) to reexamine the pathogenesis of thrombus formation and the need for anticoagulation; (2) to critically review the literature on early postoperative anticoagulation strategies; and (3) provide an estimate of the incidence of bleeding and thromboembolism for each approach to early postoperative anticoagulation.
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Affiliation(s)
- Alexander Kulik
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa Hospital, Ottawa, Canada
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Abstract
Warfarin is highly effective at reducing the risk of stroke in atrial fibrillation. The benefit of oral anticoagulant therapy strongly outweighs the risk in most patients with atrial fibrillation. More data are needed to define better the overall risk-to-benefit ratio for patients age 80 years and greater. Because a significant proportion of elderly individuals may not be optimal candidates for anticoagulant therapy, alternative stroke prevention strategies must continue to be evaluated while redoubling efforts to understand the mechanisms underlying atrial fibrillation and thrombogenesis.
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Affiliation(s)
- David A Garcia
- Department of Internal Medicine, University of New Mexico, Albuquerque, NM 87131, USA.
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del Zoppo GJ. Antithrombotic Approaches in Cerebrovascular Disease. Vasc Med 2006. [DOI: 10.1016/b978-0-7216-0284-4.50037-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Israels SJ, Michelson AD. Antiplatelet therapy in children. Thromb Res 2006; 118:75-83. [PMID: 16709476 DOI: 10.1016/j.thromres.2004.12.016] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2004] [Revised: 07/29/2004] [Accepted: 12/23/2004] [Indexed: 01/19/2023]
Abstract
Platelets are essential for the maintenance of vascular integrity and control of bleeding at sites of injury, but they are also implicated in the progression of atherosclerotic lesions and arterial vascular thrombosis. The use of antiplatelet drugs for the primary and secondary prevention of cardiovascular and cerebrovascular thromboses in adult populations has been extensively evaluated, resulting in defined management strategies. Much less is known about the appropriate use of antiplatelet drugs (primarily aspirin) in infants and children for secondary prevention in ischemic stroke, for prevention of coronary artery thrombosis in Kawasaki disease, or for prevention of thromboembolism following surgery for congenital cardiac disease. Additional studies will be required to evaluate the relative benefits of aspirin and anticoagulants in these settings. A role for newer antiplatelet drugs in the management of pediatric arterial thrombosis is as yet unexplored.
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Affiliation(s)
- Sara J Israels
- Department of Pediatrics and Child Health, and the Manitoba Institute of Cell Biology, University of Manitoba, Winnipeg, Manitoba, Canada R3E 0V9.
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Butchart EG, Gohlke-Bärwolf C, Antunes MJ, Tornos P, De Caterina R, Cormier B, Prendergast B, Iung B, Bjornstad H, Leport C, Hall RJC, Vahanian A. Recommendations for the management of patients after heart valve surgery. Eur Heart J 2005; 26:2463-71. [PMID: 16103039 DOI: 10.1093/eurheartj/ehi426] [Citation(s) in RCA: 193] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Approximately 50,000 valve replacement operations take place in Europe annually and almost as many valve repair procedures. Previous European guidelines on management of patients after valve surgery were last published in 1995 and were limited to recommendations about antithrombotic prophylaxis. American guidelines covering the broader topic of the investigation and treatment of patients with valve disease were published in 1998 but devoted relatively little space to post-surgical management. This document represents the consensus view of a committee drawn from three European Society of Cardiology (ESC) Working Groups (WG): the WG on Valvular Heart Disease, the WG on Thrombosis, and the WG on Rehabilitation and Exercise Physiology. In almost all areas of patient management after valve surgery, randomized trials and meta-analyses do not exist. Such randomized trials as do exist are very few in number, are narrowly focused with small numbers, have limited general applicability, and do not lend themselves to meta-analysis because of widely divergent methodologies and different patient characteristics. Recommendations are therefore almost entirely based on non-randomized studies and relevant basic science.
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Affiliation(s)
- Eric G Butchart
- Department of Cardiothoracic Surgery, University Hospital of Wales, Cardiff, UK.
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Falk RH. Reconsidering combined antiplatelet and anticoagulant therapy in atrial fibrillation**Editorials published in the Journal of the American College of Cardiologyreflect the views of the authors and do not necessarily represent the views of JACCor the American College of Cardiology. J Am Coll Cardiol 2004; 44:1567-9. [PMID: 15489086 DOI: 10.1016/j.jacc.2004.07.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Levine MN, Raskob G, Beyth RJ, Kearon C, Schulman S. Hemorrhagic Complications of Anticoagulant Treatment. Chest 2004; 126:287S-310S. [PMID: 15383476 DOI: 10.1378/chest.126.3_suppl.287s] [Citation(s) in RCA: 318] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
This chapter about hemorrhagic complications of anticoagulant treatment is part of the seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Bleeding is the major complication of anticoagulant therapy. The criteria for defining the severity of bleeding varies considerably between studies, accounting in part for the variation in the rates of bleeding reported. The major determinants of vitamin K antagonist-induced bleeding are the intensity of the anticoagulant effect, underlying patient characteristics, and the length of therapy. There is good evidence that vitamin K antagonist therapy, targeted international normalized ratio (INR) of 2.5 (range, 2.0 to 3.0), is associated with a lower risk of bleeding than therapy targeted at an INR > 3.0. The risk of bleeding associated with IV unfractionated heparin (UFH) in patients with acute venous thromboembolism (VTE) is < 3% in recent trials. This bleeding risk may increase with increasing heparin dosages and age (> 70 years). Low molecular weight heparin (LMWH) is associated with less major bleeding compared with UFH in acute VTE. UFH and LMWH are not associated with an increase in major bleeding in ischemic coronary syndromes, but are associated with an increase in major bleeding in ischemic stroke. Information on bleeding associated with the newer generation of antithrombotic agents has begun to emerge. In terms of treatment decision making for anticoagulant therapy, bleeding risk cannot be considered alone, ie, the potential decrease in thromboembolism must be balanced against the potential increased bleeding risk.
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Affiliation(s)
- Mark N Levine
- Henderson Research Centre, 711 Concession St, Hamilton, Ontario L8V 1C3
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Abstract
Long-term treatment of venous thromboembolism (VTE) focuses mainly on the duration of anticoagulant therapy, usually with vitamin K (VK) antagonists. The duration of therapy should be individualized based on the risk of recurrent VTE if treatment were stopped and the risk of bleeding if treatment were continued. The risk of recurrence is low if thrombosis was provoked by a major reversible risk factor such as surgery; 3 months of treatment is usually adequate for such patients. The risk of recurrence is high if thrombosis was unprovoked (“idiopathic”) or associated with an irreversible risk factor such as cancer; anticoagulant treatment for at least 6 months, and often indefinitely, is indicated for such patients. Risk of recurrence is intermediate if thrombosis was associated with a minor transient risk factor; such patients can be treated for 3 to 6 months. Within each of these categories, presentation as pulmonary embolism, >1 previous VTE, an underlying malignancy, an antiphospholipid antibody, or selected hereditary thrombophilic states favor more prolonged therapy, whereas isolated distal deep vein thrombosis, high risk of bleeding, and patient preference favor shorter treatment. The optimal intensity of anticoagulant therapy with VK antagonists corresponds to a target international normalized ratio of 2.5 (range, 2.0 to 3.0). Long-term treatment with low-molecular-weight heparin is an alternative to VK-antagonist therapy and is usually preferable in patients with active cancer. Oral direct thrombin inhibitors also appear suitable for long-term prevention of recurrent VTE but await regulatory approval and comparison with VK antagonists.
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Affiliation(s)
- Clive Kearon
- Department of Medicine, McMaster University, McMaster Clinic, Henderson General Hospital, Hamilton, Ontario, Canada.
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Abstract
BACKGROUND AND OBJECTIVE Clinicians frequently face the decision of whether to continue aspirin when starting patients on warfarin. We performed a meta-analysis to characterize the tradeoffs involved in this common clinical dilemma. DATA SOURCES Multiple computerized databases (1966 to 2003), reference lists of relevant articles, conference proceedings, and queries of primary authors. STUDY SELECTION Randomized trials comparing warfarin plus aspirin versus warfarin alone. Studies with target international normalized ratios (INRs) <2 were excluded. DATA EXTRACTION Two reviewers independently extracted baseline data and major outcomes: rates of thromboembolism, hemorrhage, and all-cause mortality. DATA SYNTHESIS Nine studies met the inclusion criteria. Of the five that enrolled patients with mechanical heart valves, four used the same target INR in both groups, while one used a reduced target INR for the warfarin plus aspirin group. Pooling the results of the first four studies demonstrated that combination of warfarin plus aspirin significantly decreased thromboembolic events (relative risk [RR], 0.33; 95% confidence interval [CI], 0.19 to 0.58), increased major bleeding (RR, 1.58; 95% CI, 1.02 to 2.44), and decreased all-cause mortality (RR, 0.43; 95% CI, 0.23 to 0.81) compared to warfarin alone. The one valve trial using a reduced INR in the warfarin plus aspirin group reported no difference in thromboembolic outcomes but found decreased major bleeding and a significant mortality benefit with combination therapy. Of the remaining trials, three evaluated a warfarin indication not routinely used in the United States (post-myocardial infarction), and the only trial that considered atrial fibrillation was terminated early due to inadequate enrollment. CONCLUSIONS For mechanical heart valve patients, the benefits of continuing aspirin when starting warfarin therapy are clear. For other routine warfarin indications, there are not adequate data to guide this common clinical decision.
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Affiliation(s)
- Robin J Larson
- VA Outcomes Group, Department of Veteran Affairs Medical Center, White River Junction, VT, USA.
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Affiliation(s)
- Christian Seiler
- University Hospital, Swiss Cardiovascular Center Bern, Freiburgstrasse, CH-3010 Bern, Switzerland.
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