Anticoagulants and Thrombolytics

Parenteral anticoagulants: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

This article describes the pharmacology of approved parenteral anticoagulants. These include the indirect anticoagulants, unfractionated heparin (UFH), low-molecular-weight heparins (LMWHs), fondaparinux, and danaparoid, as well as the direct thrombin inhibitors hirudin, bivalirudin, and argatroban. UFH is a heterogeneous mixture of glycosaminoglycans that bind to antithrombin via a unique pentasaccharide sequence and catalyze the inactivation of thrombin, factor Xa, and other clotting enzymes. Heparin also binds to cells and plasma proteins other than antithrombin causing unpredictable pharmacokinetic and pharmacodynamic properties and triggering nonhemorrhagic side effects, such as heparin-induced thrombocytopenia (HIT) and osteoporosis. LMWHs have greater inhibitory activity against factor Xa than thrombin and exhibit less binding to cells and plasma proteins than heparin. Consequently, LMWH preparations have more predictable pharmacokinetic and pharmacodynamic properties, have a longer half-life than heparin, and are associated with a lower risk of nonhemorrhagic side effects. LMWHs can be administered once daily or bid by subcutaneous injection, without coagulation monitoring. Based on their greater convenience, LMWHs have replaced UFH for many clinical indications. Fondaparinux, a synthetic pentasaccharide, catalyzes the inhibition of factor Xa, but not thrombin, in an antithrombin-dependent fashion. Fondaparinux binds only to antithrombin. Therefore, fondaparinux-associated HIT or osteoporosis is unlikely to occur. Fondaparinux exhibits complete bioavailability when administered subcutaneously, has a longer half-life than LMWHs, and is given once daily by subcutaneous injection in fixed doses, without coagulation monitoring. Three additional parenteral direct thrombin inhibitors and danaparoid are approved as alternatives to heparin in patients with HIT.

Proteoglycans in host-pathogen interactions: molecular mechanisms and therapeutic implications

Many microbial pathogens subvert proteoglycans for their adhesion to host tissues, invasion of host cells, infection of neighbouring cells, dissemination into the systemic circulation, and evasion of host defence mechanisms. Where studied, specific virulence factors mediate these proteoglycan-pathogen interactions, which are thus thought to affect the onset, progression and outcome of infection. Proteoglycans are composites of glycosaminoglycan (GAG) chains attached covalently to specific core proteins. Proteoglycans are expressed ubiquitously on the cell surface, in intracellular compartments, and in the extracellular matrix. GAGs mediate the majority of ligand-binding activities of proteoglycans, and many microbial pathogens elaborate cell-surface and secreted factors that interact with GAGs. Some pathogens also modulate the expression and function of proteoglycans through known virulence factors. Several GAG-binding pathogens can no longer attach to and invade host cells whose GAG expression has been reduced by mutagenesis or enzymatic treatment. Furthermore, GAG antagonists have been shown to inhibit microbial attachment and host cell entry in vitro and reduce virulence in vivo. Together, these observations underscore the biological significance of proteoglycan-pathogen interactions in infectious diseases.

Idiopathic massive spontaneous hemothorax: adhesion disruption

BACKGROUND

Hemothorax has been reported to occur along with spontaneous pneumothorax due to adhesion disruption. Rupture of pleural adhesions spontaneously or after unnoticeable trivial trauma causing massive hemothorax alone is rare.

METHODS

We present a series of seven cases of idiopathic massive spontaneous hemothorax due to adhesion disruption, of which all required emergency thoracotomy with ligation or cauterization of bleeding adhesions.

RESULTS

Six patients had bleeding pleural lung adhesions of which five involved the upper lobes. Another had bleeding from pleuropericardial adhesions. All patients are doing well on follow-up.

CONCLUSIONS

Disruption of pleural adhesions may cause massive hemothorax, requiring early surgical intervention. After thoracotomy the outcome in these patients is excellent.

Venous thromboembolism in intensive care patients

Venous thromboembolism frequently complicates the management of patients with severe medical and surgical illnesses. Because the diagnosis of VTE is especially challenging in critically ill patients, the focus of intensivists should be on characterization of risk factors and the appropriate choice of VTE prophylaxis. LDUH or LMHW is the preferred choice for VTE prophylaxis in ICU patients. Mechanical methods of prophylaxis should be reserved for patients with a high risk for bleeding. The effectiveness of mechanical methods and of combined strategies of prevention and the clinically important outcomes of therapy need to be explored further in critically ill patients. Few diagnostic strategies have been assessed in ICU patients with suspected PE. Ventilation-perfusion lung scans remain a pivotal diagnostic test but retain the same limitations in critically ill patients as seen in other patient populations. Newer noninvasive techniques, such as spiral CT associated with imaging of the extremities, are gaining more wide-spread use, but, thus far, pulmonary angiography remains the most reliable technique to confirm or exclude PE in patients with respiratory failure. A consensus must be reached regarding the most appropriate combination of tests for adequate and cost-effective diagnosis of VTE. Further investigation of diagnostic strategies that include adequate consideration of clinical diagnosis using standardized models and noninvasive imaging are warranted.

Heparin-induced thrombocytopenia

Heparin-induced thrombocytopenia is a rare but complex adverse drug reaction that can produce devastating results. Treatment and clinical management of the patient requires close observation and education of the pathophysiology occurring at the cellular level. Documented cases of heparin-induced thrombocytopenia have been reported in the literature for years. This case presentation details a multiple trauma patient in whom heparin-induced thrombocytopenia developed and the effect this syndrome had on her treatment and eventual recovery.