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Zhang S, Li Y, Yang Y, Gong S, Yang Z, Hong C, Cui X, Wan J, Ji Y, Chen H, Zhu L, Li C, Cheng Z, Zhang Y, Wang Q, Luo Q, Guo L, Ma G, Han B, Liu Z, Xiong C, Wang L, Ji Q, Li F, Wang S, Zhang Z, Zhang Y, Wang D, Gao Q, Huang Q, Xie W, Zhai Z, Wang C. The management pattern and outcomes of chronic thromboembolic pulmonary hypertension: rationale and design for a Chinese real-world study. BMC Pulm Med 2024; 24:265. [PMID: 38825688 PMCID: PMC11145764 DOI: 10.1186/s12890-024-03042-5] [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: 04/18/2024] [Accepted: 04/30/2024] [Indexed: 06/04/2024] Open
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is a progressive pulmonary vascular disorder with substantial morbidity and mortality, also a disease underdiagnosed and undertreated. It is potentially curable by pulmonary endarterectomy (PEA) in patients with surgically accessible thrombi. Balloon pulmonary angioplasty (BPA) and targeted medical therapy are options for patients with distal lesions or persistent/recurrent pulmonary hypertension after PEA. There is an urgent need to increase the awareness of CTEPH. Qualified CTEPH centers are still quite limited. Baseline characteristics, management pattern and clinical outcome of CTEPH in China needs to be reported. METHODS AND DESIGN The CHinese reAl-world study to iNvestigate the manaGEment pattern and outcomes of chronic thromboembolic pulmonary hypertension (CHANGE) study is designed to provide the multimodality treatment pattern and clinical outcomes of CTEPH in China. Consecutive patients who are ≥ 14 year-old and diagnosed with CTEPH are enrolled. The diagnosis of CTEPH is confirmed in right heart catheterization and imaging examinations. The multimodality therapeutic strategy, which consists of PEA, BPA and targeted medical therapy, is made by a multidisciplinary team. The blood sample and tissue from PEA are stored in the central biobank for further research. The patients receive regular follow-up every 3 or 6 months for at least 3 years. The primary outcomes include all-cause mortality and changes in functional and hemodynamic parameters from baseline. The secondary outcomes include the proportion of patients experiencing lung transplantation, the proportion of patients experiencing heart and lung transplantation, and changes in health-related quality of life. Up to 31 December 2023, the study has enrolled 1500 eligible patients from 18 expert centers. CONCLUSIONS As a real-world study, the CHANGE study is expected to increase our understanding of CTEPH, and to fill the gap between guidelines and the clinical practice in the diagnosis, assessment and treatment of patients with CTEPH. REGISTRATION NUMBER IN CLINICALTRIALS.GOV: NCT05311072.
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Affiliation(s)
- Shuai Zhang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Yishan Li
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Yuanhua Yang
- Department of Pulmonary and Critical Care Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing, P.R. China
| | - Sugang Gong
- Dpartments of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, P.R. China
| | - Zhenwen Yang
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, P.R. China
| | - Cheng Hong
- State Key Laboratory of Respiratory Diseases, Guangdong Key Laboratory of Vascular Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, P.R. China
| | - Xiaopei Cui
- Department of Geriatric Medicine, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Jun Wan
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, P.R. China
| | - Yingqun Ji
- Department of Pulmonary and Critical Care Medicine, East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hong Chen
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Ling Zhu
- Department of Respiratory Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, P.R. China
| | - Chenghong Li
- Department of Pulmonary and Critical Care Medicine, Affiliated Hospital of Jianghan University, Wuhan, P.R. China
| | - Zhaozhong Cheng
- Department of Pulmonary and Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, P.R. China
| | - Yunhui Zhang
- Department of Respiratory Medicine, The First People's Hospital of Yunnan Province, Kunming, P.R. China
| | - Qiguang Wang
- Division of Pulmonary Vascular Disease, General Hospital of Northern Theater of Command, Shenyang, P.R. China
| | - Qin Luo
- Center for Pulmonary Vascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Lu Guo
- Department of Pulmonary and Critical Care Medicine, School of Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, P.R. China
| | - Guofeng Ma
- Department of Respiratory Diseases, Sir Run Run ShawHospital, Zhejiang University School of Medicine, Hangzhou, P.R. China
| | - Baoshi Han
- Department of Cardiology, Chinese People's Liberation Army General Hospital, Beijing, P.R. China
| | - Zhihong Liu
- Center for Pulmonary Vascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Changming Xiong
- Center for Pulmonary Vascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Lan Wang
- Departments of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, P.R. China
| | - Qiushang Ji
- Department of Cardiology, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Fajiu Li
- Department of Pulmonary and Critical Care Medicine, Affiliated Hospital of Jianghan University, Wuhan, P.R. China
| | - Shengfeng Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, P.R. China
| | - Zhu Zhang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Yunxia Zhang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Dingyi Wang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Data and Project Management Unit, Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Qian Gao
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Qiang Huang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Wanmu Xie
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China.
| | - Zhenguo Zhai
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China.
| | - Chen Wang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China
- Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, P.R. China
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2
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Ben Salah R, Derbel A, Chabchoub I, Frikha F, Marzouk S, Bahloul Z. [Aspirin and prevention of the recurrence of venous thromboembolism]. Ann Cardiol Angeiol (Paris) 2024; 73:101761. [PMID: 38754180 DOI: 10.1016/j.ancard.2024.101761] [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: 02/09/2024] [Revised: 03/27/2024] [Accepted: 03/27/2024] [Indexed: 05/18/2024]
Abstract
After a first episode of unprovoked vein thrombosis, the risk of recurrence persists for many years. Long term of anticoagulant therapy prevents the recurrence of vein thrombosis but is associated with a major risk of bleeding. As platelets play a role in the initiation and propagation of venous thromboembolism as well, antiplatelet agents, may play a role in the treatment and prevention of this disease. This review summarizes available evidence on effect of aspirin in the prevention of recurrent deep vein thrombosis.
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Affiliation(s)
| | - Abir Derbel
- Department of internal medicine, Sfax university, Tunisia
| | - Imen Chabchoub
- Department of internal medicine, Sfax university, Tunisia
| | - Faten Frikha
- Department of internal medicine, Sfax university, Tunisia
| | - Sameh Marzouk
- Department of internal medicine, Sfax university, Tunisia
| | - Zouhir Bahloul
- Department of internal medicine, Sfax university, Tunisia
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3
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Ren J, Wang N, Zhang X, Song F, Zheng X, Han X. A systematic review and meta-analysis of the morbidity of efficacy endpoints and bleeding events in elderly and young patients treated with the same dose rivaroxaban. Ann Hematol 2024:10.1007/s00277-024-05767-z. [PMID: 38710878 DOI: 10.1007/s00277-024-05767-z] [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: 02/19/2024] [Accepted: 04/17/2024] [Indexed: 05/08/2024]
Abstract
Rivaroxaban is a new direct oral anticoagulant, and the same dose is recommended for older and young patients. However, recent real-world studies show that older patients may need dose adjustment to prevent major bleeding. At present, the evidence for dose adjustment in older patients is extremely limited with only a few reports on older atrial fibrillation patients. The aim of this study was to review the morbidity data of adverse events and bleeding events across all indications for older and young patients treated with the same dose of rivaroxaban to provide some support for dosage adjustment in older patients. The PubMed, EMBASE, ClinicalTrials, Cochrane and Web of Science databases were searched for randomized controlled trials (RCTs) published between January 1, 2005, and October 10, 2023. The primary outcomes were the morbidity of bleeding events and efficacy-related adverse events. Summary estimates were calculated using a random effects model. Eighteen RCTs were included in the qualitative analysis. The overall morbidity of primary efficacy endpoints was higher in older patients compared to the young patients (3.37% vs. 2.60%, χ2 = 5.24, p = 0.022). Similarly, a higher morbidity of bleeding was observed in older patients compared to the young patients (4.42% vs. 6.03%, χ2 = 13.22, p < 0.001). Among all indications, deep vein thrombosis, pulmonary embolism and atrial fibrillation were associated with the highest incidence of bleeding in older patients, suggesting that these patients may be most need dose adjustment. Patients older than 75 years may require extra attention to prevent bleeding. The same dose of rivaroxaban resulted in higher bleeding morbidity and morbidity of efficacy-related adverse events in older patients compared to the young patients. An individualized dose adjustment may be preferred for older patients rather than a fixed dose that fits all.
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Affiliation(s)
- Jianwei Ren
- Clinical Pharmacology Research Center, Beijing Key Laboratory of Clinical PK and PD Investigation for Innovative Drugs, NMPA Key Laboratory for Clinical Research and Evaluation of Drug, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Na Wang
- Clinical Pharmacology Research Center, Beijing Key Laboratory of Clinical PK and PD Investigation for Innovative Drugs, NMPA Key Laboratory for Clinical Research and Evaluation of Drug, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Xuan Zhang
- Clinical Pharmacology Research Center, Beijing Key Laboratory of Clinical PK and PD Investigation for Innovative Drugs, NMPA Key Laboratory for Clinical Research and Evaluation of Drug, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Fuyu Song
- Center for Food and Drug Inspection, National Medical Products Administration, Beijing, 100053, China
- NHC Key Laboratory of Mental Health, National Clinical Research Center for Mental Disorders, Peking University Sixth Hospital, Peking University Institute of Mental Health, Peking University, Beijing, 100191, China
| | - Xin Zheng
- Clinical Pharmacology Research Center, Beijing Key Laboratory of Clinical PK and PD Investigation for Innovative Drugs, NMPA Key Laboratory for Clinical Research and Evaluation of Drug, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
| | - Xiaohong Han
- Clinical Pharmacology Research Center, Beijing Key Laboratory of Clinical PK and PD Investigation for Innovative Drugs, NMPA Key Laboratory for Clinical Research and Evaluation of Drug, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
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4
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Gagnon E, Girard A, Bourgault J, Abner E, Gill D, Thériault S, Vohl MC, Tchernof A, Esko T, Mathieu P, Arsenault BJ. Genetic assessment of efficacy and safety profiles of coagulation cascade proteins identifies Factors II and XI as actionable anticoagulant targets. EUROPEAN HEART JOURNAL OPEN 2024; 4:oeae043. [PMID: 38933427 PMCID: PMC11200102 DOI: 10.1093/ehjopen/oeae043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/29/2024] [Accepted: 03/05/2024] [Indexed: 06/28/2024]
Abstract
Aims Anticoagulants are routinely used by millions of patients worldwide to prevent blood clots. Yet, problems with anticoagulant therapy remain, including a persistent and cumulative bleeding risk in patients undergoing prolonged anticoagulation. New safer anticoagulant targets are needed. Methods and results To prioritize anticoagulant targets with the strongest efficacy [venous thromboembolism (VTE) prevention] and safety (low bleeding risk) profiles, we performed two-sample Mendelian randomization and genetic colocalization. We leveraged three large-scale plasma protein data sets (deCODE as discovery data set and Fenland and Atherosclerosis Risk in Communities as replication data sets] and one liver gene expression data set (Institut Universitaire de Cardiologie et de Pneumologie de Québec bariatric biobank) to evaluate evidence for a causal effect of 26 coagulation cascade proteins on VTE from a new genome-wide association meta-analysis of 44 232 VTE cases and 847 152 controls, stroke subtypes, bleeding outcomes, and parental lifespan as an overall measure of efficacy/safety ratio. A 1 SD genetically predicted reduction in F2 blood levels was associated with lower risk of VTE [odds ratio (OR) = 0.44, 95% confidence interval (CI) = 0.38-0.51, P = 2.6e-28] and cardioembolic stroke risk (OR = 0.55, 95% CI = 0.39-0.76, P = 4.2e-04) but not with bleeding (OR = 1.13, 95% CI = 0.93-1.36, P = 2.2e-01). Genetically predicted F11 reduction was associated with lower risk of VTE (OR = 0.61, 95% CI = 0.58-0.64, P = 4.1e-85) and cardioembolic stroke (OR = 0.77, 95% CI = 0.69-0.86, P = 4.1e-06) but not with bleeding (OR = 1.01, 95% CI = 0.95-1.08, P = 7.5e-01). These Mendelian randomization associations were concordant across the three blood protein data sets and the hepatic gene expression data set as well as colocalization analyses. Conclusion These results provide strong genetic evidence that F2 and F11 may represent safe and efficacious therapeutic targets to prevent VTE and cardioembolic strokes without substantially increasing bleeding risk.
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Affiliation(s)
- Eloi Gagnon
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec, Y-3106, Pavillon Marguerite D'Youville, 2725 chemin Ste-Foy, Quebec, QC, Canada, G1V 4G5
| | - Arnaud Girard
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec, Y-3106, Pavillon Marguerite D'Youville, 2725 chemin Ste-Foy, Quebec, QC, Canada, G1V 4G5
| | - Jérôme Bourgault
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec, Y-3106, Pavillon Marguerite D'Youville, 2725 chemin Ste-Foy, Quebec, QC, Canada, G1V 4G5
| | - Erik Abner
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec, Y-3106, Pavillon Marguerite D'Youville, 2725 chemin Ste-Foy, Quebec, QC, Canada, G1V 4G5
| | - Dipender Gill
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
| | - Sébastien Thériault
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec, Y-3106, Pavillon Marguerite D'Youville, 2725 chemin Ste-Foy, Quebec, QC, Canada, G1V 4G5
- Department of Molecular Biology, Medical Biochemistry and Pathology, Faculty of Medicine, Université Laval, Quebec, QC, Canada
| | - Marie-Claude Vohl
- School of Nutrition, Université Laval, Quebec, QC, Canada
- Centre Nutrition, Santé et société (NUTRISS), Institut sur la nutrition et les aliments fonctionnels (INAF), Université Laval, Quebec, QC, Canada
| | - André Tchernof
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec, Y-3106, Pavillon Marguerite D'Youville, 2725 chemin Ste-Foy, Quebec, QC, Canada, G1V 4G5
- School of Nutrition, Université Laval, Quebec, QC, Canada
| | - Tõnu Esko
- Estonian Genome Center, Institute of Genomics, University of Tartu, Tartu, Estonia
| | - Patrick Mathieu
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec, Y-3106, Pavillon Marguerite D'Youville, 2725 chemin Ste-Foy, Quebec, QC, Canada, G1V 4G5
- Department of Surgery, Faculty of Medicine, Université Laval, Quebec, QC, Canada
| | - Benoit J Arsenault
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec, Y-3106, Pavillon Marguerite D'Youville, 2725 chemin Ste-Foy, Quebec, QC, Canada, G1V 4G5
- Department of Medicine, Faculty of Medicine, 1050 Av. de la Médecine, Québec City, Quebec G1V 0A6, Canada
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5
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Hu Z, Persaud Y, Ahuja S. A systematic review and meta-analysis of the effectiveness of primary thromboprophylaxis in acute lymphoblastic leukemia during early-phase therapy including asparaginase or its prolonged form. Crit Rev Oncol Hematol 2024; 197:104347. [PMID: 38583546 DOI: 10.1016/j.critrevonc.2024.104347] [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: 11/04/2023] [Revised: 03/31/2024] [Accepted: 04/04/2024] [Indexed: 04/09/2024] Open
Abstract
Asparaginase is essential in the initial management of acute lymphoblastic leukemia (ALL) but frequently leads to venous thromboembolism (VTE). Using anticoagulants for primary VTE prevention has been studied with no consensus. We conducted a systematic literature search in PubMed, Scopus, and Web of science and performed random-effect meta-analysis using Mantel-Haenszel method in RevMan 5.4 to analyze primary pharmacological thromboprophylaxis during asparaginase treatment in early-phase (induction, consolidation, or intensification phase) therapy in patients with ALL with all ages and followed with subgroup analysis by age. Meta-analysis of 13 articles describing the effect of antithrombin supplementation in 1375 patients showed that antithrombin prophylaxis decreases the risk of VTE by 43% (RR, 0.57; 95% CI, 0.38 - 0.83; p=0.004), with mild heterogeneity (I2=35%, p=0.10) and moderate certainty by GRADE. 8 articles included for meta-analysis of low-molecular weight heparin (LMWH) treatment in 612 patients showed that it decreased the risk of VTE by nearly 40% (RR, 0.61; 95% CI, 0.45 - 0.81; p=0.00081), with minimal heterogeneity (I2=14%, p=0.31) but low certainty. Subgroup analysis showed that only prophylaxis with antithrombin supplementation significantly decreased the VTE rate in adult patients with moderate certainty. In pediatric patients, one nonrandomized prospective study showed that LMWH combined with antithrombin has a better thromboprophylaxis effect than antithrombin alone. In the PREVAPIX-ALL trial, prophylaxis with direct factor Xa inhibitor Apixaban did not benefit children younger than 18 years except for cases of obesity. We concluded that thromboprophylaxis with antithrombin is effective in ALL patients older than 18 years during the early phase of therapy, and LMWH combined with antithrombin supplementation might be effective for pediatric patients with ALL. Apixaban is effective in pediatric ALL patients with obesity and needs further study in other high-risk patients.
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Affiliation(s)
- Zhongbo Hu
- Hospitalist Medicine Program, Department of Oncology, St. Jude Children's Research Hospital, 262 Danny Thomas Place Mail Stop 278, Memphis, TN 38105, USA.
| | - Yogindra Persaud
- Department of Hematology, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105, USA
| | - Sanjay Ahuja
- Department of Pediatric Hematology & Oncology, University Hospitals Rainbow Babies and Children's Hospital, 11100 Euclid Ave, Cleveland, OH 44106, USA
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6
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Khairani CD, Bejjani A, Assi A, Porio N, Talasaz AH, Piazza G, Cushman M, Bikdeli B. Direct oral anticoagulants for treatment of venous thrombosis: illustrated review of appropriate use. Res Pract Thromb Haemost 2024; 8:102424. [PMID: 38812988 PMCID: PMC11135034 DOI: 10.1016/j.rpth.2024.102424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 04/04/2024] [Indexed: 05/31/2024] Open
Abstract
Direct oral anticoagulants (DOACs) have become the preferred option for treatment of venous thromboembolism due to their favorable profile compared with other agents such as vitamin K antagonists or low-molecular-weight heparin. However, findings from randomized controlled trials suggest efficacy and/or safety concerns with DOAC use in some clinical contexts. This illustrated review will summarize indications where DOACs have proven efficacy and safety, situations where they fall short, and situations where uncertainty remains compared with other treatments for venous thromboembolism.
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Affiliation(s)
- Candrika D. Khairani
- Thrombosis Research Group, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Antoine Bejjani
- Thrombosis Research Group, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ali Assi
- Thrombosis Research Group, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nicole Porio
- Thrombosis Research Group, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Azita H. Talasaz
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Gregory Piazza
- Thrombosis Research Group, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mary Cushman
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Behnood Bikdeli
- Thrombosis Research Group, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut, USA
- Cardiovascular Research Foundation (CRF), New York, New York, USA
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7
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Woodland M, Thompson A, Lipford A, Goyal N, Schexnaildre JC, Mottamal M, Afosah DK, Al-Horani RA. New Triazole-Based Potent Inhibitors of Human Factor XIIa as Anticoagulants. ACS OMEGA 2024; 9:10694-10708. [PMID: 38463342 PMCID: PMC10918664 DOI: 10.1021/acsomega.3c09335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/10/2024] [Accepted: 02/06/2024] [Indexed: 03/12/2024]
Abstract
Factor XIIa (FXIIa) functions as a plasma serine protease within the contact activation pathway. Various animal models have indicated a substantial role for FXIIa in thromboembolic diseases. Interestingly, individuals and animals with FXII deficiency seem to maintain normal hemostasis. Consequently, inhibiting FXIIa could potentially offer a viable therapeutic approach for achieving effective and safer anticoagulation without the bleeding risks associated with the existing anticoagulants. Despite the potential, only a limited number of small molecule inhibitors targeting human FXIIa have been documented. Thus, we combined a small library of 32 triazole and triazole-like molecules to be evaluated for FXIIa inhibition by using a chromogenic substrate hydrolysis assay under physiological conditions. Initial screening at 200 μM involved 18 small molecules, revealing that 4 molecules inhibited FXIIa more than 20%. In addition to being the most potent inhibitor identified in the first round, inhibitor 8 also exhibited a substantial margin of selectivity against related serine proteases, including factors XIa, Xa, and IXa. However, the molecule also inhibited thrombin with a similar potency. It also prolonged the clotting time of human plasma, as was determined in the activated partial thromboplastin time and prothrombin time assays. Subsequent structure-activity relationship studies led to the identification of several inhibitors with submicromolar activity, among which inhibitor 22 appears to demonstrate significant selectivity not only over factors IXa, Xa, and XIa, but also over thrombin. In summary, this study introduces novel triazole-based small molecules, specifically compounds 8 and 22, identified as potent and selective inhibitors of human FXIIa. The aim is to advance these inhibitors for further development as anticoagulants to provide a more effective and safer approach to preventing and/or treating thromboembolic diseases.
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Affiliation(s)
- Ma’Lik
D. Woodland
- Division
of Basic Pharmaceutical Sciences, College of Pharmacy, Xavier University of Louisiana, New Orleans, Louisiana 70125, United States
| | - Anthony Thompson
- Department
of Chemistry, Xavier University of Louisiana, New Orleans, Louisiana 70125, United States
| | - Amanda Lipford
- Department
of Chemistry, Xavier University of Louisiana, New Orleans, Louisiana 70125, United States
| | - Navneet Goyal
- Department
of Chemistry, Xavier University of Louisiana, New Orleans, Louisiana 70125, United States
| | - John C. Schexnaildre
- Division
of Basic Pharmaceutical Sciences, College of Pharmacy, Xavier University of Louisiana, New Orleans, Louisiana 70125, United States
| | - Madhusoodanan Mottamal
- Department
of Chemistry, Xavier University of Louisiana, New Orleans, Louisiana 70125, United States
| | - Daniel K. Afosah
- Department
of Medicinal Chemistry, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia 23219, United States
| | - Rami A. Al-Horani
- Division
of Basic Pharmaceutical Sciences, College of Pharmacy, Xavier University of Louisiana, New Orleans, Louisiana 70125, United States
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8
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Elshafei MN, El-Bardissy A, Salem M, Abdelmoneim MS, Khalil A, Elhadad S, Danjuma M. Comparative Effectiveness and Safety of Direct Oral Anticoagulants Compared with Warfarin in Patients with Low Bodyweight who have Atrial Fibrillation: A Systematic Review and Meta-analysis. Am J Cardiovasc Drugs 2024; 24:255-271. [PMID: 38386247 PMCID: PMC10973089 DOI: 10.1007/s40256-024-00628-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/14/2024] [Indexed: 02/23/2024]
Abstract
INTRODUCTION oral anticoagulant (DOAC) agents are becoming the anticoagulation strategy of choice for most clinical risks for which they are indicated. However, residual uncertainty remains regarding their use in preventing stroke in patients with low bodyweight [< 60 kg or body mass index (BMI) < 18 kg/m2]. We have carried out pooled systematic analyses of published studies to determine the efficacy and safety of these agents compared with warfarin in stroke prevention in patients with low bodyweight. METHODS We carried out a comprehensive search of electronic databases from inception to June 2023 for eligible studies reporting on the efficacy and safety of direct oral anticoagulants versus warfarin in patients with atrial fibrillation who had low bodyweight. These include PubMed, EMBASE, the Cochrane Database of Systematic Reviews, the Science Citation Index, and the Database of Abstracts of Reviews of Effectiveness. Using the random effects model, derived pooled odd ratios (with their corresponding confidence intervals) of mortality outcomes in patient cohorts exposed to direct oral anticoagulants versus warfarin in patients with atrial fibrillation who had low bodyweight. RESULTS Nine studies (n = 159,514 patients) were included in our meta-analysis. DOAC analogs were associated with lower stroke recurrence compared with warfarin [odds ratio (OR) 0.66, 95% confidence interval (CI) 0.49-0.9]; however, there was no significant difference in the composite outcome (OR 0.81, 95% CI 0.59-1.09) and mortality (OR 0.82, 95% CI 0.48-1.41). Additionally, DOAC analogs showed a significant reduction in major bleeding events by 30% compared with warfarin (OR 0.70, 95% CI 0.62-0.80). CONCLUSION In this pooled meta-analytical synthesis of studies comprising both real-world and randomized controlled data, the use of DOAC analogs in patients with atrial fibrillation and low bodyweight (< 60 kg or BMI < 18 kg/m2) was associated with a significant reduction in risks of stroke and major bleeding compared with patient cohorts stabilized on warfarin-based therapy. There was uncertainty regarding the composite outcome and mortality point estimate between these two anticoagulation strategies. This finding helps to resolve the uncertainty associated with the use of DOACs in this cohort. Additionally, it suggests the need for confirmatory non-inferiority randomized controlled trials evaluating DOACs versus warfarin in this cohort of patients.
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Affiliation(s)
- Mohamed Nabil Elshafei
- Clinical Pharmacy Department, Hamad Medical Corporation, Doha, Qatar.
- Department of Pharmacy, Hamad Medical Corporation (HMC), P.O.3050, Doha, Qatar.
| | - Ahmed El-Bardissy
- Clinical Pharmacy Department, Hamad Medical Corporation, Doha, Qatar
| | - Muhammad Salem
- Clinical Pharmacy Department, Hamad Medical Corporation, Doha, Qatar
| | | | - Ahmed Khalil
- Clinical Pharmacy Department, Hamad Medical Corporation, Doha, Qatar
| | | | - Mohammed Danjuma
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
- Weill Cornell Medicine-Qatar, Doha, Qatar
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9
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Laganà A, Assanto GM, Masucci C, Passucci M, Donzelli L, Serrao A, Baldacci E, Santoro C, Chistolini A. Secondary Prophylaxis of Venous Thromboembolism (VTE) with Low Dose Apixaban or Rivaroxaban: Results from a Patient Population with More than 2 Years of Median Follow-up. Mediterr J Hematol Infect Dis 2024; 16:e2024020. [PMID: 38468835 PMCID: PMC10927198 DOI: 10.4084/mjhid.2024.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 02/08/2024] [Indexed: 03/13/2024] Open
Abstract
Background Direct oral anticoagulants (DOACs) are widely used for the treatment and secondary prophylaxis of venous thromboembolism (VTE). Nowadays, DOACs represent the gold standard for long-term anticoagulation, with low-intensity DOACs administration becoming increasingly used worldwide in such scenario. Albeit low-intensity apixaban and rivaroxaban are approved for clinical usage as secondary VTE prophylaxis, there are few literature data regarding their efficacy and safety with a long follow-up. Objectives The aim of our study was to evaluate the efficacy and safety of low-dose DOACs for VTE secondary prophylaxis in patients at high risk of VTE recurrence. Methods We retrospectively evaluated patients who required long-term anticoagulant secondary prophylaxis to prevent recurrent VTE, treated with apixaban 2.5 mg BID or rivaroxaban 10 mg daily with a follow-up ≥ 12 months. Results The examined patients were 323. The median low-dose DOAC administration time was 25.40 months (IQR 13.93-45.90). Twelve (3.7%) VTE recurrences were observed; 21 bleeding events were registered (6.5%), including one episode of Major bleeding (MB) (0.3%), 8 Clinically relevant nonmajor bleeding (CRNMB) (2.5%) and 12 minor bleeding (3.7%). No statistically significant difference in the rate of VTE recurrence and/or bleeding events emerged between the rivaroxaban and apixaban groups. Patients included in the study for multiple episodes of VTE presented a significantly higher risk of a new VTE recurrence during low-intensity DOAC. Conclusions Our data suggest that low-dose DOACs may be effective and safe in secondary VTE prophylaxis in patients at high risk of VTE recurrence; however, attention might be needed in their choice in such a scenario for patients who experienced multiple episodes of VTE.
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Affiliation(s)
- Alessandro Laganà
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | | | - Chiara Masucci
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Mauro Passucci
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Livia Donzelli
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Alessandra Serrao
- Haematology and Stem Cell Transplant Unit, A. O. San Camillo Forlanini (LR), Rome, Italy
| | - Erminia Baldacci
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Cristina Santoro
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Antonio Chistolini
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
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10
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Watson C, Saaid H, Vedula V, Cardenas JC, Henke PK, Nicoud F, Xu XY, Hunt BJ, Manning KB. Venous Thromboembolism: Review of Clinical Challenges, Biology, Assessment, Treatment, and Modeling. Ann Biomed Eng 2024; 52:467-486. [PMID: 37914979 DOI: 10.1007/s10439-023-03390-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/17/2023] [Indexed: 11/03/2023]
Abstract
Venous thromboembolism (VTE) is a massive clinical challenge, annually affecting millions of patients globally. VTE is a particularly consequential pathology, as incidence is correlated with extremely common risk factors, and a large cohort of patients experience recurrent VTE after initial intervention. Altered hemodynamics, hypercoagulability, and damaged vascular tissue cause deep-vein thrombosis and pulmonary embolism, the two permutations of VTE. Venous valves have been identified as likely locations for initial blood clot formation, but the exact pathway by which thrombosis occurs in this environment is not entirely clear. Several risk factors are known to increase the likelihood of VTE, particularly those that increase inflammation and coagulability, increase venous resistance, and damage the endothelial lining. While these risk factors are useful as predictive tools, VTE diagnosis prior to presentation of outward symptoms is difficult, chiefly due to challenges in successfully imaging deep-vein thrombi. Clinically, VTE can be managed by anticoagulants or mechanical intervention. Recently, direct oral anticoagulants and catheter-directed thrombolysis have emerged as leading tools in resolution of venous thrombosis. While a satisfactory VTE model has yet to be developed, recent strides have been made in advancing in silico models of venous hemodynamics, hemorheology, fluid-structure interaction, and clot growth. These models are often guided by imaging-informed boundary conditions or inspired by benchtop animal models. These gaps in knowledge are critical targets to address necessary improvements in prediction and diagnosis, clinical management, and VTE experimental and computational models.
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Affiliation(s)
- Connor Watson
- Department of Biomedical Engineering, The Pennsylvania State University, 122 Chemical and Biomedical Engineering Building, University Park, PA, 16802-4400, USA
| | - Hicham Saaid
- Department of Biomedical Engineering, The Pennsylvania State University, 122 Chemical and Biomedical Engineering Building, University Park, PA, 16802-4400, USA
| | - Vijay Vedula
- Department of Mechanical Engineering, Fu Foundation School of Engineering and Applied Science, Columbia University, New York, NY, USA
| | - Jessica C Cardenas
- Department of Surgery and the Center for Translational Injury Research, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - Peter K Henke
- Section of Vascular Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Franck Nicoud
- CNRS, IMAG, Université de Montpellier, Montpellier, France
- Institut Universitaire de France, Paris, France
| | - Xiao Yun Xu
- Department of Chemical Engineering, Imperial College London, London, UK
| | - Beverley J Hunt
- Department of Thrombosis and Haemostasis, King's College, London, UK
- Thrombosis and Haemophilia Centre, Guy's & St Thomas' NHS Trust, London, UK
| | - Keefe B Manning
- Department of Biomedical Engineering, The Pennsylvania State University, 122 Chemical and Biomedical Engineering Building, University Park, PA, 16802-4400, USA.
- Department of Surgery, Penn State Hershey Medical Center, Hershey, PA, USA.
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11
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Ma S, Fan G, Xu F, Zhang X, Chen Y, Tao Y, Li Y, Lyu Y, Yang P, Wang D, Zhai Z, Wang C. Efficacy and safety of anticoagulant for treatment and prophylaxis of VTE patients with renal insufficiency: a systemic review and meta-analysis. Thromb J 2024; 22:17. [PMID: 38317247 PMCID: PMC10840151 DOI: 10.1186/s12959-023-00576-2] [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: 10/13/2023] [Accepted: 12/25/2023] [Indexed: 02/07/2024] Open
Abstract
Patients with venous thromboembolism (VTE) comorbid renal insufficiency (RI) are at higher risk of bleeding and thrombosis. Recommendations in guidelines on anticoagulation therapy for those patients remain ambiguous. The goal of this study is to compare the efficacy and safety between different anticoagulant regimens in VTE patients comorbid RI at different stages of treatment and prophylaxis. We performed English-language searches of Pubmed, EMBASE, and Web of Science (inception to Nov 2022). RCTs evaluated anticoagulants for VTE treatment at the acute phase, extension phase, and prophylaxis in patients with RI and reported efficacy and safety outcomes were selected. The methodological quality of the studies was assessed at the outcome level using the risk-of-bias assessment tool developed by the Cochrane Bias Methods Group. A meta-analysis of twenty-five RCTs was conducted, comprising data from twenty-three articles, encompassing a total of 9,680 participants with RI. In the acute phase, the risk of bleeding was increased with novel oral anticoagulants (NOACs) compared to LMWH (RR 1.29, 95% CI 1.04-1.60). For the prophylaxis of VTE, NOACs were associated with an elevated risk of bleeding compared with placebo (RR 1.31, 95%CI 1.02-1.68). In comparison to non-RI patients, both NOACs and vitamin K antagonists (VKA) could increase the risk of bleeding among RI patients (RR 1.45, 95%CI 1.14-1.84 and RR 1.53, 95%CI 1.25-1.88, respectively) during acute phase, while NOACs may increase the incidence of VTE in RI population (RR 1.74, 95%CI 1.29-2.34). RI patients who are under routine anticoagulation have a significantly higher risk of adverse outcomes. LMWH is the most effective and safe option for VTE treatment or prophylaxis in patients with RI.
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Affiliation(s)
- Shuangshuang Ma
- Beijing University of Chinese Medicine. National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Guohui Fan
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College; State Key Laboratory of Respiratory Health and Multimorbidity; Key Laboratory of Pathogen Infection Prevention and Control (Peking Union Medical College), Ministry of Education, Beijing, China
- National Center for Respiratory Medicine; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Clinical Research and Data Management, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Feiya Xu
- Graduate School of Capital Medical University, Beijing, China
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Xiaomeng Zhang
- Peking University China‑Japan Friendship School of Clinical Medicine, Beijing, P.R. China
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Yinong Chen
- Peking University China‑Japan Friendship School of Clinical Medicine, Beijing, P.R. China
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Yuzhi Tao
- The First Bethune Hospital of Jilin University, Beijing, China
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Yishan Li
- The First Clinical Medical College, Shanxi Medical University, Taiyuan, China
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Yanshuang Lyu
- Changping Laboratory, Beijing, China
- Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Peiran Yang
- Department of Physiology, Institute of Basic Medical Sciences, State Key Laboratory of Respiratory Health and Multimorbidity, Chinese Academy of Medical Sciences and School of Basic Medicine, Peking Union Medical College; National Center for Respiratory Medicine; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Dingyi Wang
- National Center for Respiratory Medicine; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Clinical Research and Data Management, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.
| | - Zhenguo Zhai
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, 100029, China.
| | - Chen Wang
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases, Beijing, 100029, China.
- Chinese Academy of Medical Sciences, Peking Union Medical College, No 2, East Yinghua Road, Chaoyang District, Beijing, 100029, China.
- Department of Respiratory Medicine, Capital Medical University, No 2, East Yinghua Road, Chaoyang District, Beijing, 100029, China.
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12
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Camporese G, Bernardi E, Bortoluzzi C, Noventa F, Simioni P. Mesoglycan for the secondary prevention of superficial vein thrombosis: a randomized, controlled, double-blind study (METRO Study)-rationale and protocol. J Thromb Thrombolysis 2024; 57:226-234. [PMID: 37932589 PMCID: PMC10869363 DOI: 10.1007/s11239-023-02896-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2023] [Indexed: 11/08/2023]
Abstract
No data is available about pharmacological secondary prevention of superficial vein thrombosis (SVT) despite 10-15% of patients develop venous thromboembolic complications at 3-6 months after an adequate treatment of the acute phase. To verify efficacy and safety of mesoglycan in secondary prevention of SVT recurrence and venous thromboembolic complications. Phase III multicenter, double-blind, randomized, superiority trial comparing mesoglycan 50 mg bid vs placebo in consecutive patients with a SVT extended at least 5 cm, after the initial 45-day treatment course with fondaparinux 2.5 mg once-daily. Primary efficacy outcome: SVT recurrence/extension, symptomatic venous thromboembolism (VTE), asymptomatic proximal deep-vein thrombosis, death. Primary safety outcome: major bleeding. We hypothesized a 12-month 15% incidence of the primary efficacy outcome in placebo group and a 50% risk reduction in mesoglycan group. A bilateral log-rank test with a sample of 650 patients (randomization 1:1) reach a 90% power, with an α-error of 0.025, of detecting a 7.0% difference (HR = 0.51) after 12 months of treatment, considering a 10% patients drop-out. At deadline (December 31, 2022) 570 patients have been randomized (10% drop rate). Mean age was 63.9 years, 58.8% were women. SVT involved great saphenous vein in 69.3%, small saphenous vein in 13.1%, and collaterals in 17.6% of patients. SVT was the first event in 61.7%, a recurrence in 38.3%, provoked in 50.2% and unprovoked in 49.8%. Patients not experiencing a primary outcome, or not retiring their consent will be followed up to December 31, 2024 when the final data analysis will be performedClinicalTrials.gov: NCT03428711.
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Affiliation(s)
- G Camporese
- Department of Medicine, University of Padua, Padua, Italy.
- Thrombotic, and Hemorrhagic Disorders Unit, Department of Systems Medicine, University - Hospital Padua, Padua, Italy.
| | - E Bernardi
- Emergency Room, Department of Emergency and Accident Medicine, San Camillo Hospital, Treviso, Italy
| | - C Bortoluzzi
- Division of Internal Medicine, Department of Internal Medicine, Santa Maria delle Grazie Venice Civil Hospital, Venice, Italy
| | - F Noventa
- QUOVADIS Association and Department of Molecular Medicine, Padua University Hospital, Padua, Italy
| | - P Simioni
- Department of Medicine, University of Padua, Padua, Italy
- Thrombotic, and Hemorrhagic Disorders Unit, Department of Systems Medicine, University - Hospital Padua, Padua, Italy
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13
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Bejjani A, Khairani CD, Assi A, Piazza G, Sadeghipour P, Talasaz AH, Fanikos J, Connors JM, Siegal DM, Barnes GD, Martin KA, Angiolillo DJ, Kleindorfer D, Monreal M, Jimenez D, Middeldorp S, Elkind MSV, Ruff CT, Goldhaber SZ, Krumholz HM, Mehran R, Cushman M, Eikelboom JW, Lip GYH, Weitz JI, Lopes RD, Bikdeli B. When Direct Oral Anticoagulants Should Not Be Standard Treatment: JACC State-of-the-Art Review. J Am Coll Cardiol 2024; 83:444-465. [PMID: 38233019 DOI: 10.1016/j.jacc.2023.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/16/2023] [Accepted: 10/19/2023] [Indexed: 01/19/2024]
Abstract
For most patients, direct oral anticoagulants (DOACs) are preferred over vitamin K antagonists for stroke prevention in atrial fibrillation and for venous thromboembolism treatment. However, randomized controlled trials suggest that DOACs may not be as efficacious or as safe as the current standard of care in conditions such as mechanical heart valves, thrombotic antiphospholipid syndrome, and atrial fibrillation associated with rheumatic heart disease. DOACs do not provide a net benefit in conditions such as embolic stroke of undetermined source. Their efficacy is uncertain for conditions such as left ventricular thrombus, catheter-associated deep vein thrombosis, cerebral venous sinus thrombosis, and for patients with atrial fibrillation or venous thrombosis who have end-stage renal disease. This paper provides an evidence-based review of randomized controlled trials on DOACs, detailing when they have demonstrated efficacy and safety, when DOACs should not be the standard of care, where their safety and efficacy are uncertain, and areas requiring further research.
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Affiliation(s)
- Antoine Bejjani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Candrika D Khairani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ali Assi
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory Piazza
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Parham Sadeghipour
- Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran; Clinical Trial Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Azita H Talasaz
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran; Virginia Commonwealth University, Richmond, Virginia, USA
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jean M Connors
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Deborah M Siegal
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Karlyn A Martin
- Division of Hematology/Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | | | - Manuel Monreal
- Cátedra de Enfermedad Tromboembólica, Universidad Católica San Antonio de Murcia, Spain
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (Instituto de Ramón y Cajal de Investigación Sanitaria), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, New York, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Christian T Ruff
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Samuel Z Goldhaber
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Harlan M Krumholz
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, Connecticut, USA; Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mary Cushman
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA; Department of Pathology and Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jeffrey I Weitz
- McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA; Brazilian Clinical Research Institute, São Paulo, Brazil
| | - Behnood Bikdeli
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands; Cardiovascular Research Foundation, New York, New York, USA.
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14
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Malik A, Ha NB, Barnes GD. Choice and Duration of Anticoagulation for Venous Thromboembolism. J Clin Med 2024; 13:301. [PMID: 38202308 PMCID: PMC10779515 DOI: 10.3390/jcm13010301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/01/2024] [Accepted: 01/03/2024] [Indexed: 01/12/2024] Open
Abstract
Venous thromboembolism (VTE) is a prevalent medical condition with high morbidity, mortality, and associated costs. Anticoagulation remains the main treatment for VTE, though the decision on when, how, and for how long to administer anticoagulants is increasingly complex. This review highlights the different phases of VTE management, with special circumstances for consideration such as antiphospholipid syndrome, coronary artery disease, cancer-associated thrombus, COVID-19, and future anticoagulation options. Anticoagulation management will continue to be a complex decision, applying evidence-based medicine to individual patients with the hope of maximizing effectiveness while minimizing risks.
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Affiliation(s)
- Aroosa Malik
- Department of Internal Medicine, Division of Cardiovascular Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI 48109, USA
| | - Nghi B. Ha
- Pharmacy Innovations & Partnerships, University of Michigan, Ann Arbor, MI 48108, USA;
| | - Geoffrey D. Barnes
- Department of Internal Medicine, Division of Cardiovascular Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI 48109, USA
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15
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Talerico R, Pola R, Klok FA, Huisman MV. Direct-Acting Oral Anticoagulants in patients at extremes of body weight: a review of pharmacological considerations and clinical implications. TH OPEN 2024; 8:e31-e41. [PMID: 38197017 PMCID: PMC10774013 DOI: 10.1055/s-0043-1776989] [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: 07/28/2023] [Accepted: 10/16/2023] [Indexed: 01/11/2024] Open
Abstract
Patients at extremes of body weight are underrepresented in randomized controlled trials of direct-acting oral anticoagulants (DOACs). Therefore, their optimal anticoagulant treatment remains a topic of debate. The aim of this narrative review is to summarize the evidence on the pharmacokinetic and pharmacodynamic profile of DOACs for treating patients at extremes of body weight in venous thromboembolism (VTE) and in the prevention of cardioembolic stroke in nonvalvular atrial fibrillation (NVAF). A literature search was conducted in the main bibliographic databases, and the most relevant reviews and original articles on the topic were selected. Although data in these patient groups are limited, apixaban and rivaroxaban show a favorable pharmacokinetic and pharmacodynamic profile in obese VTE treatment and NVAF patients and, in the case of apixaban, also in underweight patients. In particular, these drugs demonstrated comparable efficacy and safety to standard therapy. Very few data were available for dabigatran and edoxaban; the latter drug was safer at a lower dose, mainly in underweight patients. Our findings are in line with the last International Society of Haemostasis and Thrombosis position paper and European Heart Rhythm Association 2021 practical guide, suggesting the use of apixaban and rivaroxaban in morbidly obese patients (>120 kg or body mass index ≥40 kg/m 2 ) and the reduced dosage of edoxaban in low-weight patients. Future studies should focus on large populations of patients at extremes of body weights to acquire more clinical and pharmacokinetic evidence on all available DOACs, especially those currently less investigated.
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Affiliation(s)
- Rosa Talerico
- Section of Internal Medicine and Thromboembolic Diseases, Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
- IRCCS San Raffaele, Rome, Italy
| | - Roberto Pola
- Section of Internal Medicine and Thromboembolic Diseases, Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Frederikus Albertus Klok
- Department of Medicine—Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.
| | - Menno Volkert Huisman
- Department of Medicine—Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.
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16
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Chan MD, Yasamanova AN, Avakian GG, Nikonova AA, Kamchatnov PR. [The multidirectional effects of thrombin and the possibility of their control in neurology]. Zh Nevrol Psikhiatr Im S S Korsakova 2024; 124:42-48. [PMID: 38512094 DOI: 10.17116/jnevro202412403242] [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] [Indexed: 03/22/2024]
Abstract
The review presents the main physiological functions of thrombin. The procoagulant and anticoagulant activities of the key serine protease are discussed in both physiological and pathological conditions of hemostasis. The involvement of thrombin in atherogenesis, as well as its role as a mediator of vascular dysfunction and inflammation in both the peripheral and central nervous system, is highlighted. A pronounced imbalance between the pro- and anticoagulant systems leads to an increase in thrombin formation and creates conditions for the development of thrombosis. Tests that allow direct or indirect assessment of thrombin's functional activity are presented. The potential applications of direct thrombin inhibitors and direct blockers of thrombin PAR receptors in vascular neurology are also considered.
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Affiliation(s)
- M D Chan
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A N Yasamanova
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - G G Avakian
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A A Nikonova
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - P R Kamchatnov
- Pirogov Russian National Research Medical University, Moscow, Russia
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17
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Malerba P, Laera N, Pagnesi M, Bonzi B, Rizzoni D, Metra M, Nardin M. Right ventricular thrombosis: from a case report to pathophysiology mechanisms and current treatment options. J Cardiovasc Med (Hagerstown) 2024; 25:88-94. [PMID: 38064342 DOI: 10.2459/jcm.0000000000001551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Paolo Malerba
- Division of Medicine, Department of Medicine, ASST Spedali Civili, Montichiari
- Department of Clinical and Experimental Sciences, University of Brescia
| | - Nicola Laera
- Department of Clinical and Experimental Sciences, University of Brescia
- Second Medicine Division, Department of Medicine, ASST Spedali Civili
| | | | - Bianca Bonzi
- Division of Medicine, Department of Medicine, ASST Spedali Civili, Montichiari
| | - Damiano Rizzoni
- Division of Medicine, Department of Medicine, ASST Spedali Civili, Montichiari
- Department of Clinical and Experimental Sciences, University of Brescia
| | - Marco Metra
- Division of Cardiology, ASST Spedali Civili
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia
| | - Matteo Nardin
- Department of Biomedical Sciences, Humanitas University, Milan
- Third Medicine Division, Department of Medicine, ASST Spedali Civili, Brescia, Italy
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18
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Siniscalchi C, Basaglia M, Riva M, Meschi M, Meschi T, Castaldo G, Di Micco P. Statins Effects on Blood Clotting: A Review. Cells 2023; 12:2719. [PMID: 38067146 PMCID: PMC10706238 DOI: 10.3390/cells12232719] [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: 11/01/2023] [Revised: 11/16/2023] [Accepted: 11/24/2023] [Indexed: 12/18/2023] Open
Abstract
Statins are powerful lipid-lowering drugs that inhibit cholesterol biosynthesis via downregulation of hydroxymethylglutaryl coenzyme-A reductase, which are largely used in patients with or at risk of cardiovascular disease. Available data on thromboembolic disease include primary and secondary prevention as well as bleeding and mortality rates in statin users during anticoagulation for VTE. Experimental studies indicate that statins alter blood clotting at various levels. Statins produce anticoagulant effects via downregulation of tissue factor expression and enhanced endothelial thrombomodulin expression resulting in reduced thrombin generation. Statins impair fibrinogen cleavage and reduce thrombin generation. A reduction of factor V and factor XIII activation has been observed in patients treated with statins. It is postulated that the mechanisms involved are downregulation of factor V and activated factor V, modulation of the protein C pathway and alteration of the tissue factor pathway inhibitor. Clinical and experimental studies have shown that statins exert antiplatelet effects through early and delayed inhibition of platelet activation, adhesion and aggregation. It has been postulated that statin-induced anticoagulant effects can explain, at least partially, a reduction in primary and secondary VTE and death. Evidence supporting the use of statins for prevention of arterial thrombosis-related cardiovascular events is robust, but their role in VTE remains to be further elucidated. In this review, we present biological evidence and experimental data supporting the ability of statins to directly interfere with the clotting system.
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Affiliation(s)
- Carmine Siniscalchi
- Angiology Unit, Department of Internal Medicine, Parma University Hospital, 43121 Parma, Italy
| | - Manuela Basaglia
- Department of Internal Medicine, Parma University Hospital, 43121 Parma, Italy
| | - Michele Riva
- Department of Internal Medicine, Parma University Hospital, 43121 Parma, Italy
| | - Michele Meschi
- UOC Internal Medicine, Fidenza Hospital, 43036 Parma, Italy
| | - Tiziana Meschi
- Department of Medicine and Surgery, Parma University Hospital, 43121 Parma, Italy
| | - Giampiero Castaldo
- Department of Medicine and Surgery, Parma University Hospital, 43121 Parma, Italy
| | - Pierpaolo Di Micco
- AFO Medicina PO Santa Maria delle Grazie, Pozzuoli Naples Hospital 2 Nord, 80078 Naples, Italy
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Abstract
Cardiovascular diseases are highly prevalent among patients on dialysis. For these diseases, antiplatelets and antithrombotic therapies including heparin, vitamin K antagonists, and direct oral anticoagulants, are being used. However, the benefit-risk balance of these therapies could differ for dialysis patients compared with the general population. This review article focuses on the bleeding risk associated with the use of heparin, antiplatelets, vitamin K antagonists, and direct oral anticoagulants in patients receiving hemodialysis.
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Affiliation(s)
| | - Pearl Pai
- Department of Medicine, University of Hong Kong Li Ka Shing Faculty of Medicine, Hong Kong; Department of Medicine, University of Hong Kong Shenzhen Hospital, Shenzhen, China
| | - Wenjuan Zhu
- Department of Medicine, University of Hong Kong Shenzhen Hospital, Shenzhen, China
| | - Gurbey Ocak
- Department of Internal Medicine, Sint Antonius Hospital, Nieuwegein, The Netherlands
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20
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Galyfos G, Chamzin A, Charalampopoulos G, Liasis N, Sigala F, Filis K. Direct oral anticoagulants for deep vein thrombosis among patients with hereditary thrombophilia-A cohort study. Phlebology 2023; 38:599-604. [PMID: 37647589 DOI: 10.1177/02683555231199004] [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] [Indexed: 09/01/2023]
Abstract
OBJECTIVES to evaluate direct oral anticoagulants (DOACs) in patients with hereditary thrombophilia and deep venous thrombosis (DVT). METHODS This is a retrospective observational study. RESULTS In total, 45 patients were treated between 01/2012 and 12/2022 (mean follow-up: 1.5 +/- 0.3 years). The most frequent thrombophilias were heterozygous V Leiden (20%), heterozygous MTHFR C677T (37.8%), heterozygous MTHFR A1298C (24.4%), and hyperhomocysteinemia (26.7%). The patients received rivaroxaban (n = 19), apixaban (n = 15), and dabigatran (n = 11). Three cases presented symptoms' recurrence without evidence of thrombosis' recurrence (two under rivaroxaban and one under apixaban; p > .05). These patients improved under parenteral anticoagulation and were further treated with dabigatran. No other event or major bleeding occurred during the follow-up. The presence of more than two factors was associated with acute recurrence of symptoms (OR = 25.9; 95% CI [1.454-461.262]; p = .026). CONCLUSIONS DOACs seem to be safe and efficient for patients with hereditary thrombophilia and DVT. The presence of more than two thrombophilia factors is associated with a higher risk for symptom recurrence. Although statistically non-significant, symptoms' recurrence was also observed more frequently among patients under anti-Xa inhibitors than antithrombin inhibitors. This should be verified in larger comparative studies.
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Affiliation(s)
- George Galyfos
- First Department of Propedeutic Surgery, Vascular Surgery Unit, National and Kapodistrian University of Athens, Hippocration Hospital, Athens, Greece
| | - Alexandros Chamzin
- First Department of Propedeutic Surgery, Vascular Surgery Unit, National and Kapodistrian University of Athens, Hippocration Hospital, Athens, Greece
| | - Georgios Charalampopoulos
- First Department of Propedeutic Surgery, Vascular Surgery Unit, National and Kapodistrian University of Athens, Hippocration Hospital, Athens, Greece
| | - Nikolaos Liasis
- First Department of Propedeutic Surgery, Vascular Surgery Unit, National and Kapodistrian University of Athens, Hippocration Hospital, Athens, Greece
| | - Frangiska Sigala
- First Department of Propedeutic Surgery, Vascular Surgery Unit, National and Kapodistrian University of Athens, Hippocration Hospital, Athens, Greece
| | - Konstantinos Filis
- First Department of Propedeutic Surgery, Vascular Surgery Unit, National and Kapodistrian University of Athens, Hippocration Hospital, Athens, Greece
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Adelhelm JBH, Christensen R, Balbi GGM, Voss A. Therapy with direct oral anticoagulants for secondary prevention of thromboembolic events in the antiphospholipid syndrome: a systematic review and meta-analysis of randomised trials. Lupus Sci Med 2023; 10:e001018. [PMID: 37899090 PMCID: PMC10619019 DOI: 10.1136/lupus-2023-001018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 09/23/2023] [Indexed: 10/31/2023]
Abstract
OBJECTIVE Antiphospholipid syndrome (APS) is a systemic autoimmune disorder characterised by venous thrombosis (VT) or arterial thrombosis (AT) and/or pregnancy morbidity and the presence of antiphospholipid antibodies. Direct oral anticoagulants (DOACs) hold several advantages to vitamin K antagonists (VKAs) for prevention of thrombosis and we wish to evaluate DOACs compared with VKAs in secondary prevention of thromboembolic events in patients with APS. METHODS We conducted searches of the published literature using relevant data sources (MEDLINE, Embase and Cochrane CENTRAL), and of trial registers for unpublished data and ongoing trials. We included randomised trials examining individuals >18 years with APS classified according to the criteria valid when the trial was carried out. Randomised controlled trials had to examine any DOAC agent compared with any comparable drug. We tabulated all occurrences of events from all eligible randomised trials. Due to few events, ORs and 95% CIs were calculated using the Peto method. RESULTS 5 randomised trials comprising 624 patients met the predefined eligibility criteria. The primary outcome measure was new thrombotic events, a composite endpoint of any VT or AT, during the VKA-controlled phase of treatment. According to the I2 inconsistency index, there was evidence of statistical heterogeneity across the studies (I2=60%). Across trials, 29 and 10 thrombotic events were observed in 305 and 319 patients with APS treated with DOAC and VKA, respectively, corresponding to a combined Peto OR of 3.01 (95% CI 1.56 to 5.78, p=0.001). There was a significantly increased risk of AT while treated with DOACs compared with VKA (OR 5.5 (2.5, 12.1) p<0.0001), but no difference in the risk of VT (p=0.87). We found no significant difference in risk of bleeding. CONCLUSIONS DOACs were associated with a significant increase in the risk of a new thrombotic event, especially AT, favouring standard prophylaxis with warfarin. PROSPERO REGISTRATION NUMBER CRD42019126720.
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Affiliation(s)
| | - Robin Christensen
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
| | - Gustavo G M Balbi
- Department of Clinical Medicine, Federal University of Juiz de Fora, Juiz de Fora, Brazil
| | - Anne Voss
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
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22
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Mitchell A, Elmasry Y, van Poelgeest E, Welsh TJ. Anticoagulant use in older persons at risk for falls: therapeutic dilemmas-a clinical review. Eur Geriatr Med 2023; 14:683-696. [PMID: 37392359 PMCID: PMC10447288 DOI: 10.1007/s41999-023-00811-z] [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: 01/23/2023] [Accepted: 06/02/2023] [Indexed: 07/03/2023]
Abstract
PURPOSE The aim of this clinical narrative review was to summarise the existing knowledge on the use of anticoagulants and potential adverse events in older people at risk of falls with a history of atrial fibrillation or venous thromboembolism. The review also offers practical steps prescribers can take when (de-)prescribing anticoagulants to maximise safety. METHODS Literature searches were conducted using PubMed, Embase and Scopus. Additional articles were identified by searching reference lists. RESULTS Anticoagulants are often underused in older people due to concerns about the risk of falls and intracranial haemorrhage. However, evidence suggests that the absolute risk is low and outweighed by the reduction in stroke risk. DOACs are now recommended first line for most patients due to their favourable safety profile. Off-label dose reduction of DOACs is not recommended due to reduced efficacy with limited reduction in bleeding risk. Medication review and falls prevention strategies should be implemented before prescribing anticoagulation. Deprescribing should be considered in severe frailty, limited life expectancy and increased bleeding risk (e.g., cerebral microbleeds). CONCLUSION When considering whether to (de-)prescribe anticoagulants, it is important to consider the risks associated with stopping therapy in addition to potential adverse events. Shared decision-making with the patient and their carers is crucial as patient and prescriber views often differ.
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Affiliation(s)
- Anneka Mitchell
- Research Institute for the Care of Older People (RICE), Bath, UK.
- Pharmacy Department, University Hospitals Plymouth NHS Trust, Plymouth, UK.
- Life Sciences Department, University of Bath, Bath, UK.
| | - Yasmin Elmasry
- Pharmacy Department, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - Tomas J Welsh
- Research Institute for the Care of Older People (RICE), Bath, UK
- Bristol Medical School, University of Bristol, Bristol, UK
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
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23
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Fang MC, Reynolds K, Fan D, Prasad PA, Sung SH, Portugal C, Garcia E, Go AS. Clinical Outcomes of Direct Oral Anticoagulants vs Warfarin for Extended Treatment of Venous Thromboembolism. JAMA Netw Open 2023; 6:e2328033. [PMID: 37581888 PMCID: PMC10427945 DOI: 10.1001/jamanetworkopen.2023.28033] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 06/29/2023] [Indexed: 08/16/2023] Open
Abstract
Importance Extending the duration of oral anticoagulation for venous thromboembolism (VTE) beyond the initial 3 to 6 months of treatment is often recommended, but it is not clear whether clinical outcomes differ when using direct oral anticoagulants (DOACs) or warfarin. Objective To compare rates of recurrent VTE, hospitalizations for hemorrhage, and all-cause death among adults prescribed DOACs or warfarin whose anticoagulant treatment was extended beyond 6 months after acute VTE. Design, Setting, and Participants This cohort study was conducted in 2 integrated health care delivery systems in California with adults aged 18 years or older who received a diagnosis of incident VTE between 2010 and 2018 and completed at least 6 months of oral anticoagulant treatment with DOACs or warfarin. Patients were followed from the end of the initial 6-month treatment period until discontinuation of anticoagulation, occurrence of an outcome event, health plan disenrollment, or end of the study follow-up period (December 31, 2019). Data were obtained from the Kaiser Permanente Virtual Data Warehouse and electronic health records. Data analysis was conducted from March 2022 to January 2023. Exposure Dispensed prescriptions of DOACs or warfarin after a 6-month initial treatment for VTE. Main Outcomes and Measures The primary outcomes were rates per 100 person-years of recurrent VTE, hospitalizations for hemorrhage, and all-cause death. Comparison of DOAC and warfarin outcomes were performed using multivariable Cox proportional hazards regression. Results A total of 18 495 patients (5477 [29.6%] aged ≥75 years; 8973 women [48.5%]) with VTE who were treated with at least 6 months of anticoagulation were identified, of whom 2134 (11.5%) were receiving DOAC therapy and 16 361 (88.5%) were receiving warfarin therapy. Unadjusted event rates were lower for patients receiving DOAC therapy than warfarin therapy for recurrent VTE (event rate per 100 person-years, 2.92 [95% CI, 2.29-3.54] vs 4.14 [95% CI, 3.90-4.38]), hospitalizations for hemorrhage (event rate per 100 person-years, 1.02 [95% CI, 0.66-1.39] vs 1.81 [95% CI, 1.66-1.97]), and all-cause death (event rate per 100 person-years, 3.79 [95% CI, 3.09-4.49] vs 5.40 [95% CI, 5.13-5.66]). After multivariable adjustment, DOAC treatment was associated with a lower risk of recurrent VTE (adjusted hazard ratio [aHR], 0.66; 95% CI, 0.52-0.82). For patients prescribed DOAC treatment, the risks of hospitalization for hemorrhage (aHR, 0.79; 95% CI, 0.54-1.17) and all-cause death (aHR, 0.96; 95% CI, 0.78-1.19) were not significantly different than those for patients prescribed warfarin treatment. Conclusions and Relevance In this cohort study of patients with VTE who continued warfarin or DOAC anticoagulation beyond 6 months, DOAC treatment was associated with a lower risk of recurrent VTE, supporting the use of DOACs for the extended treatment of VTE in terms of clinical outcomes.
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Affiliation(s)
- Margaret C. Fang
- Division of Hospital Medicine, University of California, San Francisco
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
- Department of Health System Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Dongjie Fan
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Priya A. Prasad
- Division of Hospital Medicine, University of California, San Francisco
| | - Sue Hee Sung
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Cecilia Portugal
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Elisha Garcia
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Alan S. Go
- Department of Health System Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Medicine, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Department of Medicine, Stanford University, Palo Alto, California
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24
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Bacci C, Schiazzano C, Zanon E, Stellini E, Sbricoli L. Bleeding Disorders and Dental Implants: Review and Clinical Indications. J Clin Med 2023; 12:4757. [PMID: 37510872 PMCID: PMC10380778 DOI: 10.3390/jcm12144757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/10/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Bleeding disorders can be divided into three categories: congenital coagulation disorders (CCDs), antiplatelet-induced bleeding disorders (APBDs) and anticoagulant-induced bleeding disorders (ACBDs). Implant placement can be challenging in these kinds of patients. The aim of this study is to provide evidence on implant surgery in patients with bleeding disorders and to generate some practical recommendations for clinicians. MATERIAL AND METHODS Pubmed/MEDLINE, Scopus, Web of Science and Cochrane Library databases were screened. The latest search was performed in July 2022. Case reports, case series, cohort studies, cross-sectional studies, case control studies, reviews, consensus reports, surveys and animal studies were included in the analysis. RESULTS Seventeen articles on CCDs were found, fourteen on APBDs and twenty-six on ACBDs. Most of these articles were case reports or case series. Patients with CCDs can be treated after the infusion of the missing coagulation factor. Patients with APBDs can be treated without withdrawing the therapy. Patients with ACBDs should be treated depending on the anticoagulative medication. CONCLUSION Despite the low level of evidence, dental implants can be safely placed in patients with bleeding disorders. However, careful preoperative evaluation and the adoption of local and post-operative bleeding control measures are mandatory.
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Affiliation(s)
- Christian Bacci
- Department of Neurosciences, School of Dentistry, University of Padua, 35128 Padua, Italy
| | - Claudia Schiazzano
- Department of Neurosciences, School of Dentistry, University of Padua, 35128 Padua, Italy
| | - Ezio Zanon
- Haemophilia Centre, General Medicine, Padua University Hospital, 35128 Padua, Italy
| | - Edoardo Stellini
- Department of Neurosciences, School of Dentistry, University of Padua, 35128 Padua, Italy
| | - Luca Sbricoli
- Department of Neurosciences, School of Dentistry, University of Padua, 35128 Padua, Italy
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25
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Li M, Li J, Wang X, Hui X, Wang Q, Xie S, Yan P, Tian J, Li J, Xie P, Yang K, Yao L. Oral direct thrombin inhibitors or oral factor Xa inhibitors versus conventional anticoagulants for the treatment of pulmonary embolism. Cochrane Database Syst Rev 2023; 4:CD010957. [PMID: 37057837 PMCID: PMC10103165 DOI: 10.1002/14651858.cd010957.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
BACKGROUND Pulmonary embolism (PE) is a potentially life-threatening condition in which a clot can migrate from the deep veins, most commonly in the leg, to the lungs. Conventional treatment of PE used unfractionated heparin (UFH), low molecular weight heparin (LMWH), fondaparinux, and vitamin K antagonists (VKAs). Recently, two forms of direct oral anticoagulants (DOACs) have been developed: oral direct thrombin inhibitors (DTIs) and oral factor Xa inhibitors. DOACs have characteristics that may be favourable to conventional treatment, including oral administration, a predictable effect, no need for frequent monitoring or re-dosing, and few known drug interactions. This review reports the efficacy and safety of these drugs in the long-term treatment of PE (minimum duration of three months). This is an update of a Cochrane Review first published in 2015. OBJECTIVES: To assess the efficacy and safety of oral DTIs and oral factor Xa inhibitors versus conventional anticoagulants for the long-term treatment of PE. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases, the World Health Organization International Clinical Trials Registry Platform and the ClinicalTrials.gov trials registers to 2 March 2022. We checked the reference lists of relevant articles for additional studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) in which people with a PE confirmed by standard imaging techniques were allocated to receive an oral DTI or an oral factor Xa inhibitor compared with a conventional anticoagulant or compared with each other for the long-term treatment of PE (minimum duration three months). DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were recurrent PE, recurrent venous thromboembolism (VTE), and deep vein thrombosis (DVT). Secondary outcomes were all-cause mortality, major bleeding, and health-related quality of life. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS We identified five additional RCTs with 1484 participants for this update. Together with the previously included trials, we have included ten RCTs with a total of 13,073 participants. Two studies investigated an oral DTI (dabigatran) and eight studies investigated oral factor Xa inhibitors (three rivaroxaban, three apixaban, and two edoxaban). The studies were of good methodological quality overall. Meta-analysis showed no clear difference in the efficacy and safety of oral DTI compared with conventional anticoagulation in preventing recurrent PE (odds ratio (OR) 1.02, 95% confidence interval (CI) 0.50 to 2.04; 2 studies, 1602 participants; moderate-certainty evidence), recurrent VTE (OR 0.93, 95% CI 0.52 to 1.66; 2 studies, 1602 participants; moderate-certainty evidence), DVT (OR 0.79, 95% CI 0.29 to 2.13; 2 studies, 1602 participants; moderate-certainty evidence), and major bleeding (OR 0.50, 95% CI 0.15 to 1.68; 2 studies, 1527 participants; moderate-certainty evidence). We downgraded the certainty of evidence by one level for imprecision due to the low number of events. There was also no clear difference between the oral factor Xa inhibitors and conventional anticoagulation in the prevention of recurrent PE (OR 0.92, 95% CI 0.66 to 1.29; 3 studies, 8186 participants; moderate-certainty evidence), recurrent VTE (OR 0.83, 95% CI 0.66 to 1.03; 8 studies, 11,416 participants; moderate-certainty evidence), DVT (OR 0.77, 95% CI 0.48 to 1.25; 2 studies, 8151 participants; moderate-certainty evidence), all-cause mortality (OR 1.16, 95% CI 0.79 to 1.70; 1 study, 4817 participants; moderate-certainty evidence) and major bleeding (OR 0.71, 95% CI 0.36 to 1.41; 8 studies, 11,447 participants; low-certainty evidence); the heterogeneity for major bleeding was significant (I2 = 79%). We downgraded the certainty of the evidence to moderate and low because of imprecision due to the low number of events and inconsistency due to clinical heterogeneity. None of the included studies measured health-related quality of life. AUTHORS' CONCLUSIONS Available evidence shows there is probably little or no difference between DOACs and conventional anticoagulation in the prevention of recurrent PE, recurrent VTE, DVT, all-cause mortality, and major bleeding. The certainty of evidence was moderate or low. Future large clinical trials are required to identify if individual drugs differ in effectiveness and bleeding risk, and to explore effect differences in subgroups, including people with cancer and obesity.
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Affiliation(s)
- Meixuan Li
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Jing Li
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Xiaoqin Wang
- Michael G DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Canada
| | - Xu Hui
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Qi Wang
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Shitong Xie
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, China
| | - Peijing Yan
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Jinhui Tian
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Jianfeng Li
- Department of Cardiology, Gansu Provincial Hospital, Lanzhou, China
| | - Ping Xie
- Department of Cardiology, Gansu Provincial Hospital, Lanzhou, China
| | - Kehu Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Liang Yao
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
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Wang X, Ma Y, Hui X, Li M, Li J, Tian J, Wang Q, Yan P, Li J, Xie P, Yang K, Yao L. Oral direct thrombin inhibitors or oral factor Xa inhibitors versus conventional anticoagulants for the treatment of deep vein thrombosis. Cochrane Database Syst Rev 2023; 4:CD010956. [PMID: 37058421 PMCID: PMC10105633 DOI: 10.1002/14651858.cd010956.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
BACKGROUND Deep vein thrombosis (DVT) is a condition in which a clot forms in the deep veins, most commonly of the leg. It occurs in approximately one in 1000 people. If left untreated, the clot can travel up to the lungs and cause a potentially life-threatening pulmonary embolism (PE). Previously, a DVT was treated with the anticoagulants heparin and vitamin K antagonists. However, two forms of direct oral anticoagulants (DOACs) have been developed: oral direct thrombin inhibitors (DTIs) and oral factor Xa inhibitors, which have characteristics that may be favourable compared to conventional treatment, including oral administration, a predictable effect, lack of frequent monitoring or dose adjustment and few known drug interactions. DOACs are now commonly being used for treating DVT: recent guidelines recommended DOACs over conventional anticoagulants for both DVT and PE treatment. This Cochrane Review was first published in 2015. It was the first systematic review to measure the effectiveness and safety of these drugs in the treatment of DVT. This is an update of the 2015 review. OBJECTIVES: To assess the effectiveness and safety of oral DTIs and oral factor Xa inhibitors versus conventional anticoagulants for the long-term treatment of DVT. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 1 March 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) in which people with a DVT, confirmed by standard imaging techniques, were allocated to receive an oral DTI or an oral factor Xa inhibitor compared with conventional anticoagulation or compared with each other for the treatment of DVT. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were recurrent venous thromboembolism (VTE), recurrent DVT and PE. Secondary outcomes included all-cause mortality, major bleeding, post-thrombotic syndrome (PTS) and quality of life (QoL). We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS We identified 10 new studies with 2950 participants for this update. In total, we included 21 RCTs involving 30,895 participants. Three studies investigated oral DTIs (two dabigatran and one ximelagatran), 17 investigated oral factor Xa inhibitors (eight rivaroxaban, five apixaban and four edoxaban) and one three-arm trial investigated both a DTI (dabigatran) and factor Xa inhibitor (rivaroxaban). Overall, the studies were of good methodological quality. Meta-analysis comparing DTIs to conventional anticoagulation showed no clear difference in the rate of recurrent VTE (odds ratio (OR) 1.17, 95% confidence interval (CI) 0.83 to 1.65; 3 studies, 5994 participants; moderate-certainty evidence), recurrent DVT (OR 1.11, 95% CI 0.74 to 1.66; 3 studies, 5994 participants; moderate-certainty evidence), fatal PE (OR 1.32, 95% CI 0.29 to 6.02; 3 studies, 5994 participants; moderate-certainty evidence), non-fatal PE (OR 1.29, 95% CI 0.64 to 2.59; 3 studies, 5994 participants; moderate-certainty evidence) or all-cause mortality (OR 0.66, 95% CI 0.41 to 1.08; 1 study, 2489 participants; moderate-certainty evidence). DTIs reduced the rate of major bleeding (OR 0.58, 95% CI 0.38 to 0.89; 3 studies, 5994 participants; high-certainty evidence). For oral factor Xa inhibitors compared with conventional anticoagulation, meta-analysis demonstrated no clear difference in recurrent VTE (OR 0.85, 95% CI 0.71 to 1.01; 13 studies, 17,505 participants; moderate-certainty evidence), recurrent DVT (OR 0.70, 95% CI 0.49 to 1.01; 9 studies, 16,439 participants; moderate-certainty evidence), fatal PE (OR 1.18, 95% CI 0.69 to 2.02; 6 studies, 15,082 participants; moderate-certainty evidence), non-fatal PE (OR 0.93, 95% CI 0.68 to 1.27; 7 studies, 15,166 participants; moderate-certainty evidence) or all-cause mortality (OR 0.87, 95% CI 0.67 to 1.14; 9 studies, 10,770 participants; moderate-certainty evidence). Meta-analysis showed a reduced rate of major bleeding with oral factor Xa inhibitors compared with conventional anticoagulation (OR 0.63, 95% CI 0.45 to 0.89; 17 studies, 18,066 participants; high-certainty evidence). AUTHORS' CONCLUSIONS: The current review suggests that DOACs may be superior to conventional therapy in terms of safety (major bleeding), and are probably equivalent in terms of efficacy. There is probably little or no difference between DOACs and conventional anticoagulation in the prevention of recurrent VTE, recurrent DVT, pulmonary embolism and all-cause mortality. DOACs reduced the rate of major bleeding compared to conventional anticoagulation. The certainty of evidence was moderate or high.
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Affiliation(s)
- Xiaoqin Wang
- Michael G DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Canada
| | - Yanfang Ma
- School of Chinese Medicine, Hong Kong Baptist University, Hong Kong Special Administrative Region, China
| | - Xu Hui
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Meixuan Li
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Jing Li
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Jinhui Tian
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Qi Wang
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Peijing Yan
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Jianfeng Li
- Department of Cardiology, Gansu Provincial Hospital, Lanzhou, China
| | - Ping Xie
- Department of Cardiology, Gansu Provincial Hospital, Lanzhou, China
| | - Kehu Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Liang Yao
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
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27
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de Winter MA, Büller HR, Carrier M, Cohen AT, Hansen JB, Kaasjager KAH, Kakkar AK, Middeldorp S, Raskob GE, Sørensen HT, Visseren FLJ, Wells PS, Dorresteijn JAN, Nijkeuter M. Recurrent venous thromboembolism and bleeding with extended anticoagulation: the VTE-PREDICT risk score. Eur Heart J 2023; 44:1231-1244. [PMID: 36648242 PMCID: PMC10079391 DOI: 10.1093/eurheartj/ehac776] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 10/23/2022] [Accepted: 12/07/2022] [Indexed: 01/18/2023] Open
Abstract
AIMS Deciding to stop or continue anticoagulation for venous thromboembolism (VTE) after initial treatment is challenging, as individual risks of recurrence and bleeding are heterogeneous. The present study aimed to develop and externally validate models for predicting 5-year risks of recurrence and bleeding in patients with VTE without cancer who completed at least 3 months of initial treatment, which can be used to estimate individual absolute benefits and harms of extended anticoagulation. METHODS AND RESULTS Competing risk-adjusted models were derived to predict recurrent VTE and clinically relevant bleeding (non-major and major) using 14 readily available patient characteristics. The models were derived from combined individual patient data from the Bleeding Risk Study, Hokusai-VTE, PREFER-VTE, RE-MEDY, and RE-SONATE (n = 15,141, 220 recurrences, 189 bleeding events). External validity was assessed in the Danish VTE cohort, EINSTEIN-CHOICE, GARFIELD-VTE, MEGA, and Tromsø studies (n = 59 257, 2283 recurrences, 3335 bleeding events). Absolute treatment effects were estimated by combining the models with hazard ratios from trials and meta-analyses. External validation in different settings showed agreement between predicted and observed risks up to 5 years, with C-statistics ranging from 0.48-0.71 (recurrence) and 0.61-0.68 (bleeding). In the Danish VTE cohort, 5-year risks ranged from 4% to 19% for recurrent VTE and 1% -19% for bleeding. CONCLUSION The VTE-PREDICT risk score can be applied to estimate the effect of extended anticoagulant treatment for individual patients with VTE and to support shared decision-making.
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Affiliation(s)
- Maria A de Winter
- Department of Acute Internal Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584CX Utrecht, The Netherlands
| | - Harry R Büller
- Department of Vascular Medicine, Amsterdam UMC, Meibergdreef 9 1105 AZ Amsterdam, The Netherlands
| | - Marc Carrier
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, 501 Smyth Rd, K1H8L6 Ottawa, Ontario, Canada
| | - Alexander T Cohen
- Department of Haematological Medicine, Guys and St Thomas’ Hospitals, King's College London, Westminster Bridge Road, London, SE1 7EH, UK
| | - John-Bjarne Hansen
- Thrombosis Research Center (TREC), Department of Clinical Medicine, UiT - The Arctic University of Norway, 9037, Tromsø and Thrombosis Research Center (TREC), Division of internal medicine, University hospital of North Norway, 9038, Tromsø, Norway
| | - Karin A H Kaasjager
- Department of Acute Internal Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584CX Utrecht, The Netherlands
| | - Ajay K Kakkar
- Thrombosis Research Institute London, 1B Manresa Road Chelsea, SW3 6LR, London, UK
| | - Saskia Middeldorp
- Department of Internal Medicine & Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Geert Grooteplein 10, 6525 GA Nijmegen, The Netherlands
| | - Gary E Raskob
- Hudson College of Public Health, University of Oklahoma Health Sciences Center, 801 N.E. 13th Street, Oklahoma City, OK 73104, USA
| | - Henrik T Sørensen
- Department of Clinical Medicine - Department of Clinical Epidemiology, Olof Palmes Allé 43-45, 8200 Aarhus N, Denmark
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands
| | - Philip S Wells
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, 501 Smyth Rd, K1H8L6 Ottawa, Ontario, Canada
| | - Jannick A N Dorresteijn
- Department of Vascular Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands
| | - Mathilde Nijkeuter
- Department of Acute Internal Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584CX Utrecht, The Netherlands
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28
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Hirsh J, de Vries TAC, Eikelboom JW, Bhagirath V, Chan NC. Clinical Studies with Anticoagulants that Have Changed Clinical Practice. Semin Thromb Hemost 2023; 49:242-254. [PMID: 36603813 DOI: 10.1055/s-0042-1760330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Anticoagulant therapy is the cornerstone of treatment and prevention of arterial and venous thromboembolism. Taking a historical perspective, starting in the 1960s, and progressing through to 2022, we discuss key clinical trials of anticoagulants that have changed clinical practice, and examine obstacles encountered in bringing these anticoagulants to the clinic. The design of some of the early studies that shaped clinical practice was poor by current standards, but their results were influential because nothing better was available. Both heparin and vitamin K antagonists had been in clinical use for several decades before well-designed trials in the 1980s optimized their dosing and enhanced their safety and efficacy. Low-molecular-weight heparin then replaced unfractionated heparin because it had a more predictable dose-response and a longer half-life, thereby allowing it to be used conveniently in out-of-hospital settings. More recently, direct oral anticoagulants became the oral anticoagulants of choice for most indications because they were shown to be at least as safe and effective as vitamin K antagonists when used in fixed doses without the need for laboratory monitoring. The design of the trials that led to the approval of the direct oral anticoagulants was excellent, but further studies are required to optimize their dosing in selected patients who were underrepresented in these trials.
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Affiliation(s)
- Jack Hirsh
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Tim A C de Vries
- Heart Center, Department of Clinical and Experimental Cardiology and Cardiothoracic Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.,Heart Failure and Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - John W Eikelboom
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Division of Hematology and Thromboembolism, Department of Medicine, Population Health Research Institute, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Vinai Bhagirath
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Division of Hematology and Thromboembolism, Department of Medicine, Population Health Research Institute, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Noel C Chan
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Division of Hematology and Thromboembolism, Department of Medicine, Population Health Research Institute, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
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29
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Lin TK, Pan LF, Jong GP. Correspondence on 'Risk of venous thromboembolism in knee, hip and hand osteoarthritis: a general population-based cohort study'. Ann Rheum Dis 2023; 82:e98. [PMID: 33408082 DOI: 10.1136/annrheumdis-2020-219733] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 12/18/2020] [Indexed: 12/31/2022]
Affiliation(s)
- Tsung-Kun Lin
- Department of Pharmacy, Taoyuan Armed Forces General Hospital, Lungtan, Taoyuan, Taiwan
- School of Pharmacy, National Defense Medical Center, Taipei, Taiwan
| | - Lung-Fa Pan
- Graduate Institute of Radiological Science, Central Taiwan University of Sciences and Technology, Taichung, Taiwan
- Department of Cardiology, Taichung Armed Forces General Hospital, Taichung, Taiwan
| | - Gwo-Ping Jong
- Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
- Chung Shan Medical University, Taichung, Taiwan
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30
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Becattini C, Vedovati MC. Major acute cardiovascular events after venous thromboembolism: a meta-analysis of randomized trials. J Thromb Haemost 2023; 21:1674-1676. [PMID: 36898581 DOI: 10.1016/j.jtha.2023.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 02/22/2023] [Accepted: 02/23/2023] [Indexed: 03/12/2023]
Affiliation(s)
- Cecilia Becattini
- Internal Vascular and Emergency Medicine, Stroke-Unit, University of Perugia, Perugia, Italy.
| | - Maria Cristina Vedovati
- Internal Vascular and Emergency Medicine, Stroke-Unit, University of Perugia, Perugia, Italy
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31
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Rho S, Wang C, Hosseini Dehkordi SH, Sears JJ, Hu ZI. Bleeding and thrombotic events in bevacizumab-treated patients with colorectal cancer on novel oral anticoagulants and antiplatelet medications. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2023; 27:100283. [PMID: 38511095 PMCID: PMC10945962 DOI: 10.1016/j.ahjo.2023.100283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/17/2023] [Accepted: 02/19/2023] [Indexed: 03/22/2024]
Abstract
Background Bevacizumab is a humanized monoclonal anti-VEGF antibody often given in combination with fluorouracil-based chemotherapy as therapy for metastatic colorectal cancer (mCRC). The bleeding and thrombotic event rates in the setting of concurrent novel oral anticoagulants with and without aspirin and bevacizumab treatment in patients with mCRC remain unclear. Methods 462 patients with mCRC at Barnes-Jewish Hospital were identified between December 1, 2016 and December 1, 2021 and screened for concurrent treatment with bevacizumab and anticoagulant or antiplatelet therapy. Demographic and clinical information was extracted by electronic chart review. Results 21 patients were identified who received bevacizumab and either apixaban or rivaroxaban for mCRC treatment. Aspirin was prescribed in some of these patients within three years of starting apixaban or rivaroxaban. Of the 13 patients without aspirin prescription, nine were given apixaban, and four were given rivaroxaban while on bevacizumab. Four out of nine of the patients who received apixaban had epistaxis, and only one case resulted in any treatment discontinuation. Three out of four of the patients who received rivaroxaban experienced bleeding, and one of these three patients discontinued bevacizumab. We also looked at eight patients who had received aspirin. Two out of seven patients who received apixaban/bevacizumab/aspirin experienced bleeding and discontinued a medication. The patient who received rivaroxaban/bevacizumab/aspirin experienced bleeding and discontinued bevacizumab. No patient experienced adverse thrombotic events. Conclusions Patients with mCRC treated with bevacizumab and apixaban with no history of aspirin use within three years have a relatively low risk of bleeding that warrants treatment discontinuation.
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Affiliation(s)
- Shinji Rho
- School of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Chris Wang
- School of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | | | - James J. Sears
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Z. Ian Hu
- Department of Medicine, Division of Oncology, Section of Medical Oncology, Washington University School of Medicine, St. Louis, MO, USA
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32
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Piazza G. Walking the tightrope: a balanced discussion of the benefits and harms of extended duration anticoagulation for venous thrombo-embolism. Eur Heart J 2023; 44:1245-1247. [PMID: 36656796 DOI: 10.1093/eurheartj/ehac731] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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33
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Schenker C, Stalder O, Méan M, Tritschler T, Righini M, Rodondi N, Aujesky D. Bleeding Risk in Elderly Patients with Venous Thromboembolism Who Would Have Been Excluded from Anticoagulation Trials. Thromb Haemost 2023; 123:427-437. [PMID: 36649737 DOI: 10.1055/s-0042-1760365] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Older patients with venous thromboembolism (VTE) are underrepresented in clinical anticoagulation trials. We examined to which extent elderly patients with VTE would be excluded from such trials and compared the bleeding risk between hypothetically excluded and enrolled patients. We studied 991 patients aged ≥65 years with acute VTE in a prospective multicenter cohort. We identified 12 landmark VTE oral anticoagulation trials from the eighth and updated ninth American College of Chest Physician Guidelines. For each trial, we abstracted the exclusion criteria and calculated the proportion of our study patients who would have been excluded from trial participation. We examined the association between five common exclusion criteria (hemodynamic instability, high bleeding risk, comorbidity, co-medication, and invasive treatments) and major bleeding (MB) within 36 months using competing risk regression, adjusting for age, sex, and periods of anticoagulation. A median of 31% (range: 20-52%) of our patients would have been excluded from participation in the landmark trials. Hemodynamic instability (sub-hazard ratio [SHR]: 2.2, 95% CI: 1.1-4.7), comorbidity (SHR: 1.5, 95% CI: 1.1-2.2), and co-medication (SHR: 1.5, 95% CI: 1.0-2.3) were associated with MB. Compared to eligible patients, those with ≥2 exclusion criteria had a twofold (SHR: 2.16, 95% CI: 1.38-3.39) increased risk of MB. Overall, about one-third of older patients would not be eligible for participation in guideline-defining VTE anticoagulation trials. The bleeding risk increases significantly with the number of exclusion criteria present. Thus, results from such trials may not be generalizable to older, multimorbid, and co-medicated patients.
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Affiliation(s)
- Carla Schenker
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Marie Méan
- Division of Internal Medicine, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Tobias Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Khan F, Thavorn K, Coyle D, van Katwyk S, Tritschler T, Hutton B, Le Gal G, Rodger M, Fergusson D. Protocol for a modelling study to assess the clinical and cost-effectiveness of indefinite anticoagulant therapy for first unprovoked venous thromboembolism. BMJ Open 2023; 13:e053927. [PMID: 36609323 PMCID: PMC9827190 DOI: 10.1136/bmjopen-2021-053927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Deciding whether to stop or extend anticoagulant therapy indefinitely after completing at least 3 months of initial treatment for a first unprovoked venous thromboembolism (VTE) remains a challenge for clinicians, patients and policy makers. Guidelines suggest an indefinite duration of anticoagulant therapy in these patients, yet its benefits, harms and costs have not been formally assessed. The aim of this proposed modelling study is to assess the differences in clinical benefits, harms and costs of stopping versus continuing anticoagulant therapy indefinitely for a first unprovoked VTE. METHODS AND ANALYSIS We will develop a probabilistic Markov model, adopting a 1-month cycle length and a lifetime horizon, to estimate life-years, quality-adjusted life-years, costs and the incremental cost-effectiveness ratios for a simulated population of patients with a first unprovoked VTE who will receive indefinite duration of anticoagulant therapy versus a population who will not receive extended treatment after completing 3 months of initial anticoagulant therapy. The economic evaluation will adopt a third-party payer perspective relating to a Canadian publicly funded healthcare system. Estimates for the probability of relevant clinical events will be informed by systematic reviews and meta-analyses, while costs and utility values will be obtained from published Canadian sources. Stratified analyses based on sex, age and site of initial VTE will also be performed to identify subgroups of patients with a first unprovoked VTE in whom continuing anticoagulant therapy indefinitely might prove to be clinically beneficial and cost-effective over stopping treatment. We will also conduct sensitivity and scenario analyses to assess robustness of study findings to changes in individual or groups of key parameters. ETHICS AND DISSEMINATION Ethical approval is not applicable for this study. The results will be disseminated through presentations at relevant conferences and in a manuscript that will be submitted to a peer-reviewed journal.
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Affiliation(s)
- Faizan Khan
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Doug Coyle
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Sasha van Katwyk
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Tobias Tritschler
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of General Internal Medicine, Inselspital University Hospital Bern, Bern, Switzerland
| | - Brian Hutton
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Gregoire Le Gal
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Marc Rodger
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, Faculty of Medicine, McGill University, Montreal, Québec, Canada
| | - Dean Fergusson
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
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35
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Khairani CD, Bejjani A, Piazza G, Jimenez D, Monreal M, Chatterjee S, Pengo V, Woller SC, Cortes-Hernandez J, Connors JM, Kanthi Y, Krumholz HM, Middeldorp S, Falanga A, Cushman M, Goldhaber SZ, Garcia DA, Bikdeli B. Direct Oral Anticoagulants vs Vitamin K Antagonists in Patients With Antiphospholipid Syndromes: Meta-Analysis of Randomized Trials. J Am Coll Cardiol 2023; 81:16-30. [PMID: 36328154 PMCID: PMC9812926 DOI: 10.1016/j.jacc.2022.10.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/05/2022] [Accepted: 10/12/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND The efficacy and safety of direct oral anticoagulants (DOACs) for patients with thrombotic antiphospholipid syndrome remain controversial. OBJECTIVES The authors performed a systematic review and meta-analysis of randomized controlled trials that compared DOACs with vitamin K antagonists (VKAs). METHODS We searched PubMed, EMBASE, and Cochrane Central Register of Controlled Trials through April 9, 2022. The 2 main efficacy outcomes were a composite of arterial thrombotic events and venous thromboembolic events (VTEs). The main safety outcome was major bleeding. Random effects models with inverse variance were used. RESULTS Our search retrieved 253 studies. Four open-label randomized controlled trials involving 472 patients were included (mean control-arm time-in-therapeutic-range 60%). All had proper random sequence generation and adequate allocation concealment. Overall, the use of DOACs compared with VKAs was associated with increased odds of subsequent arterial thrombotic events (OR: 5.43; 95% CI: 1.87-15.75; P < 0.001, I2 = 0%), especially stroke, and the composite of arterial thrombotic events or VTE (OR: 4.46; 95% CI: 1.12-17.84; P = 0.03, I2 = 0%). The odds of subsequent VTE (OR: 1.20; 95% CI: 0.31-4.55; P = 0.79, I2 = 0%), or major bleeding (OR: 1.02; 95% CI: 0.42-2.47; P = 0.97; I2 = 0%) were not significantly different between the 2 groups. Most findings were consistent within subgroups. CONCLUSIONS Patients with thrombotic antiphospholipid syndrome randomized to DOACs compared with VKAs appear to have increased risk for arterial thrombosis. No significant differences were observed between patients randomized to DOACs vs VKAs in the risk of subsequent VTE or major bleeding.
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Affiliation(s)
- Candrika D Khairani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Antoine Bejjani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory Piazza
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (Instituto de Ramón y Cajal de Investigación Sanitaria), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Manuel Monreal
- Universidad Católica San Antonio de Murcia, Murcia, Spain
| | - Saurav Chatterjee
- Division of Cardiology, St Luke's-Roosevelt Hospital Center of the Mount Sinai Health System, New York, New York, USA
| | - Vittorio Pengo
- Thrombosis Research Laboratory, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University of Padua, Padua, Italy; Arianna Foundation on Anticoagulation, Bologna, Italy
| | - Scott C Woller
- Department of Medicine, Intermountain Medical Center, Murray, Utah, USA; Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | | | - Jean M Connors
- Division of Hematology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Yogendra Kanthi
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA; Laboratory of Vascular Thrombosis and Inflammation, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Harlan M Krumholz
- Yale/YNHH Center for Outcomes Research and Evaluation, New Haven, Connecticut, USA; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA; Department of Health Policy and Administration, Yale School of Public Health, New Haven, Connecticut, USA
| | - Saskia Middeldorp
- Department of Internal Medicine and Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Anna Falanga
- University of Milan Bicocca, School of Medicine, Milan, Italy; Department of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Mary Cushman
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA; Department of Pathology and Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Samuel Z Goldhaber
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David A Garcia
- Division of Hematology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Behnood Bikdeli
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Yale/YNHH Center for Outcomes Research and Evaluation, New Haven, Connecticut, USA; Cardiovascular Research Foundation, New York, New York, USA.
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Anticoagulation in older people with atrial fibrillation moving to care homes: a data linkage study. Br J Gen Pract 2023; 73:e43-e51. [PMID: 36543561 PMCID: PMC9799341 DOI: 10.3399/bjgp.2022.0156] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 10/17/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Treatment decisions about oral anticoagulants (OACs) for atrial fibrillation (AF) are complex in older care home residents. AIM To explore factors associated with OAC prescription. DESIGN AND SETTING Retrospective cohort study set in care homes in Wales, UK, listed in the Care Inspectorate Wales Registry 2017/18. METHOD Analysis of anonymised individual-level electronic health and administrative data was carried out on people aged ≥65 years entering a care home between 1 January 2003 and 31 December 2018, provisioned from the Secure Anonymised Information Linkage Databank. RESULTS Between 2003 and 2018, 14 493 people with AF aged ≥65 years became new residents in care homes in Wales and 7057 (48.7%) were prescribed OACs (32.7% in 2003 compared with 72.7% in 2018) within 6 months before care home entry. Increasing age and prescription of antiplatelet therapy were associated with lower odds of OAC prescription (adjusted odds ratio [aOR] 0.96 per 1-year age increase, 95% confidence interval [CI] = 0.95 to 0.96 and aOR 0.91, 95% CI = 0.84 to 0.98, respectively). Conversely, prior venous thromboembolism (aOR 4.06, 95% CI = 3.17 to 5.20), advancing frailty (mild: aOR 4.61, 95% CI = 3.95 to 5.38; moderate: aOR 6.69, 95% CI = 5.74 to 7.80; and severe: aOR 8.42, 95% CI = 7.16 to 9.90), and year of care home entry from 2011 onwards (aOR 1.91, 95% CI = 1.76 to 2.06) were associated with higher odds of an OAC prescription. CONCLUSION There has been an increase in OAC prescribing in older people newly admitted to care homes with AF. This study provides an insight into the factors influencing OAC prescribing in this population.
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Ballestri S, Romagnoli E, Arioli D, Coluccio V, Marrazzo A, Athanasiou A, Di Girolamo M, Cappi C, Marietta M, Capitelli M. Risk and Management of Bleeding Complications with Direct Oral Anticoagulants in Patients with Atrial Fibrillation and Venous Thromboembolism: a Narrative Review. Adv Ther 2023; 40:41-66. [PMID: 36244055 PMCID: PMC9569921 DOI: 10.1007/s12325-022-02333-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 09/21/2022] [Indexed: 01/25/2023]
Abstract
Atrial fibrillation (AF) and venous thromboembolism (VTE) are highly prevalent conditions with a significant healthcare burden, and represent the main indications for anticoagulation. Direct oral anticoagulants (DOACs) are the first choice treatment of AF/VTE, and have become the most prescribed class of anticoagulants globally, overtaking vitamin K antagonists (VKAs). Compared to VKAs, DOACs have a similar or better efficacy/safety profile, with reduced risk of intracerebral hemorrhage (ICH), while the risk of major bleeding and other bleeding harms may vary depending on the type of DOAC. We have critically reviewed available evidence from randomized controlled trials and observational studies regarding the risk of bleeding complications of DOACs compared to VKAs in patients with AF and VTE. Special patient populations (e.g., elderly, extreme body weights, chronic kidney disease) have specifically been addressed. Management of bleeding complications and possible resumption of anticoagulation, in particular after ICH and gastrointestinal bleeding, are also discussed. Finally, some suggestions are provided to choose the optimal DOAC to minimize adverse events according to individual patient characteristics and bleeding risk.
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Affiliation(s)
- Stefano Ballestri
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy.
| | - Elisa Romagnoli
- Internal Medicine and Critical Care Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Dimitriy Arioli
- Internal Medicine and Critical Care Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Valeria Coluccio
- Hematology Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Alessandra Marrazzo
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy
| | - Afroditi Athanasiou
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy
| | - Maria Di Girolamo
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy
| | - Cinzia Cappi
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy
| | - Marco Marietta
- Hematology Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Mariano Capitelli
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy
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Li D, Liu Y, Song Y, Wen A. Antithrombotic therapy for secondary prevention of unprovoked venous thromboembolism: a systematic review and network meta-analysis of randomized controlled trials. Ann Med 2022; 54:253-261. [PMID: 35023788 PMCID: PMC8759723 DOI: 10.1080/07853890.2022.2026002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Extended antithrombotic treatment is recommended for secondary prevention of unprovoked venous thromboembolism (VTE), however, there is no consensus on which antithrombotic strategy is preferable. AIM To compare the efficacy and safety of different antithrombotic strategies for secondary prevention unprovoked VTE. METHODS Cochrane Central Register of Controlled Trials, Embase, and MEDLINE were systematically searched from inception to 22 July 2020 for randomized controlled trials (RCTs) that compared the efficacy and/or safety of extended antithrombotic strategies including aspirin, warfarin and direct oral anticoagulants (DOACs) for secondary prevention of unprovoked VTE. The primary outcome was risk of major bleeding and the secondary outcomes were risks of recurrent VTE and all-cause death. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using pairwise and network meta-analysis with random effect. Possible ranking of extended antithrombotic strategies was plotted using the surface under the cumulative ranking curve and mean ranks. RESULTS Seventeen RCTs met the inclusion criteria, and meta-analysis results showed that warfarin was associated with significantly higher risk of major bleeding than placebo/observation (OR 2.71, 95% CI 1.32-5.55) or apixaban (OR 10.65, 95% CI 1.06-107.13). Apixaban and low-apixaban were the top two strategies according to the ranking of major bleeding. Warfarin (OR 0.25, 95%CI 0.13-0.49), rivaroxaban (OR 0.18, 95%CI 0.03-0.90), apixaban (OR 0.18, 95%CI 0.04-0.85) and low-apixaban (OR 0.18, 95%CI 0.04-0.82) were related to significantly lower risk than placebo/observation; edoxaban was non-inferior to warfarin on the risk of recurrent VTE. Furthermore, apixaban was linked with significantly lower risk of all-cause death than placebo/observation (OR 0.29, 95% CI 0.09-0.88). CONCLUSION Apixaban showed superiority to other antithrombotic strategies on major bleeding and all-cause death for secondary prevention of unprovoked VTE. Further studies are warranted owing to the limited number of studies and positive cases.Key messagesAll antithrombotic strategies including warfarin, DOACs and aspirin were superior to placebo/observation on recurrent VTE for secondary prevention of unprovoked VTE.Apixaban demonstrated lower risk of major bleeding than warfarin, and lower risk of all-cause death than placebo/observation.Further research about the efficacy and safety of antithrombotic treatments for secondary prevention of unprovoked VTE is warranted.
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Affiliation(s)
- Dandan Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yi Liu
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yao Song
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Aiping Wen
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Wenger N, Sebastian T, Beer JH, Mazzolai L, Aujesky D, Hayoz D, Engelberger RP, Korte W, Voci D, Kucher N, Barco S, Spirk D. Differences in duration of anticoagulation after pulmonary embolism and deep vein thrombosis: Findings from the SWIss Venous ThromboEmbolism Registry (SWIVTER). Thromb Res 2022; 220:65-71. [DOI: 10.1016/j.thromres.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 09/18/2022] [Accepted: 10/10/2022] [Indexed: 11/17/2022]
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Liu Z, Tan J, Deng Y, Hua L, Guo T. Clinical and Safety Outcomes Associated with Extended Treatment of Venous Thromboembolism: A Network Meta-Analysis. J Cardiovasc Dev Dis 2022; 9:jcdd9120414. [PMID: 36547411 PMCID: PMC9781418 DOI: 10.3390/jcdd9120414] [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: 10/26/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Many anticoagulant strategies are available for the extended treatment of venous thromboembolism, yet little guidance exists regarding which drug is most effective and safe. AIM A network meta-analysis was performed to resolve this uncertainty. METHODS We searched the medical literature through June 2022 for randomized controlled trials (RCTs) evaluating the efficacy and safety of anticoagulants for adults with VTE compared with other anticoagulants or a placebo. RESULTS We identified 13 eligible RCTs in 12 articles. All pooled hazard ratios (HR) and 95% credible intervals (CrI) mentioned below, except that for aspirin, were calculated by comparison with standard-intensity warfarin. Novel oral anticoagulants (NOACs) were not inferior to standard-intensity warfarin in preventing recurrence, and edoxaban was ranked first among the NOACs (HR, 0.99; 95% CrI, 0.70-1.39). All the NOACs, except rivaroxaban, were superior to standard-intensity warfarin in preventing bleeding events. Apixaban was ranked first and was considered to be safer than other NOACs for control of both major bleeding (HR = 0.07, 95% CrI: 0.01-0.37) and clinically relevant non-major bleeding (CRNMB, HR = 0.30, 95% CrI: 0.13-0.67). Edoxaban was ranked second among the NOACs for control of major bleeding (HR = 0.44, 95% CI: 0.21-0.88), and dabigatran was ranked second among the NOACs for control of CRNMB (HR = 0.54, 95% CrI: 0.4-0.73). CONCLUSIONS There existed no statistically significant differences in recurrence between NOACs and standard-intensity warfarin, and NOACs were associated with a lower risk of bleeding events. Edoxaban effectively prevented VTE recurrence and major bleeding, and apixaban was the best anticoagulant for controlling bleeding events.
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Affiliation(s)
| | | | | | - Lu Hua
- Correspondence: (L.H.); (T.G.)
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Chazova IE, Martynyuk TV, Gorbachevskii SV, Gramovich VV, Danilov NM, Panchenko EP, Chernyavskiy AM, Shmalts AA, Yavelov IS. ["Guiding lights" for the diagnosis of chronic thromboembolic pulmonary hypertension in the flow of patients with pulmonary embolism]. TERAPEVT ARKH 2022; 94:1052-1056. [PMID: 36286754 DOI: 10.26442/00403660.2022.09.201836] [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: 10/24/2022] [Accepted: 10/24/2022] [Indexed: 06/16/2023]
Abstract
On December 13, 2021, an expert council was held to determine the position of experts of different specialties regarding the reasons for the low level of diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH) in real clinical practice in a pandemic of a new coronavirus infection and possible ways to improve detection in patients with pulmonary embolism (PE) ) in history. The reasons for the low level of diagnosis of CTEPH are the insufficient level of knowledge of specialists, especially primary care physicians; lack of clear regulatory documents and expert centers for the management of this category of patients. Primary diagnosis of CTEPH in a pandemic can be strengthened through the widespread use of telemedicine for consultations of primary care physicians with specialists from expert centers; to maximize the role of echocardiography and computed tomography (CT) as differential diagnostic tools for dyspnea, in particular in patients with COVID-19. To increase the detection rate of CTEPH, diagnostic vigilance is required in patients with risk factors and episodes of venous thromboembolism. To improve the screening of CTEPH, it is necessary to create an algorithm for monitoring patients who have had PE; provide educational activities, including through the media; create materials for patients with accessible information. The regulatory documents should designate the circle of responsible specialists who will be engaged in long-term monitoring of patients with PE. Educational programs are needed for primary care physicians, cardiologists, and other physicians who come into the field of view of patients with CTEPH; introduction of a program to create expert centers for monitoring and managing patients with the possibility of performing ventilation-perfusion lung scintigraphy, cardiopulmonary stress test, CT, right heart catheterization. It seems important to build cooperation with the Ministry of Health of Russia in order to create special protocols, procedures for managing patients with PE and CTEPH.
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Affiliation(s)
- I E Chazova
- Chazov National Medical Research Center of Cardiology
| | - T V Martynyuk
- Chazov National Medical Research Center of Cardiology
- The Russian National Research Medical University named after N.I. Pirogov
| | - S V Gorbachevskii
- Bakoulev Scientific Center for Cardiovascular Surgery
- Russian Medical Academy of Continuous Professional Education
| | - V V Gramovich
- Chazov National Medical Research Center of Cardiology
| | - N M Danilov
- Chazov National Medical Research Center of Cardiology
| | - E P Panchenko
- Chazov National Medical Research Center of Cardiology
| | | | - A A Shmalts
- Bakoulev Scientific Center for Cardiovascular Surgery
- Russian Medical Academy of Continuous Professional Education
| | - I S Yavelov
- National Medical Research Center for Therapy and Preventive Medicine
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Gastrointestinal Bleeding on Oral Anticoagulation: What is Currently Known. Drug Saf 2022; 45:1449-1456. [PMID: 36227528 DOI: 10.1007/s40264-022-01243-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2022] [Indexed: 11/03/2022]
Abstract
Gastrointestinal bleeding (GIB) is the most common type of bleeding occurring in patients on oral anticoagulation. A meta-analysis of the landmark randomized controlled trials (RCTs) for patients with atrial fibrillation demonstrated that direct oral anticoagulants (DOACs) were associated with higher GIB rates compared to warfarin. However, significant heterogeneity existed between studies. While rivaroxaban, high-dose dabigatran, and high-dose edoxaban were associated with higher GIB rates than warfarin, GIB rates were similar between warfarin users and both apixaban and low-dose dabigatran users. Additionally, previous observational studies have yielded conflicting reports on whether GIB rates differ between warfarin and DOACs. Meta-analyses of observational studies demonstrated that warfarin is associated with lower rates of GIB compared to rivaroxaban, similar or lower rates compared to dabigatran, and higher rates compared to apixaban. Importantly, no RCT has compared individual DOACs directly and due to the different selection criteria of the initial RCTs, indirect comparisons between DOACs using these studies are unreliable. The best available information of comparisons between individual DOACs is therefore limited to observational studies. There is mounting evidence that suggests that rivaroxaban is associated with a higher risk of GIB compared to other DOACs. Finally, GIB induced by oral anticoagulation may have some positive aspects. Interestingly, there are studies that indicate oral anticoagulation facilitates colorectal cancer detection. Furthermore, results from RCTs and observational studies suggest that warfarin may even decrease the incidence of cancer.
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Attard LM, Gatt A, Bertoletti L, Delluc A, Riva N. Direct Oral Anticoagulants for the Prevention and Acute Treatment of Cancer-Associated Thrombosis. Vasc Health Risk Manag 2022; 18:793-807. [PMID: 36268462 PMCID: PMC9576495 DOI: 10.2147/vhrm.s271411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/05/2022] [Indexed: 12/05/2022] Open
Abstract
Cancer is a major risk factor for venous thromboembolism (VTE), and cancer-associated thrombosis (CAT) constitutes approximately 15-25% of all VTE cases. For decades, the standard treatment for CAT used to be daily subcutaneous low molecular weight heparin (LMWH). Data on the safety and efficacy of the direct oral anticoagulants (DOACs) in this population emerged only in recent years and specific DOACs were included into recent guidelines recommendations. In this narrative review of the literature, we reported the results of the phase III randomized controlled trials that evaluated the DOACs for the prevention and the acute treatment of CAT. For the acute phase treatment, the anti-Xa inhibitors (apixaban, edoxaban, rivaroxaban) showed better efficacy than LMWH in preventing VTE recurrence; however, rivaroxaban and edoxaban were also associated with an increased risk of bleeding events. For primary prevention of CAT in ambulatory cancer patients starting chemotherapy, apixaban and rivaroxaban showed better efficacy than placebo but a trend towards higher bleeding rates. Recent guidelines suggest the DOACs for the treatment of CAT in selected cancer patients (eg, low bleeding risk, no luminal gastrointestinal or genitourinary malignancies, no interfering medications). The DOACs are also suggested for primary thromboprophylaxis in selected ambulatory cancer patients at high risk of VTE (eg, Khorana score ≥2 prior to starting new chemotherapy, low bleeding risk, no interfering medications).
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Affiliation(s)
| | - Alex Gatt
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Laurent Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, Saint-Etienne, France,INSERM, UMR1059, Université Jean-Monnet, Saint-Etienne, France,INNOVTE, CHU de Saint-Etienne, Saint-Etienne, France
| | - Aurelien Delluc
- Ottawa Hospital Research Institute, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Nicoletta Riva
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta,Correspondence: Nicoletta Riva, Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, MSD 2080, Malta, Email
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Højen AA, Nielsen PB, Overvad TF, Albertsen IE, Klok FA, Rolving N, Søgaard M, Ording AG. Long-Term Management of Pulmonary Embolism: A Review of Consequences, Treatment, and Rehabilitation. J Clin Med 2022; 11:jcm11195970. [PMID: 36233833 PMCID: PMC9571065 DOI: 10.3390/jcm11195970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/29/2022] [Accepted: 10/01/2022] [Indexed: 12/02/2022] Open
Abstract
The concept of pulmonary embolism is evolving. Recent and emerging evidence on the treatment of specific patient populations, its secondary prevention, long-term complications, and the unmet need for rehabilitation has the potential to change clinical practice for the benefit of the patients. This review discusses the recent evidence from clinical trials, observational studies, and guidelines focusing on anticoagulation treatment, rehabilitation, emotional stress, quality of life, and the associated outcomes for patients with pulmonary embolism. Guidelines suggest that the type and duration of treatment with anticoagulation should be based on prevalent risk factors. Recent studies demonstrate that an anticoagulant treatment that is longer than two years may be effective and safe for some patients. The evidence for extended treatment in cancer patients is limited. Careful consideration is particularly necessary for pulmonary embolisms in pregnancy, cancer, and at the end of life. The rehabilitation and prevention of unnecessary deconditioning, emotional distress, and a reduced quality of life is an important, but currently they are unmet priorities for many patients with a pulmonary embolism. Future research could demonstrate optimal anticoagulant therapy durations, follow-ups, and rehabilitation, and effective patient-centered decision making at the end of life. A patient preferences and shared decision making should be incorporated in their routine care when weighing the benefits and risks with primary treatment and secondary prevention.
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Affiliation(s)
- Anette Arbjerg Højen
- Unit for Thrombosis and Drug Research, Aalborg University Hospital, 9000 Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - Peter Brønnum Nielsen
- Unit for Thrombosis and Drug Research, Aalborg University Hospital, 9000 Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Medicine, Aalborg University, 9000 Aalborg, Denmark
| | - Thure Filskov Overvad
- Unit for Thrombosis and Drug Research, Aalborg University Hospital, 9000 Aalborg, Denmark
- Department of Clinical Pharmacology, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - Ida Ehlers Albertsen
- Unit for Thrombosis and Drug Research, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, 2333 Leiden, The Netherlands
| | - Nanna Rolving
- Department of Physical and Occupational Therapy, Aarhus University Hospital, 8200 Aarhus, Denmark
- Department of Public Health, Aarhus University, 8200 Aarhus, Denmark
| | - Mette Søgaard
- Unit for Thrombosis and Drug Research, Aalborg University Hospital, 9000 Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Medicine, Aalborg University, 9000 Aalborg, Denmark
| | - Anne Gulbech Ording
- Unit for Thrombosis and Drug Research, Aalborg University Hospital, 9000 Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark
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Abstract
IMPORTANCE Pulmonary embolism (PE) is characterized by occlusion of blood flow in a pulmonary artery, typically due to a thrombus that travels from a vein in a lower limb. The incidence of PE is approximately 60 to 120 per 100 000 people per year. Approximately 60 000 to 100 000 patients die from PE each year in the US. OBSERVATIONS PE should be considered in patients presenting with acute chest pain, shortness of breath, or syncope. The diagnosis is determined by chest imaging. In patients with a systolic blood pressure of at least 90 mm Hg, the following 3 steps can be used to evaluate a patient with possible PE: assessment of the clinical probability of PE, D-dimer testing if indicated, and chest imaging if indicated. The clinical probability of PE can be assessed using a structured score or using clinical gestalt. In patients with a probability of PE that is less than 15%, the presence of 8 clinical characteristics (age <50 years, heart rate <100/min, an oxygen saturation level of > 94%, no recent surgery or trauma, no prior venous thromboembolism event, no hemoptysis, no unilateral leg swelling, and no estrogen use) identifies patients at very low risk of PE in whom no further testing is needed. In patients with low or intermediate clinical probability, a D-dimer level of less than 500 ng/mL is associated with a posttest probability of PE less than 1.85%. In these patients, PE can be excluded without chest imaging. A further refinement of D-dimer threshold is possible in patients aged 50 years and older, and in patients with a low likelihood of PE. Patients with a high probability of PE (ie, >40% probability) should undergo chest imaging, and D-dimer testing is not necessary. In patients with PE and a systolic blood pressure of 90 mm Hg or higher, compared with heparin combined with a vitamin K antagonist such as warfarin followed by warfarin alone, direct oral anticoagulants such as apixaban, edoxaban, rivaroxaban, or dabigatran, are noninferior for treating PE and have a 0.6% lower rate of bleeding. In patients with PE and systolic blood pressure lower than 90 mm Hg, systemic thrombolysis is recommended and is associated with an 1.6% absolute reduction of mortality (from 3.9% to 2.3%). CONCLUSIONS AND RELEVANCE In the US, PE affects approximately 370 000 patients per year and may cause approximately 60 000 to 100 000 deaths per year. First-line therapy consists of direct oral anticoagulants such as apixaban, edoxaban, rivaroxaban, or dabigatran, with thrombolysis reserved for patients with systolic blood pressure lower than 90 mm Hg.
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Affiliation(s)
- Yonathan Freund
- Sorbonne Université, Improving Emergency Care FHU, Paris, France
- Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Fleur Cohen-Aubart
- Sorbonne Université, Improving Emergency Care FHU, Paris, France
- Internal Medicine Department 2, French National Referral Center for Rare Systemic Diseases and Histiocytoses, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Ben Bloom
- Emergency Department, Barts Health NHS Trust, London, United Kingdom
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46
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el marraki Z, bouzhir A, eddhima Z, el bouanani AE, mouine N, benyass A. Homozygous factor V leiden mutation: Rare etiology of pulmonary embolism. Ann Med Surg (Lond) 2022; 82:104569. [PMID: 36268447 PMCID: PMC9577392 DOI: 10.1016/j.amsu.2022.104569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 08/29/2022] [Accepted: 09/04/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction and importance Venous thromboembolic disease (VTE), which includes pulmonary embolism (PE) and deep vein thrombosis (DVT), is a major public health problem with high morbidity and mortality. The main risk factors for VTE are surgery, active cancer, immobilization, trauma or fracture, pregnancy and estrogen therapy. Genetic risk factors are also present and are dominated by the factor V Leiden mutation, which is present in 20% of VTE and in 2–5% of the general population with an annual incidence of 0.1% (Margaglione and Grandone, 2011; Ridker et al., 1995) [4,5]. This mutation can be heterozygous or homozygous, which is rarer. In this context, we report the case of a 37-year-old patient with no medical or surgical history and no notable risk factors who was admitted to the emergency room for the management of acute dyspnea at rest in connection with a bilateral proximal pulmonary embolism originating from a homozygous factor V Leiden mutation. Despite the efforts of the World Health organization, pulmonary embolism remains a major cause of morbidity and mortality in our days, and the etiological assessment is performed in a very few cases, which makes the management standardized and not specific. That is why it is important to make an etiological assessment in a systematic way especially in young subjects for an optimal management and to avoid recurrences. Case presentation Here, we report a rare case of a 37-year-old patient, who was admitted for the management of resting dyspnea related to bilateral proximal pulmonary embolism, in whom the etiological work-up was in favor of a homozygous factor V Leiden mutation. This case shows diagnostic difficulties and management of this rare disease. Pulmonary embolism is a frequent and potentially serious pathology. The etiological assessment of pulmonary embolism is not carried out in a systematic way which makes the management not optimal with the possibility of repeated pulmonary embolism. Long-term anticoagulation is the mainstay of treatment for pulmonary embolism secondary to factor V Leiden mutation.
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47
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Fan G, Wang D, Zhang M, Luo X, Zhai Z, Wu S. Anticoagulant for treatment and prophylaxis of venous thromboembolism patients with renal dysfunction: A systematic review and network meta-analysis. Front Med (Lausanne) 2022; 9:979911. [PMID: 36226154 PMCID: PMC9548609 DOI: 10.3389/fmed.2022.979911] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 08/15/2022] [Indexed: 11/13/2022] Open
Abstract
Objective The aim of this study was to compare the efficacy and safety for particular regimen and dosage in venous thromboembolism (VTE) patients with renal insufficiency. Methods English language searches of PubMed, Embase, and Web of Science (inception to May 2021). RCTs evaluating anticoagulants for VTE treatment at acute phase, extension phase, and VTE prophylaxis in patients with renal insufficiency and reporting efficacy (death, recurrence, or occurrence of VTE) and safety (bleeding) outcomes were selected. The methodological quality of each study included was assessed at the outcome level using the risk-of-bias assessment tool developed by the Cochrane Bias Methods Group. Results Twenty-one trials that involved 76,574 participants and 8,972 (11.7%) patients with renal insufficiency were enrolled, including 10 trials on VTE treatment in acute phase (3–12 months), four trials on VTE treatment in extension phase (6–36 months), and seven trials for VTE prophylaxis. For acute VTE treatment, compared with dabigatran etexilate, apixaban (RR 5.90, 95%CI 1.00–34.60) and rivaroxaban (RR 6.18, 95%CI 1.17–32.75) were significantly associated with increased risk of death or recurrence. For extension treatment of VTE, aspirin had the highest probability of the most effective and safest treatment, followed by apixaban. For VTE prophylaxis, compared with enoxaparin, desirudin was associated with lower risk of VTE occurrence (RR 0.56, 95% CI 0.34–0.91), but had higher risk of bleeding than dabigatran etexilate. Conclusion The network meta-analysis informs the optimal choice of anticoagulants and their particular dosage for treatment and prophylaxis of VTE patients comorbid renal insufficiency. Systematic review registration www.crd.york.ac.uk/prospero/, identifier: CRD42021254086.
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Affiliation(s)
- Guohui Fan
- Department of Clinical Research and Data Management, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Disease, Beijing, China
- National Clinical Research Center for Respiratory Disease, Beijing, China
- Institute of Respiratory Medicine, Chinses Academy of Medical Sciences, Beijing, China
| | - Dingyi Wang
- Department of Clinical Research and Data Management, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Disease, Beijing, China
- National Clinical Research Center for Respiratory Disease, Beijing, China
- Institute of Respiratory Medicine, Chinses Academy of Medical Sciences, Beijing, China
| | - Meng Zhang
- Department of Respiratory and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xufei Luo
- School of Public Health, Lanzhou University, Lanzhou, China
| | - Zhenguo Zhai
- National Center for Respiratory Disease, Beijing, China
- National Clinical Research Center for Respiratory Disease, Beijing, China
- Institute of Respiratory Medicine, Chinses Academy of Medical Sciences, Beijing, China
- Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Sinan Wu
- Department of Clinical Research and Data Management, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Disease, Beijing, China
- National Clinical Research Center for Respiratory Disease, Beijing, China
- Institute of Respiratory Medicine, Chinses Academy of Medical Sciences, Beijing, China
- *Correspondence: Sinan Wu
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48
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Ingason AB, Rumba E, Hreinsson JP, Agustsson AS, Lund SH, Palsson DA, Reynisson IE, Gudmundsdottir BR, Onundarson PT, Tryggvason G, Bjornsson ES. Warfarin is associated with higher rates of epistaxis compared to direct oral anticoagulants: A nationwide propensity score-weighted study. J Intern Med 2022; 292:501-511. [PMID: 35411982 DOI: 10.1111/joim.13498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although epistaxis is one of the most common side effects of oral anticoagulation, it is unclear whether epistaxis rates vary between different oral anticoagulants (OAC). OBJECTIVE To compare rates of clinically relevant epistaxis between OAC. METHODS Epistaxis event rates were compared between new users of apixaban, dabigatran, rivaroxaban, and warfarin in a nationwide population-based cohort study over a 5-year study period, 2014-2019. Data was collected from the Icelandic Medicine Registry and the five major hospitals in Iceland. Inverse probability weighting (IPW) was used to yield balanced baseline characteristics, and epistaxis rates were compared using Kaplan-Meier survival estimates and Cox regression. RESULTS During the study period, 2098 patients received apixaban, 474 dabigatran, 3106 rivaroxaban, and 1403 warfarin. In total, 93 patients presented with clinically relevant epistaxis, including 11 (12%) major epistaxis events and one fatal epistaxis episode. Furthermore, seven patients (9%) with non-major epistaxis later presented with major bleeding during the follow-up period. Warfarin use was associated with higher rates of epistaxis compared to apixaban (2.2 events per 100-person years (events/100-py) vs. 0.6 events/100-py, hazard ratio [HR] 4.22, 95% confidence interval [CI] 2.08-8.59, p < 0.001), rivaroxaban (2.2 events/100-py vs. 1.0 events/100-py, HR 2.26, 95% CI 1.28-4.01, p = 0.005), and dabigatran (2.2 events/100-py vs. no events, HR n/a, p < 0.001). CONCLUSION Warfarin treatment was associated with higher rates of clinically relevant epistaxis compared to direct oral anticoagulants.
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Affiliation(s)
- Arnar B Ingason
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Gastroenterology and Hepatology, Landspitali University Hospital, Reykjavik, Iceland
| | - Edward Rumba
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Gastroenterology and Hepatology, Landspitali University Hospital, Reykjavik, Iceland
| | - Johann P Hreinsson
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Arnar S Agustsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Gastroenterology and Hepatology, Landspitali University Hospital, Reykjavik, Iceland
| | | | - Daniel A Palsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Gastroenterology and Hepatology, Landspitali University Hospital, Reykjavik, Iceland
| | | | - Brynja R Gudmundsdottir
- Department of Laboratory Hematology and Coagulation Center, Landspitali University Hospital, Reykjavik, Iceland
| | - Pall T Onundarson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Laboratory Hematology and Coagulation Center, Landspitali University Hospital, Reykjavik, Iceland
| | - Geir Tryggvason
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Otolaryngology - Head and Neck Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Einar S Bjornsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Gastroenterology and Hepatology, Landspitali University Hospital, Reykjavik, Iceland
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49
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Kanjee Z, Freed JA, Carroll BJ, Reynolds EE. How Would You Treat This Patient With Pulmonary Embolism? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2022; 175:1161-1169. [PMID: 35939811 DOI: 10.7326/m22-0989] [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] [Indexed: 11/22/2022] Open
Abstract
Pulmonary embolism can be acutely life-threatening and is associated with long-term consequences such as recurrent venous thromboembolism and chronic thromboembolic pulmonary hypertension. In 2020, the American Society of Hematology published updated guidelines on the management of patients with venous thromboembolism. Here, a hematologist and a cardiology and vascular medicine specialist discuss these guidelines in the context of the care of a patient with pulmonary embolism. They discuss advanced therapies such as catheter-directed thrombolysis in the short-term management of patients with intermediate-risk disease, recurrence risk stratification at presentation, and ideal antithrombotic regimens for patients whose pulmonary embolism was associated with a transient minor risk factor.
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Affiliation(s)
- Zahir Kanjee
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (Z.K., J.A.F., B.J.C., E.E.R.)
| | - Jason A Freed
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (Z.K., J.A.F., B.J.C., E.E.R.)
| | - Brett J Carroll
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (Z.K., J.A.F., B.J.C., E.E.R.)
| | - Eileen E Reynolds
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (Z.K., J.A.F., B.J.C., E.E.R.)
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50
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Mitchell LG, Röshammar D, Huang F, Albisetti M, Brandão LR, Bomgaars L, Chalmers E, Halton J, Luciani M, Joseph D, Tartakovsky I, Gropper S, Brueckmann M. Anticoagulant Effects of Dabigatran on Coagulation Laboratory Parameters in Pediatric Patients: Combined Data from Five Pediatric Clinical Trials. Thromb Haemost 2022; 122:1573-1583. [PMID: 35909257 PMCID: PMC9420551 DOI: 10.1055/s-0042-1744542] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Background
Dabigatran etexilate, a direct oral thrombin inhibitor, is approved to treat venous thromboembolism (VTE) in both adults and children.
Objectives
This population analysis characterized relationships between dabigatran total plasma concentrations and coagulation laboratory parameters (activated partial thromboplastin time [aPTT]; diluted thrombin time [dTT]; ecarin clotting time [ECT]).
Methods
Data from three phase 2a and one single-arm and one randomized, comparative phase 2b/3 pediatric studies (measurements: aPTT 2,925 [
N
= 358]; dTT 2,348 [
N
= 324]; ECT 2,929 [
N
= 357]) were compared with adult data (5,740 aPTT, 3,472 dTT, 3,817 ECT measurements;
N
= 1,978). Population models were fitted using nonlinear mixed-effects modeling. Covariates (e.g., sex, age) were assessed on baseline and drug-effect parameters, using a stepwise covariate model-building procedure.
Results
Overall, relationships between dabigatran, aPTT, dTT, and ECT were similar in children and adults. For children aged <6 months, a higher proportion of baseline samples were outside or close to the upper aPTT and ECT adult ranges. No age-related differences were detected for dTT. With increasing dabigatran concentration, aPTT rose nonlinearly (half the maximum effect at 368 ng/mL dabigatran) while dTT and ECT increased linearly (0.37 and 0.73% change per ng/mL dabigatran, respectively). Mean baseline aPTT (45 vs. 36 seconds) and ECT (40 vs. 36 seconds) were slightly increased for those aged <6 months versus older children.
Conclusion
The similar relationships of laboratory parameters observed across pediatric age groups suggests that developmental changes in the hemostatic system may have little effect on response to dabigatran.
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Affiliation(s)
- Lesley G Mitchell
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | | | - Fenglei Huang
- Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut, United States
| | - Manuela Albisetti
- Hematology Department, University Children's Hospital, Zürich, Switzerland
| | - Leonardo R Brandão
- Division of Hematology/Oncology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Lisa Bomgaars
- Department of Pediatrics, Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas, United States
| | - Elizabeth Chalmers
- The Glasgow Children's Haemophilia Unit, Royal Hospital for Children, Glasgow, Scotland, United Kingdom
| | - Jacqueline Halton
- Division of Hematology/Oncology, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Matteo Luciani
- Pediatric Hematology/Oncology Department, Pediatric Hospital Bambino Gesù, Rome, Italy
| | - David Joseph
- Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut, United States
| | - Igor Tartakovsky
- Therapeutic Area Cardiovascular Medicine, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Savion Gropper
- Therapeutic Area Inflammation Medicine, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Martina Brueckmann
- Therapeutic Area Cardiovascular Medicine, Boehringer Ingelheim International GmbH, Ingelheim, Germany.,Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim, Germany
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