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Brekelmans MPA, Ginkel KV, Daams JG, Hutten BA, Middeldorp S, Coppens M. Benefits and harms of 4-factor prothrombin complex concentrate for reversal of vitamin K antagonist associated bleeding: a systematic review and meta-analysis. J Thromb Thrombolysis 2018; 44:118-129. [PMID: 28540468 PMCID: PMC5486892 DOI: 10.1007/s11239-017-1506-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Prothrombin complex concentrate (PCC) is used for reversal of vitamin K antagonists (VKA) in patients with bleeding complications. This study aims to assess benefits and harms of 4-factor PCC compared to fresh frozen plasma (FFP) or no treatment in VKA associated bleeding. PubMed, EMBASE and CENTRAL were searched from 1945 to August 2015. Studies reporting 4-factor PCC use for VKA associated bleeding and providing data on INR normalization, mortality or thromboembolic (TE) complications were eligible. Two authors screened titles and full articles for inclusion, extracted data, and assessed risk of bias. Mortality data were pooled using Mantel–Haenszel random effects meta-analysis. Nineteen studies were included (N = 2878); 18 cohort studies and one RCT. Six studies had good methodological quality, 9 moderate and 4 poor. Baseline INR values ranged from 2.2 to >20. The INR within 1 h after PCC administration ranged from 1.4 to 1.9, and after FFP administration from 2.2 to 12. PCC reduced the time to reach INR correction in comparison with FFP or no treatment. The observed mortality rate ranged from 0 to 43% (mean 17%) in the PCC, 4.8–54% (mean 16%) in the FFP and 23–69% (mean 51%) in the no treatment group. Meta-analysis of mortality data resulted in an OR of 0.64 (95% confidence interval [CI] 0.27–1.5) for PCC versus FFP and an OR 0.41 (95% CI 0.13–1.3) for PCC versus no treatment. TE complications were observed in 0–18% (mean 2.5%) of PCC and in 6.4% of FFP recipients. Four-factor PCC is an effective and safe option in reversal of VKA bleeding events.
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Affiliation(s)
- Marjolein P A Brekelmans
- Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
| | | | - Joost G Daams
- Medical Library, Academic Medical Center, Amsterdam, the Netherlands
| | - Barbara A Hutten
- Department of Clinical Epidemiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Michiel Coppens
- Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
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Eerenberg ES, Kampuisen PW, Levi M. Anticoagulants. Hamostaseologie 2017; 31:229-35. [DOI: 10.5482/ha-1153] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Accepted: 06/06/2011] [Indexed: 11/05/2022] Open
Abstract
SummaryAnticoagulants are effective in the prevention and treatment of a variety of arterial and venous thrombotic disorders but are associated with an increased risk of serious bleeding complications. Based on well documented studies of patients using vitamin K antagonists the incidence of major bleeding is 0.5%/year and the incidence of intracranial bleeding is 0.2%/year, however, in real life practice this incidence may be even higher. Risk factors for bleeding are the intensity of anticoagulation, the management strategy to keep the anticoagulant effect in the desired range, and patient characteristics. Recently, a new generation of anticoagulants have been developed and is currently evaluated in clinical trials. Initial results show a similar or superior efficacy over conventional anticoagulant agents with a good safety profile. In case of serious bleeding complications in a patient who uses vitamin K antagonists, this anticoagulant treatment can be quickly reversed by administration of vitamin K or coagulation factor concentrates. For the newer anticoagulants, quick reversal strategies are more cumbersome, although some interventions, including prothrombin complex concentrates, show promising results in initial experimental studies.
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Use of three procoagulants in improving bleeding outcomes in the warfarin patient with intracranial hemorrhage. Blood Coagul Fibrinolysis 2017; 28:612-616. [PMID: 28654426 DOI: 10.1097/mbc.0000000000000645] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
: When patients on anticoagulation present with intracranial bleeding, stopping the bleeding is paramount. Despite the availability of multiple options to reverse anticoagulation, no study has directly compared the effectiveness of the procoagulants recombinant activated factor VII (rFVIIa), the rFVIIa and 3-factor prothrombin complex concentrate (PCC) combination, and 4-factor PCC on improving patient outcomes compared with a control. This study examined the medical records of 197 warfarin patients with intracranial hemorrhage, an initial international normalized ratio (INR) greater than 1.5, and who received rFVIIa (26), the combination (84), 4-PCC (50), or no procoagulant, the control group (37). Mortality, length of stay, location discharged, change in INR prior to and postdrug administration, plasma use, and number of thromboembolic complications were used to assess effectiveness. Although INR decreased in all groups (1.31 rFVIIa vs. 2.04 combination vs. 1.41 4-PCC vs. 1.20 control, P = 0.07), the combination group had the greatest percentage to reach an INR of less than 1.3 (46.2 vs. 73.8 vs. 58.0 vs. 43.2%, P = 0.004). The combination and control groups experienced a high, though nonsignificant, number of thromboembolic complications (5.6 vs. 19.0 vs. 7.7 vs. 12.9%, P = 0.533). The rFVIIa group used the most plasma and had the longest length of stay. Mortality did not differ significantly among groups. Although the combination improved INR compared with control, this had a high number of complications. Judicious use of procoagulants is recommended due to their expense and lack of significant improvement in outcomes compared with control.
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Lin LM, Paff M, Xu R, Jiang B, Colby GP, Coon AL. Chronic anticoagulation with warfarin is associated with decreased functional outcome and increased length of stay following craniotomy for acute subdural hematoma. INTERDISCIPLINARY NEUROSURGERY 2017. [DOI: 10.1016/j.inat.2017.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Chang Y, Kim YJ, Song TJ. Management of Oral Anti-Thrombotic Agents Associated Intracerebral Hemorrhage. JOURNAL OF NEUROCRITICAL CARE 2016. [DOI: 10.18700/jnc.160082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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DeLoughery E, Avery B, DeLoughery TG. Retrospective study of rFVIIa, 4-factor PCC, and a rFVIIa and 3-factor PCC combination in improving bleeding outcomes in the warfarin and non-warfarin patient. Am J Hematol 2016; 91:705-8. [PMID: 27074566 DOI: 10.1002/ajh.24384] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 04/06/2016] [Accepted: 04/07/2016] [Indexed: 11/07/2022]
Abstract
In case of severe bleeding, the physician must rapidly and effectively halt bleeding without the risk of thromboembolic complications. Despite widespread use, no study has directly compared recombinant activated factor VII (rFVIIa), the rFVIIa and 3-factor prothrombin complex concentrate (PCC) combination ("combination"), and 4-factor PCC on their effectiveness in improving patient outcomes. This study examined the medical records of 299 patients, 65.2% on warfarin prior to admission, who received these hemostatic agents and were admitted to an ICU or through the emergency department at Oregon Health & Science University. Mortality, length of stay, change in international normalized ratio (INR), plasma use, and number of thromboembolic complications were used to assess effectiveness. In patients receiving warfarin, the combination group had the greatest decrease in INR as well as lowest overall INR, but experienced a higher number of clotting complications, while the rFVIIa group used the most plasma. Non-warfarin patients in the combination group had the shortest length of stay among survivors, but the rFVIIa group had the lowest mortality. Based on this data, it may be prudent to further study the use of rFVIIa in treating extreme bleeding in the non-warfarin patient, while this study supports other data that 4-factor PCC may be the most prudent for the warfarin patient. Am. J. Hematol. 91:705-708, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Emma DeLoughery
- Westminster College; Salt Lake City Utah
- Division of Hematology/Medical Oncology; Knight Cancer Institute, Oregon Health & Science University; Portland Oregon
| | | | - Thomas G. DeLoughery
- Division of Hematology/Medical Oncology; Knight Cancer Institute, Oregon Health & Science University; Portland Oregon
- Division of Laboratory Medicine; Department of Pathology; Oregon Health & Science University; Portland Oregon
- Division of Hematology/Medical Oncology; Department of Pediatrics; Oregon Health & Science University; Portland Oregon
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Sartori MT, Prandoni P. How to effectively manage the event of bleeding complications when using anticoagulants. Expert Rev Hematol 2015; 9:37-50. [DOI: 10.1586/17474086.2016.1112733] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Hemphill JC, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, Fung GL, Goldstein JN, Macdonald RL, Mitchell PH, Scott PA, Selim MH, Woo D. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2015; 46:2032-60. [PMID: 26022637 DOI: 10.1161/str.0000000000000069] [Citation(s) in RCA: 1979] [Impact Index Per Article: 219.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of spontaneous intracerebral hemorrhage. METHODS A formal literature search of PubMed was performed through the end of August 2013. The writing committee met by teleconference to discuss narrative text and recommendations. Recommendations follow the American Heart Association/American Stroke Association methods of classifying the level of certainty of the treatment effect and the class of evidence. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Oversight Committee and Stroke Council Leadership Committee. RESULTS Evidence-based guidelines are presented for the care of patients with acute intracerebral hemorrhage. Topics focused on diagnosis, management of coagulopathy and blood pressure, prevention and control of secondary brain injury and intracranial pressure, the role of surgery, outcome prediction, rehabilitation, secondary prevention, and future considerations. Results of new phase 3 trials were incorporated. CONCLUSIONS Intracerebral hemorrhage remains a serious condition for which early aggressive care is warranted. These guidelines provide a framework for goal-directed treatment of the patient with intracerebral hemorrhage.
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Comparison of a low, fixed dose and a high, weight-based dose of recombinant factor VIIa in the treatment of warfarin-associated intracranial hemorrhage. Neurocrit Care 2015; 20:466-9. [PMID: 23595666 DOI: 10.1007/s12028-013-9841-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Recombinant activated Factor VII (rFVIIa) can be used for rapid INR normalization in patients with warfarin-associated intracranial hemorrhage (WA-ICH); however, the optimal dose to normalize INR has not been established. METHODS This is a retrospective review comparing two rFVIIa hospital protocols for WA-ICH [weight-based dose (80 mcg/kg) or fixed dose (2 mg)]. Primary endpoint was the percentage of patients with INR reversal (INR <1.3) at the next INR draw and the need for further doses of rFVIIa. Secondary endpoints included time to documented INR reversal and sustained INR normalization, morbidity, mortality, change in hematoma size, cost, and adverse drug reactions. RESULTS Twenty-nine patients were included in each group. The weight-based group received a mean dose of 78.9 ± 21 mcg/kg versus 26.6 ± 8 mcg/kg in the fixed dose group. More patients in the fixed dose protocol achieved documented INR reversal than those in the weight-based group (92.6 vs 72.4 %, p = 0.19). The weight-based group achieved INR normalization in 229.5 [102, 331] minutes versus 165 [83, 447] minutes in the fixed dose group (p=0.02). Time to sustained INR normalization was similar in both groups. Four patients in the fixed dose group received an additional dose of 1 mg per hospital protocol. With the exception of medication acquisition cost savings of about $4,300 per patient who received fixed dose protocol, all other endpoints were similar between groups. CONCLUSIONS A low, fixed dose of rFVIIa appears to be as effective as a high, weight-based dose in achieving INR normalization in patients with WA-ICH.
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Ray B, Keyrouz SG. Management of anticoagulant-related intracranial hemorrhage: an evidence-based review. Crit Care 2014; 18:223. [PMID: 24970013 PMCID: PMC4056075 DOI: 10.1186/cc13889] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The increased use of anticoagulants for the prevention and treatment of thromboembolic diseases has led to a rising incidence of anticoagulant-related intracranial hemorrhage (AICH) in the aging western population. High mortality accompanies this form of hemorrhagic stroke, and significant and debilitating long-term consequences plague survivors. Although management guidelines for such hemorrhages are available for the older generation anticoagulants, they are still lacking for newer agents, which are becoming popular among physicians. Supportive care, including blood pressure control, and reversal of anticoagulation remain the cornerstone of acute management of AICH. Prothrombin complex concentrates are gaining popularity over fresh frozen plasma, and reversal agents for newer anticoagulation agents are being developed. Surgical interventions are options fraught with complications, and are decided on a case-by-case basis. Our current state of understanding of this condition and its management is insufficient. This deficit calls for more population-based studies and therapeutic trials to better evaluate risk factors for, and to prevent and treat AICH.
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Affiliation(s)
- Bappaditya Ray
- Division of Critical Care Neurology, Department of Neurology, The University of Oklahoma Health Sciences Center, 920 Stanton L Young Blvd, Ste 2040, Oklahoma City, OK 73104, USA
| | - Salah G Keyrouz
- Department of Neurology, Washington University School of Medicine, 660 South Euclid Avenue, Box 8111, St Louis, MO 63110, USA
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Teo KC, Mahboobani NR, Lee R, Siu CW, Cheung RTF, Ho SL, Lau KK, Chan KH. Warfarin associated intracerebral hemorrhage in Hong Kong Chinese. Neurol Res 2013; 36:143-9. [DOI: 10.1179/1743132813y.0000000275] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Abstract
Currently, recombinant activated factor VII (rFVIIa) (NovoSeven) is indicated for the treatment of spontaneous and surgical bleeding in congenital haemophilia A and B patients with inhibitors to factors VIII (FVIII) and IX (FIX) >5 Bethesda units (BU) worldwide, and in patients with acquired haemophilia, congenital FVII deficiency and Glanzmann's thrombasthenia in Europe. Until April 2003, almost three-quarters of a milion doses of rFVIIa have been administered proving its efficacy and excellent safety record. According to results from initial clinical trials and a large number of case reports, the rFVIIa may be effective not only in treating haemophilia patients but also in treatment of bleeding in patients on oral anticoagulation or heparin, patients with liver diseases, von Willebrand disease (vWD), thrombocytopenia, various platelet defects, congenital or acquired deficiency of FVII, and in subjects without any pre-existing coagulopathy with diffuse life-threatening bleeding triggered by surgery or trauma. This review will briefly summarize rFVIIa mode of action in haemostasis, the current clinical experience with rFVIIa and focus on the alternative use of rFVIIa in patients at the high risk of bleeding in both spontaneous cases and clinical trials reports.
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Affiliation(s)
- Peter Kubisz
- Department of Hematology and Blood Transfusion, Jessenius Medical School of Comenius University, Martin, Slovakia.
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Frumkin K. Rapid reversal of warfarin-associated hemorrhage in the emergency department by prothrombin complex concentrates. Ann Emerg Med 2013; 62:616-626.e8. [PMID: 23829955 DOI: 10.1016/j.annemergmed.2013.05.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 05/23/2013] [Accepted: 05/29/2013] [Indexed: 10/26/2022]
Abstract
Life-threatening warfarin-associated hemorrhage is common, with a high mortality. In the United States, the most commonly used therapies--fresh frozen plasma and vitamin K--are slow and unpredictable and can result in volume overload. Outside of the United States, prothrombin complex concentrates are often used instead; these pooled plasma products reverse warfarin anticoagulation in minutes rather than hours. This article reviews the literature relating to warfarin reversal with fresh frozen plasma, prothrombin complex concentrates, and recombinant factor VIIa and provides elements for a management protocol based on this literature.
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Affiliation(s)
- Kenneth Frumkin
- Emergency Medicine Department, Naval Medical Center Portsmouth, VA.
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Nitzki-George D, Wozniak I, Caprini JA. Current State of Knowledge on Oral Anticoagulant Reversal Using Procoagulant Factors. Ann Pharmacother 2013; 47:841-55. [DOI: 10.1345/aph.1r724] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE: To discuss current trends and challenges in the use of procoagulants for treating bleeding caused by use of oral anticoagulants. DATA SOURCES: Literature searches of PubMed (MEDLINE), Google, and Medscape were conducted in February 2013. There were no date limitations. Search terms included anticoagulation agents, anticoagulation reversal, anticoagulation reversal agents, apixaban, clinical studies, dabigatran, 3-factor PCCs, 4-factor PCCs, FEIBA, fresh frozen plasma, human studies, pharmacology, prescribing information, rFVIIa, rivaroxaban, vitamin K, and warfarin. DATA SYNTHESIS: Warfarin has been the mainstay for the treatment and prevention of primary and secondary thrombosis in patients with cardiovascular disorders such as atrial fibrillation, deep vein thrombosis, pulmonary embolism, and stroke. Three oral anticoagulants have recently become available in the US: a direct thrombin inhibitor, dabigatran etexilate, and 2 direct factor Xa inhibitors, rivaroxaban and apixaban. Reversal strategies for anticoagulant-associated bleeding are well established for warfarin; however, strategies to stop bleeding in a patient who has taken one of the newer anticoagulants are less clear. In the US, agents available for oral anticoagulant reversal include activated prothrombin complex concentrate (APCC), 3-factor PCCs, and recombinant activated factor VII (rFVIIa). Few studies have evaluated the 3-factor PCCs, and current evidence for APCC and rFVIIa as reversal agents for dabigatran and rivaroxaban is based primarily on laboratory or animal studies, or on small studies in healthy humans and case reports. CONCLUSIONS: Patients contemplating using the new oral anticoagulants should be informed about specific clinical situations that could pose a bleeding risk such as the need for emergency surgery because no reliable antidote is available to stop the bleeding, which could prove fatal.
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Affiliation(s)
- Diane Nitzki-George
- Diane Nitzki-George PharmD, Clinical Specialist, Anticoagulation Clinic, NorthShore University HealthSystem, Glenbrook Hospital, Glenview, IL
| | - Izabela Wozniak
- Izabela Wozniak PharmD, Clinical Specialist, NorthShore University HealthSystem, Evanston Hospital, Evanston, IL
| | - Joseph A Caprini
- Joseph A Caprini MD MS FACS RVT, Clinical Professor of Surgery, Pritzker School of Medicine, The University of Chicago, Chicago, IL
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da Silva IRF, Provencio JJ. Intracerebral hemorrhage in patients receiving oral anticoagulation therapy. J Intensive Care Med 2013; 30:63-78. [PMID: 23753250 DOI: 10.1177/0885066613488732] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Intracerebral hemorrhage (ICH) in patients with oral anticoagulation therapy is an increasingly prevalent problem in large part due to the aging population and the increased use of anticoagulants for patients at high risk of thrombosis. Warfarin has been virtually the only outpatient anticoagulant choice until fairly recently. The development of subcutaneously injected heparinoids, and more recently, of direct thrombin inhibitors, has made the treatment and prognostication of ICH in anticoagulated patients more difficult. In this review, we will review the current state of diagnosis, prognostication, and treatment for patients with this often-devastating type of bleeding. We will focus on warfarin therapy, because the preponderance of evidence comes from studies of warfarin treatment. Where there is evidence, we will contrast warfarin with some of the newer treatment modalities. We review the evidence of the 4 major reversal agents for warfarin, vitamin K, prothrombin complex concentrates, activated factor VII, and fresh frozen plasma as well as rational treatment choices. We offer possible treatments for the newer anticoagulants based on the limited evidence available. Finally, we review recommendations from the major societies and studies that support early and aggressive therapies in intensive care units with dedicated neurological specialists.
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Affiliation(s)
| | - J Javier Provencio
- Neurointensive Care Unit, Cerebrovascular Center, Cleveland Clinic, Cleveland, OH, USA Neuroinflammation Research Center, Cleveland Clinic, Cleveland, OH, USA
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H-Y CS, Xuemei C, G KR, M BL, V HG, A SF, K FS. Thromboembolic risks of recombinant factor VIIa Use in warfarin-associated intracranial hemorrhage: a case-control study. BMC Neurol 2012; 12:158. [PMID: 23241423 PMCID: PMC3538560 DOI: 10.1186/1471-2377-12-158] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Accepted: 11/19/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recombinant factor VIIa (rFVIIa) may be used for rapid hemostasis in life-threatening hemorrhage. In warfarin-associated intracerebral hemorrhage (wICH), FVIIa use is controversial and may carry significant thromboembolic risks. We compared incidence of baseline thromboembolic risk factors and thromboembolism rates in wICH patients treated with additional rFVIIa to those treated with standard therapy of fresh frozen plasma (FFP) and vitamin K alone. METHODS We identified 45 consecutive wICH patients treated with additional rFVIIa over 5-year period, and 34 consecutive wICH patients treated with standard therapy alone as comparison group. We compared the incidence of post-hemorrhage cardiac and extra-cardiac thromboembolic complications between two treatment groups, and used logistic regression to adjust for significant confounders such as baseline thromboembolic risk factors. We performed secondary analysis comparing the quantity of FFP transfused between two treatment cohorts. RESULTS Both rFVIIa-treated and standard therapy-treated wICH patients had a high prevalence of pre-existing thromboembolic diseases including atrial fibrillation (73% vs 68%), deep venous thrombosis (DVT) or pulmonary embolism (PE) (22% vs 18%), coronary artery disease (CAD) (38% vs 32%), and abnormal electrocardiogram (EKG) (78% vs 85%). Troponin elevation following wICH was prevalent in both groups (47% vs 41%). Clinically significant myocardial infarction (MI), defined as troponin > 1.0 ng/dL, occurred in 13% of rFVIIa-treated and 6% of standard therapy-treated patients (p=0.52). Past history of CAD (p=0.0061) and baseline abnormal EKG (p=0.02) were independently associated with clinically significant MI following wICH while rFVIIa use was not. The incidences of DVT/PE (2% vs 9%; p=0.18) and ischemic stroke (2% vs 0%; p=0.38) were similar between two treatment groups. Recombinant FVIIa-treated patients had lower mean INR at 3 (p=0.0001) and 6 hours (p<0.0001) and received fewer units of FFP transfusion (3 vs 5; p=0.003). CONCLUSIONS Pre-existing thromboembolic risk factors as well as post-hemorrhage troponin elevation are prevalent in wICH patients. Clinically significant MI occurs in up to 13% of wICH patients. rFVIIa use was not associated with increased incidence of clinically significant MI or other venous or arterial thromboembolic events in this wICH cohort.
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Affiliation(s)
- Chou Sherry H-Y
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA.
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Emergency reversal of anticoagulation with vitamin K antagonists with 3-factor prothrombin complex concentrates in patients with major bleeding. J Thromb Thrombolysis 2012; 36:102-8. [DOI: 10.1007/s11239-012-0817-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Zareh M, Davis A, Henderson S. Reversal of warfarin-induced hemorrhage in the emergency department. West J Emerg Med 2012; 12:386-92. [PMID: 22224125 PMCID: PMC3236169 DOI: 10.5811/westjem.2011.3.2051] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Revised: 09/22/2010] [Accepted: 03/21/2011] [Indexed: 11/11/2022] Open
Abstract
Warfarin, an oral vitamin K antagonist, is used to prevent arterial and venous thromboembolism in patients suffering from a multitude of diseases. In 2004, 31 million warfarin prescriptions were dispensed in the United States. Warfarin inhibits the activation of the vitamin K-dependent clotting factors (Factors II, VII, IX, and X) and regulatory proteins (proteins C, S, and Z). It is one of the leading drugs implicated in emergency room visits for adverse drug reactions. Annually the frequency of bleeding complications associated with overanticoagulation is 15% to 20%, with fatal bleeds measuring as high as 1% to 3%. The most effective method of warfarin reversal involves the use of Four Factor Prothrombin Complex Concentrate (PCC), which is widely used throughout Europe but is unavailable in the United States. The current therapies available to emergency room physicians in the United States are fresh frozen plasma, recombinant Factor VIIa (rFVIIa), Factor Eight Inhibitory Bypassing Activity, or Three Factor PCC concomitantly administered with vitamin K. We review the advantages and disadvantages of these therapies and recommend Three Factor PCC with small doses of rFVIIa and with vitamin K in life-threatening situations if Four Factor PCC is unavailable.
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Affiliation(s)
- Meena Zareh
- Department of Emergency Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
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Rincon F, Mayer SA. Intracerebral hemorrhage: clinical overview and pathophysiologic concepts. Transl Stroke Res 2012; 3:10-24. [PMID: 24323860 DOI: 10.1007/s12975-012-0175-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Revised: 04/09/2012] [Accepted: 04/11/2012] [Indexed: 10/28/2022]
Abstract
Intracerebral hemorrhage is by far the most destructive form of stroke. Apart from the management in a specialized stroke or neurological intensive care unit (NICU), no specific therapies have been shown to consistently improve outcomes after ICH. Current guidelines endorse early aggressive optimization of physiologic derangements with ventilatory support when indicated, blood pressure control, reversal of any preexisting coagulopathy, intracranial pressure monitoring for certain cases, osmotherapy, temperature modulation, seizure prophylaxis, treatment of hyerglycemia, and nutritional support in the stroke unit or NICU. Ventriculostomy is the cornerstone of therapy for control of intracranial pressure patients with intraventricular hemorrhage. Surgical hematoma evacuation does not improve outcome for more patients, but is a reasonable option for patients with early worsening due to mass effect due to large cerebellar or lobar hemorrhages. Promising experimental treatments currently include ultra-early hemostatic therapy, intraventricular clot lysis with thrombolytics, pioglitazone, temperature modulation, and deferoxamine to reduce iron-mediated perihematomal inflammation and tissue injury.
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Affiliation(s)
- Fred Rincon
- Department of Neurology and Neurosurgery, Division of Critical Care and Neurotrauma, Thomas Jefferson University, Philadelphia, PA, USA
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Panduranga P, Al-Mukhaini M, Al-Muslahi M, Haque MA, Shehab A. Management dilemmas in patients with mechanical heart valves and warfarin-induced major bleeding. World J Cardiol 2012; 4:54-9. [PMID: 22451852 PMCID: PMC3312231 DOI: 10.4330/wjc.v4.i3.54] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Revised: 03/20/2012] [Accepted: 03/23/2012] [Indexed: 02/06/2023] Open
Abstract
Management of warfarin-induced major bleeding in patients with mechanical heart valves is challenging. There is vast controversy and confusion in the type of treatment required to reverse anticoagulation and stop bleeding as well as the ideal time to restart warfarin therapy safely without recurrence of bleeding and/or thromboembolism. Presently, the treatments available to reverse warfarin-induced bleeding are vitamin K, fresh frozen plasma, prothrombin complex concentrates and recombinant activated factor VIIa. Currently, vitamin K and fresh frozen plasma are the recommended treatments in patients with mechanical heart valves and warfarin-induced major bleeding. The safe use of prothrombin complex concentrates and recombinant activated factor VIIa in patients with mechanical heart valves is controversial and needs well-designed clinical studies. With regard to restarting anticoagulation in patients with warfarin-induced major bleeding and mechanical heart valves, the safe period varies from 7-14 d after the onset of bleeding for patients with intracranial bleed and 48-72 h for patients with extra-cranial bleed. In this review article, we present relevant literature about these controversies and suggest recommendations for management of patients with warfarin-induced bleeding and a mechanical heart valve. Furthermore, there is an urgent need for separate specific guidelines from major associations/ professional societies with regard to mechanical heart valves and warfarin-induced bleeding.
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Affiliation(s)
- Prashanth Panduranga
- Prashanth Panduranga, Mohammed Al-Mukhaini, Department of Cardiology, Royal Hospital, PB 1331, Muscat-111, Oman
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Bhagirath VC, O'Malley L, Crowther MA. Management of bleeding complications in the anticoagulated patient. Semin Hematol 2012; 48:285-94. [PMID: 22000094 DOI: 10.1053/j.seminhematol.2011.08.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
As new anticoagulants become available, and the number of anticoagulated patients continues to rise, it is necessary to know how to deal with associated bleeding complications. In this review, reversal strategies for traditional anticoagulants (warfarin and heparin) as well as newer anticoagulants are described. Prothrombin complex concentrates (PPCs) can be used to reverse vitamin K antagonists (VKA), and plasma may be used where they are not available. Recombinant activated factor VII (rFVIIa) may be useful to reverse pentasaccharide anticoagulants. 1-Desamino-8-D-arginine vasopressin (DDAVP), cryoprecipitate, PCCs, and dialysis may help to reverse direct thrombin inhibitors, while rFVIIa seems to be ineffective. The effect of direct factor Xa inhibitors may be reversed by PCCs, FVIIa, or factor Xa concentrates.
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Singh SP, Chauhan S, Choudhary M, Vasdev S, Talwar S. Recombinant activated factor VII for hemorrhage after pediatric cardiac surgery. Asian Cardiovasc Thorac Ann 2012; 20:19-23. [DOI: 10.1177/0218492311432584] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Postoperative bleeding is a common complication after pediatric cardiac surgery. Use of recombinant activated factor VII for intractable hemorrhage after cardiac, pediatric, and neurosurgery has been shown to decrease postoperative bleeding, but data in children are limited. This retrospective study analyzed 20 children <15 years-old who underwent cardiac surgery and received recombinant activated factor VII for refractory postoperative hemorrhage. All patients underwent mediastinal reexploration before recombinant activated factor VII was administered as a bolus dose over 2–3 min as rescue therapy. If no significant decrease in chest tube drainage was observed, the dose was repeated after an interval of at least 2 h. The median dose of recombinant activated factor VII administered per bleeding episode was 83.33 µg·kg−1 (range, 72.47–87.50 µg·kg−1), and the dose per patient was 154.16 µg·kg−1 (range, 93.06–180.52 µg·kg−1). The median number of doses found to be effective in these children was 1.76. There were significant decreases in mediastinal chest tube drainage and the volume of packed red blood cells, platelet concentrates, and cryoprecipitate administered after recombinant activated factor VII. No complications were observed during the therapy.
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Affiliation(s)
- Sarvesh Pal Singh
- Department of Cardiac Anesthesia, Cardio-Thoracic Sciences Center, All India Institute of Medical Sciences, New Delhi, India
| | - Sandeep Chauhan
- Department of Cardiac Anesthesia, Cardio-Thoracic Sciences Center, All India Institute of Medical Sciences, New Delhi, India
| | - Minati Choudhary
- Department of Cardiac Anesthesia, Cardio-Thoracic Sciences Center, All India Institute of Medical Sciences, New Delhi, India
| | - Sumit Vasdev
- Department of Cardiac Anesthesia, Cardio-Thoracic Sciences Center, All India Institute of Medical Sciences, New Delhi, India
| | - Sachin Talwar
- Department of Cardio-Thoracic and Vascular Surgery, Cardio-Thoracic Sciences Center, All India Institute of Medical Sciences, New Delhi, India
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Treatments for reversing warfarin anticoagulation in patients with acute intracranial hemorrhage: a structured literature review. Int J Emerg Med 2011; 4:40. [PMID: 21740550 PMCID: PMC3141388 DOI: 10.1186/1865-1380-4-40] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Accepted: 07/08/2011] [Indexed: 12/01/2022] Open
Abstract
Study objective The acute management of patients on warfarin with spontaneous or traumatic intracranial hemorrhage continues to be debated in the medical literature. The objective of this paper was to conduct a structured review of the medical literature and summarize the advantages and risks of the available treatment options for reversing warfarin anticoagulation in patients who present to the emergency department with acute intracranial hemorrhage. Methods A structured literature search and review of articles relevant to intracranial hemorrhage and warfarin and treatment in the emergency department was performed. Databases for PubMed, CINAHL, and Cochrane EBM Reviews were electronically searched using keywords covering the concepts of anticoagulation drugs, intracranial hemorrhage (ICH), and treatment. The results generated by the search were limited to English- language articles and reviewed for relevance to our topic. The multiple database searches revealed 586 papers for review for possible inclusion. The final consensus of our comprehensive search strategy was a total of 23 original studies for inclusion in our review. Results Warfarin not only increases the risk of but also the severity of ICH by causing hematoma expansion. Prothrombin complex concentrate is statistically significantly faster at correcting the INR compared to fresh frozen plasma transfusions. Recombinant factor VIIa appears to rapidly reverse warfarin's effect on INR; however, this treatment is not FDA-approved and is associated with a 5% thromboembolic event rate. Slow intravenous dosing of vitamin K is recommended in patients with ICH. The 30-day risk for ischemic stroke after discontinuation of warfarin therapy was 3-5%. The risks of not reversing the anticoagulation in ICH generally outweigh the risk of thrombosis in the acute setting. Conclusions Increasing numbers of patients are on anticoagulation including warfarin. There is no uniform standard for reversing warfarin in intracranial hemorrhage. Intravenous vitamin K in addition to fresh frozen plasma or prothrombin complex concentrate is recommended be used to reverse warfarin-associated intracranial hemorrhage. No mortality benefit for one treatment regimen over another has been shown. Emergency physicians should know their hospital's available warfarin reversal options and be comfortable administering these treatments to critically ill patients.
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Pinner NA, Hurdle AC, Oliphant C, Reaves A, Lobo B, Sills A. Treatment of warfarin-related intracranial hemorrhage: a comparison of prothrombin complex concentrate and recombinant activated factor VII. World Neurosurg 2011; 74:631-5. [PMID: 21492631 DOI: 10.1016/j.wneu.2010.06.030] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2009] [Accepted: 06/14/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Warfarin-related intracranial hemorrhage (ICH) is a devastating complication of warfarin therapy. Several studies have demonstrated successful correction of the international normalized ratio (INR) using prothrombin complex concentrate (PCC) or recombinant activated factor VII (rFVIIa). To our knowledge, no study has directly compared these agents for treatment of warfarin-related ICH. METHODS We retrospectively reviewed the charts of 15 patients who received rFVIIa and 9 who received PCC for treatment of warfarin-related ICH over a 2-year period. The primary objective was to compare the efficacy of rFVIIa and PCC in correcting the INR to 1.3 or less. Baseline INR was compared to INR obtained within 1, 3, 6, 12, and 24 hours after rFVIIa or PCC administration. RESULTS Six patients in the rFVIIa group and five in the PCC group had a follow-up INR within 1 hour of agent administration. In the rFVIIa group, the mean INR decreased from 6.1 to 1.1 and from 2.3 to 1.48 in the PCC group. At 6 hours, all rFVIIa patients and six (67%) PCC patients had at least one subsequent INR, with 93% and 50% correcting to an INR of 1.3 or less. Mean dose for all patients included was 53.4 ± 17.5 μg/kg and 27.8 ± 15.4 units/kg for rFVIIa and PCC, respectively. CONCLUSION Correction of the INR is more reliably obtained with rFVIIa when compared to PCC. Larger, prospective studies comparing these therapies for warfarin-related ICH are needed.
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Affiliation(s)
- Nathan A Pinner
- Department of Pharmacy Practice, Auburn University, Tuscaloosa, Alabama, USA.
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Abstract
Abstract
Intracerebral hemorrhage in patients with warfarin-associated coagulopathy is an increasingly common life-threatening condition that requires emergent management. The evolution of therapeutic options in this setting, as well as recently published guidelines, has resulted in some heterogeneity in recommendations by professional societies. This heterogeneity can be attributed to lack of evidence-based support for plasma therapy; the variability in availability of prothrombin complex concentrates; the variability in the coagulation factor levels and contents of prothrombin complex concentrates; ambiguity about the optimal dose and route of administration of vitamin K; and the lack of standardized clinical care pathways, particularly in community hospitals, for the management of these critical care patients. In this review, we summarize the relevant literature about these controversies and present recommendations for management of patients with warfarin-associated coagulopathy and intracerebral hemorrhage.
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Dubourg J, Messerer M. State of the art in managing nontraumatic intracerebral hemorrhage. Neurosurg Focus 2011; 30:E22. [DOI: 10.3171/2011.3.focus1145] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Nontraumatic intracerebral hemorrhage constitutes a major public health problem worldwide. Intracerebral hemorrhage leads to a high rate of morbidity and mortality. To date, no medical or surgical trials have clearly attested to the benefit of a particular therapy. The aim of this review was to summarize the best evidence for management decision-making in intracerebral hemorrhage.
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Affiliation(s)
- Julie Dubourg
- 1Centre d'Investigation Clinique CIC201, EPICIME, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Claude Bernard Lyon 1; and
| | - Mahmoud Messerer
- 2Département de Neurochirurgie A, Hôpital Neurologique Pierre Wertheimer, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Claude Bernard Lyon, Lyon, France
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Masotti L, Di Napoli M, Godoy DA, Rafanelli D, Liumbruno G, Koumpouros N, Landini G, Pampana A, Cappelli R, Poli D, Prisco D. The practical management of intracerebral hemorrhage associated with oral anticoagulant therapy. Int J Stroke 2011; 6:228-40. [PMID: 21557810 DOI: 10.1111/j.1747-4949.2011.00595.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Oral anticoagulant-associated intracerebral hemorrhage is increasing in incidence and is the most feared complication of therapy with vitamin K1 antagonists. Anticoagulant-associated intracerebral hemorrhage has a high risk of ongoing bleeding, death, or disability. The most important aspect of clinical management of anticoagulant-associated intracerebral hemorrhage is represented by urgent reversal of coagulopathy, decreasing as quickly as possible the international normalized ratio to values ≤1·4, preferably ≤1·2, together with life support and surgical therapy, when indicated. Protocols for anticoagulant-associated intracerebral hemorrhage emphasize the immediate discontinuation of anticoagulant medication and the immediate intravenous administration of vitamin K1 (mean dose: 10-20 mg), and the use of prothrombin complex concentrates (variable doses calculated estimate circulating functional prothrombin complex) or fresh-frozen plasma (15-30 ml/kg) or recombinant activated factor VII (15-120 μg/kg). Because of cost and availability, there is limited randomized evidence comparing different reversal strategies that support a specific treatment regimen. In this paper, we emphasize the growing importance of anticoagulant-associated intracerebral hemorrhage and describe options for acute coagulopathy reversal in this setting. Additionally, emphasis is placed on understanding current consensus-based guidelines for coagulopathy reversal and the challenges of determining best evidence for these treatments. On the basis of the available knowledge, inappropriate adherence to current consensus-based guidelines for coagulopathy reversal may expose the physician to medico-legal implications.
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Affiliation(s)
- Luca Masotti
- Internal Medicine, Cecina Hospital, Cecina, Italy Neurological Service, San Camillo de' Lellis General Hospital, Rieti, Italy.
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Hall AB, Carson BC. Reversal of warfarin-induced coagulopathy: review of treatment options. J Emerg Nurs 2011; 38:98-101. [PMID: 21474171 DOI: 10.1016/j.jen.2010.12.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2010] [Revised: 12/01/2010] [Accepted: 12/10/2010] [Indexed: 01/21/2023]
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Končar IB, Davidović LB, Savić N, Sinđelić RB, Ilić N, Dragas M, Markovic M, Kostic D. Role of recombinant factor VIIa in the treatment of intractable bleeding in vascular surgery. J Vasc Surg 2011; 53:1032-7. [DOI: 10.1016/j.jvs.2010.07.075] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2009] [Revised: 05/05/2010] [Accepted: 07/18/2010] [Indexed: 02/05/2023]
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Emergency reversal of anticoagulation with a three-factor prothrombin complex concentrate in patients with intracranial haemorrhage. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2011; 9:148-55. [PMID: 21251465 DOI: 10.2450/2011.0065-10] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Accepted: 12/20/2010] [Indexed: 11/21/2022]
Abstract
BACKGROUND Intracranial haemorrhage is a serious and potentially fatal complication of oral anticoagulant therapy. Prothrombin complex concentrates can substantially shorten the time needed to reverse the effects of oral anticoagulants. The aim of this study was to determine the efficacy and safety of a prothrombin complex concentrate for rapid reversal of oral anticoagulant therapy in patients with intracranial haemorrhage. METHODS Patients receiving oral anticoagulant therapy and suffering from acute intracranial haemorrhage were eligible for this prospective cohort study if their International Normalised Ratio (INR) was higher than or equal to 2.0. The prothrombin complex concentrate was infused at doses of 35-50 IU/kg, stratified according to the initial INR. RESULTS Forty-six patients (25 males; mean age: 75 years; range 38-92 years) were enrolled. The median INR at presentation was 3.5 (range, 2-9). At 30 minutes after administration of the prothrombin complex concentrate, the median INR was 1.3 (range, 0.9-3), and the INR then declined to less than or equal to 1.5 in 75% of patients. The benefit of the prothrombin complex concentrate was maintained for a long time, since the median INR remained lower than or equal to 1.5 (median, 1.16; range, 0.9-2.2) at 96% of all post-infusion time-points up to 96 hours. No thrombotic complications or significant adverse events were observed during hospitalisation; six patients (13%) died, but none of these deaths was judged to be related to administration of the prothrombin complex concentrate. CONCLUSIONS Prothrombin complex concentrates are an effective, rapid and safe treatment for the urgent reversal of oral anticoagulation in patients with intracranial haemorrhage. Broader use of prothrombin complex concentrates in this clinical setting appears to be appropriate.
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Sørensen B, Spahn DR, Innerhofer P, Spannagl M, Rossaint R. Clinical review: Prothrombin complex concentrates--evaluation of safety and thrombogenicity. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:201. [PMID: 21345266 PMCID: PMC3222012 DOI: 10.1186/cc9311] [Citation(s) in RCA: 212] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Prothrombin complex concentrates (PCCs) are used mainly for emergency reversal of vitamin K antagonist therapy. Historically, the major drawback with PCCs has been the risk of thrombotic complications. The aims of the present review are to examine thrombotic complications reported with PCCs, and to compare the safety of PCCs with human fresh frozen plasma. The risk of thrombotic complications may be increased by underlying disease, high or frequent PCC dosing, and poorly balanced PCC constituents. The causes of PCC thrombogenicity remain uncertain but accumulating evidence indicates the importance of factor II (prothrombin). With the inclusion of coagulation inhibitors and other manufacturing improvements, today's PCCs may be considered safer than earlier products. PCCs may be considered preferable to fresh frozen plasma for emergency anticoagulant reversal, and this is reflected in the latest British and American guidelines. Care should be taken to avoid excessive substitution with prothrombin, however, and accurate monitoring of patients' coagulation status may allow thrombotic risk to be reduced. The risk of a thrombotic complication due to treatment with PCCs should be weighed against the need for rapid and effective correction of coagulopathy.
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Affiliation(s)
- Benny Sørensen
- Haemostasis Research Unit, Centre for Haemostasis and Thrombosis, Department of Haematology and Oncology, Guy's and St Thomas' Hospital & NHS Trust Foundation, King's College London School of Medicine, 1st Floor, North Wing, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK.
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Rama-Maceiras P, Ingelmo-Ingelmo I, Fàbregas-Julià N, Hernández-Palazón J. Rol del factor VII recombinante activado en pacientes neuroquirúrgicos y neurocríticos. Neurocirugia (Astur) 2011. [DOI: 10.1016/s1130-1473(11)70016-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Bal S, Ojha P, Hill MD. Stroke prevention treatment of patients with atrial fibrillation: old and new. Curr Neurol Neurosci Rep 2010; 11:15-27. [PMID: 21086074 DOI: 10.1007/s11910-010-0161-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Atrial fibrillation is the most common cause of cardioembolic ischemic stroke and has a rising prevalence worldwide. Stroke prevention in this condition is poised to take a substantial leap forward with the evolution of new anticoagulant medications, with superior properties compared to vitamin K antagonists. New, safer and more effective chronic therapy is on the horizon. However, many issues surrounding the management of stroke prevention after an acute stroke and during the course of chronic anticoagulant therapy remain to be resolved.
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Affiliation(s)
- Simerpreet Bal
- Departments of Clinical Neurosciences, Calgary Stroke Program, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
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Abstract
Thrombophilias, an inherited and/or acquired predisposition to vascular thrombosis beyond hemostatic needs are common in cardiovascular medicine and include systemic disorders such as coronary atherosclerosis, atrial fibrillation, exogenous obesity, metabolic syndrome, collagen vascular disease, human immunodeficiency virus, blood replacement therapy and several commonly used medications. A contemporary approach to patients with suspected thrombophilias, in addition to a very selective investigation for gain-of-function and loss-of-function gene mutations affecting thromboresistance, must consider prevalent diseases and management decisions encountered regularly by cardiologists in clinical practice. An appropriate recognition of common disease states as thrombophilias will also stimulate platforms for much needed scientific investigation.
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Affiliation(s)
- Richard C Becker
- Divisions of Cardiology and Hematology, Duke University School of Medicine, Duke Clinical Research Institute, 2400 Pratt Street, DUMC 3850, Durham, NC 27705, USA.
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Abstract
The use of warfarin has a well-known bleeding risk. Recombinant activated factor VII (rFVIIa) is a non–plasma-derived, rapid-acting, and rapidly infused potential treatment. This randomized, single-center, placebo-controlled, double-blinded, dose-escalation, exploratory phase 1 trial assessed safety and effects of rFVIIa in reversing warfarin-induced changes in bleeding and coagulation parameters, using a punch biopsy–induced bleeding model in healthy subjects. The effects of warfarin (experiment 1) and rFVIIa (5-80 μg/kg; experiment 2) were evaluated. Outcomes were bleeding duration, blood loss, coagulation parameters, and safety. Warfarin treatment significantly increased bleeding duration and blood loss from pretreatment (experiment 1, 12 subjects). However, these parameters after rFVIIa treatment were not significantly different from placebo (experiment 2, 85 subjects). Mean activated partial thromboplastin time, prothrombin time, and international normalized ratio were reduced from warfarin-elevated levels. rFVIIa (80 μg/kg) significantly reversed warfarin effects on all thromboelastography parameters, compared with placebo (P < .05), and returned the thrombin generation speed to baseline. There were no thromboembolic or serious adverse events. In this exploratory trial, the reversal of warfarin effects was observed in the thromboelastography, thrombin generation, and clotting assays. However, this reversal did not translate to improvements in the bleeding model parameters evaluated in the punch biopsy model. Trial registration is exempt (phase 1).
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Morgenstern LB, Hemphill JC, Anderson C, Becker K, Broderick JP, Connolly ES, Greenberg SM, Huang JN, MacDonald RL, Messé SR, Mitchell PH, Selim M, Tamargo RJ. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2010; 41:2108-29. [PMID: 20651276 DOI: 10.1161/str.0b013e3181ec611b] [Citation(s) in RCA: 993] [Impact Index Per Article: 70.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of acute spontaneous intracerebral hemorrhage. METHODS A formal literature search of MEDLINE was performed. Data were synthesized with the use of evidence tables. Writing committee members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Statements Oversight Committee and Stroke Council Leadership Committee. It is intended that this guideline be fully updated in 3 years' time. RESULTS Evidence-based guidelines are presented for the care of patients presenting with intracerebral hemorrhage. The focus was subdivided into diagnosis, hemostasis, blood pressure management, inpatient and nursing management, preventing medical comorbidities, surgical treatment, outcome prediction, rehabilitation, prevention of recurrence, and future considerations. CONCLUSIONS Intracerebral hemorrhage is a serious medical condition for which outcome can be impacted by early, aggressive care. The guidelines offer a framework for goal-directed treatment of the patient with intracerebral hemorrhage.
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Robinson MT, Rabinstein AA, Meschia JF, Freeman WD. Safety of recombinant activated factor VII in patients with warfarin-associated hemorrhages of the central nervous system. Stroke 2010; 41:1459-63. [PMID: 20522813 DOI: 10.1161/strokeaha.110.581538] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Recombinant Factor VIIa decreases hematoma growth after spontaneous intracerebral hemorrhage (ICH) and rapidly decreases international normalized ratios in patients on warfarin but is also associated with an increased risk for thromboembolic complications. In this study, we assessed the risk of thromboembolic events in patients receiving recombinant Factor VIIa after ICH associated with warfarin treatment. METHODS We reviewed the medical charts, laboratory data, and radiological findings of consecutive patients with anticoagulation-related hemorrhages of the central nervous system who received recombinant Factor VIIa at Mayo Clinic Rochester and Mayo Clinic Florida between 2002 and 2009. The primary end point was the frequency of new thromboembolic events, including myocardial infarction, deep vein thrombosis, ischemic stroke, and pulmonary embolism. RESULTS We identified 101 patients; 54% had ICH and 30% subdural hematomas. The most common indications for anticoagulation were atrial fibrillation, deep vein thrombosis, and prosthetic valve. Thirteen patients (12.8%) had new thromboembolic events (10 deep vein thromboses and 3 ischemic strokes) within 90 days after recombinant Factor VIIa administration. Eight of these adverse events occurred within 2 weeks of treatment. In patients with ICH, the rate of thromboembolic complications was 5% and all events were venous. CONCLUSIONS The risk of thromboembolic events in patients who received recombinant Factor VIIa for anticoagulation-associated ICH was not higher than that seen in patients treated for spontaneous ICH in the Factor Seven for Acute Hemorrhagic Stroke (FAST) trial. Spontaneous deep vein thrombosis was the most common complication in our series.
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Evaluation of coagulation kinetics using thromboelastometry—methodologic influence of activator and test medium. Ann Hematol 2010; 89:1155-61. [DOI: 10.1007/s00277-010-0982-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Accepted: 04/29/2010] [Indexed: 10/19/2022]
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Rolfe S, Papadopoulos S, Cabral KP. Controversies of Anticoagulation Reversal in Life-Threatening Bleeds. J Pharm Pract 2010; 23:217-25. [DOI: 10.1177/0897190010362168] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Therapeutic anticoagulation with heparins, warfarin, and anti-Xa inhibitors carry an inherent risk of complications due to their multifaceted pharmacokinetic and pharmacodynamic properties as well as narrow therapeutic ranges. When an anticoagulated patient presents with a major or life-threatening bleed, immediate and effective therapy may be necessary to reverse the effects of the anticoagulant, minimize blood loss, and reduce patient morbidity and mortality. Optimal agents and strategies for anticoagulant reversal are limited, particularly for newer anticoagulants. The literature describing such strategies available to reverse the effects of anticoagulants in the setting of a bleed is limited, and therefore many controversies exist. Thus, as new anticoagulants become available, without a specific agent for reversal, the concerns and controversies related to this topic must be addressed. The purpose of this review is to discuss the management of major or life-threatening bleeds by addressing the following controversies: (1) the use of recombinant factor VIIa for rapid reversal of warfarin in patients with intracerebral hemorrhage, (2) the role of prothrombin complex concentrate in emergent warfarin reversal, and (3) the optimal approach to reverse newer anticoagulants such as low molecular weight heparins, fondaparinux, and direct thrombin inhibitors.
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Affiliation(s)
- Stephen Rolfe
- Department of Pharmacy, UMass Memorial Medical Center, Worcester, MA, USA
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Abstract
OBJECTIVE Acute intracranial hemorrhage and intraventricular hemorrhage are devastating disorders. The goal of this review is to familiarize clinicians with recent information pertaining to the acute care of intracranial hemorrhage and intraventricular hemorrhage. DATA SOURCES PubMed search and review of the relevant medical literature. SUMMARY The management of intracranial hemorrhage and intraventricular hemorrhage is complex. Effective treatment should include strategies designed to reduce hematoma expansion and limit the medical consequences of intracranial hemorrhage and intraventricular hemorrhage. At present, there are a number of new approaches to treatment that may reduce mortality and improve clinical outcomes. Clinicians should recognize that patients with large hematomas may make a substantial recovery. CONCLUSIONS Patients with intracranial hemorrhage and intraventricular hemorrhage should be cared for in an intensive care unit. New therapies designed to stabilize hematoma growth and reduce hematoma burden may improve outcomes.
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Affiliation(s)
- Paul Nyquist
- Neurology/Anesthesiology Critical Care Medicine/ Neurosurgery, Johns Hopkins School of Medicine, Baltimore Maryland, USA.
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Abstract
PURPOSE OF REVIEW Spontaneous intracerebral hemorrhage (ICH) is the most devastating type of stroke and a leading cause of disability and mortality in the United States and the rest of the world. The purpose of this article is to review recent advances in the management of spontaneous intracerebral hemorrhage. RECENT FINDINGS Although no interventions have consistently shown an improvement of mortality or functional outcomes after ICH, results from multicenter prospective randomized controlled trials have shown that early hemostasis to prevent hematoma growth, removal of clot by surgical or minimally invasive interventions, clearance of intraventricular hemorrhage, and adequate blood pressure control for the optimization of cerebral perfusion pressure may constitute the most important therapeutic goals to ameliorate secondary neurological damage, decrease mortality, and improve functional outcomes after ICH. CONCLUSION Several promising methods may be ready for routine clinical use in a few years to decrease disability and mortality from ICH.
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Rowe AS, Turner RM. Coagulation factor VIIa (recombinant) for warfarin-induced intracranial hemorrhage. Am J Health Syst Pharm 2010; 67:361-5. [DOI: 10.2146/ajhp080478] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- A. Shaun Rowe
- Department of Pharmacy Services, University of Tennessee Medical Center (UTMC), Knoxville
| | - Ryan M. Turner
- Department of Pharmacy, Saint Francis Hospital—Downtown, Greenville, SC; at the time of writing he was Postgraduate Year 1 Pharmacy Resident, Department of Pharmacy Services, UTMC
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Beshay JE, Morgan H, Madden C, Yu W, Sarode R. Emergency reversal of anticoagulation and antiplatelet therapies in neurosurgical patients. J Neurosurg 2010; 112:307-18. [PMID: 19663548 DOI: 10.3171/2009.7.jns0982] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intracranial hemorrhage (ICH) is a common problem encountered by neurosurgeons. Patient outcomes are influenced by hematoma size, growth, location, and the timing of evacuation, when indicated. Patients may have abnormal coagulation due to pharmacological anticoagulation or coagulopathy due to underlying systemic disease or blood transfusions. Strategies to reestablish the integrity of the clotting cascade and platelet function assume a familiarity with these processes. As patients are increasingly treated with anticoagulants and antiplatelet agents, it is essential that the physicians who care for patients with ICH understand these pathways and recognize how they can be manipulated to restore hemostasis.
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Affiliation(s)
- Joseph E Beshay
- Department of Neurological Surgery, University of Texas Southwestern, Dallas, Texas 75390, USA.
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Pontes-Neto OM, Oliveira-Filho J, Valiente R, Friedrich M, Pedreira B, Rodrigues BCB, Liberato B, Freitas GRD. Diretrizes para o manejo de pacientes com hemorragia intraparenquimatosa cerebral espontânea. ARQUIVOS DE NEURO-PSIQUIATRIA 2009; 67:940-50. [DOI: 10.1590/s0004-282x2009000500034] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2009] [Accepted: 08/15/2009] [Indexed: 01/24/2023]
Abstract
A hemorragia intraparenquimatosa cerebral (HIC) é o subtipo de AVC de pior prognóstico e com tratamento ainda controverso em diversos aspectos. O comitê executivo da Sociedade Brasileira de Doenças Cerebrovasculares, através de uma revisão ampla dos artigos publicados em revistas indexadas, elaborou sugestões e recomendações que são aqui descritas com suas respectivas classificações de níveis de evidência. Estas diretrizes foram elaboradas com o objetivo de prover o leitor de um racional para o manejo apropriado dos pacientes com HIC, baseado em evidências clínicas.
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47
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Gerlach R, Krause M, Seifert V, Goerlinger K. Hemostatic and hemorrhagic problems in neurosurgical patients. Acta Neurochir (Wien) 2009; 151:873-900; discussion 900. [PMID: 19557305 DOI: 10.1007/s00701-009-0409-z] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2007] [Accepted: 10/22/2008] [Indexed: 01/10/2023]
Abstract
BACKGROUND Abnormalities of the hemostasis can lead to hemorrhage, and on the other hand to thrombosis. Intracranial neoplasms, complex surgical procedures, and head injury have a specific impact on coagulation and fibrinolysis. Moreover, the number of neurosurgical patients on medication (which interferes with platelet function and/or the coagulation systems) has increased over the past years. METHOD The objective of this review is to recall common hemostatic disorders in neurosurgical patients on the basis of the "new concept of hemostasis". Therefore the pertinent literature was searched to provide a structured and up to date manuscript about hemostasis in Neurosurgery. FINDINGS According to recent scientific publications abnormalities of the coagulation system are discussed. Pathophysiological background and the rational for specific (cost)-effective perioperative hemostatic therapy is provided. CONCLUSIONS Perturbations of hemostasis can be multifactorial and maybe encountered in the daily practice of neurosurgery. Early diagnosis and specific treatment is the prerequisite for successful treatment and good patients outcome.
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Affiliation(s)
- Ruediger Gerlach
- Department of Neurosurgery, Johann Wolfgang Goethe University, Schleusenweg 2-16, 60528 Frankfurt am Main, Germany.
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48
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Hvitfeldt Poulsen L, Christiansen K, Sørensen B, Ingerslev J. Whole blood thrombelastographic coagulation profiles using minimal tissue factor activation can display hypercoagulation in thrombosis‐prone patients. Scandinavian Journal of Clinical and Laboratory Investigation 2009; 66:329-36. [PMID: 16777761 DOI: 10.1080/00365510600672783] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Recently, our laboratory devised a dynamic whole blood (WB) thrombelastographic coagulation model employing activation with minute amounts of tissue factor. A series of studies were conducted to validate the feasibility of the model to illustrate hypocoagulation in various bleeding disorders and its usefulness in detecting the haemostatic effect of pro-coagulants by ex vivo titration experiments. In this context, the present study hypothesized that the thrombelastographic model also can reveal hypercoagulation. Hence, the objective of the present study was to record dynamic WB coagulation profiles in a series of patients (n=76) who had previously suffered from a venous (n=34) or arterial (n=42) thrombo-embolic event and to compare the results with those of a group of healthy reference subjects (n=60). MATERIAL AND METHODS Patients receiving vitamin K antagonist treatment were not enrolled in the study. Forty-four of the patients had no known thrombophilia risk factor and 32 patients had at least one thrombophilia risk factor. RESULTS The most commonly found risk factors were mild hyperhomocysteinaemia and heterozygosity for the factor V Leiden polymorphism. The data showed that, as compared with the healthy controls, patients with a history of venous or arterial thromboembolism had a significantly greater hypercoagulant WB coagulation clot signature as defined by a shortened clotting time together with an accelerated maximum velocity of clot propagation. CONCLUSIONS In future studies with ex vivo dose titration assessment of pro-coagulant components mixed with blood from a patient suffering from compromised haemostasis, observation of a significantly shortened clot initiation concomitant with a distinctly accelerated clot propagation is likely to indicate an increased risk of thrombosis.
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Affiliation(s)
- L Hvitfeldt Poulsen
- Centre for Haemophilia and Thrombosis, Department of Biochemistry, Aarhus University Hospital, Skejby, Denmark
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49
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Abstract
Vitamin K antagonists are effective in the prevention and treatment of a variety of arterial and venous thrombotic disorders, but are associated with an increased risk of serious bleeding complications. According to well documented studies of patients using vitamin K antagonists, the incidence of major bleeding is 0.5% per year and the incidence of intracranial bleeding is 0.2% per year, however, in real life practice this incidence may be even higher. Risk factors for bleeding are the intensity of anticoagulation, the management strategy to keep the INR in the desired range, and patient characteristics. In case of serious bleeding complications in a patient who uses vitamin K antagonists, this anticoagulant treatment can be quickly reversed by administration of vitamin K or coagulation factor concentrates.
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Affiliation(s)
- M Levi
- Department of Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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50
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Aiyagari V. CORRECTION OF COAGULOPATHY SECONDARY TO ORAL AND PARENTERAL ANTICOAGULANTS. Continuum (Minneap Minn) 2009. [DOI: 10.1212/01.con.0000348823.04125.eb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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