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Olsen M, Adie SK, Divens A, Popova K, Brancaccio A. Low-Intensity Heparin Infusion Compared With High-Intensity Heparin Infusion Dosing in Patients With Mechanical Mitral Valves: A Retrospective Cohort Study. J Cardiovasc Pharmacol 2024; 84:383-388. [PMID: 39027972 DOI: 10.1097/fjc.0000000000001608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 06/15/2024] [Indexed: 07/20/2024]
Abstract
ABSTRACT Patients with a mechanical mitral valve have an increased risk of thrombosis, and guidelines recommend a higher international normalized ratio goal for vitamin K antagonists-based anticoagulation. Guidelines provide recommendations for bridging with unfractionated heparin; however, there is no clear guidance on the heparin infusion intensity that should be used. This study was a retrospective, single-center, cohort study of patients aged ≥18 years or older with a mechanical mitral valve admitted from June 2019 to September 2022 who were maintained on a singular heparin infusion intensity nomogram for at least 48 hours. The patients were stratified into either a low- or a high-intensity heparin infusion nomogram. The exclusion criteria included non-nomogram heparin infusions and patients within 30 days of valve implantation. The primary outcome of this study was a composite of all bleeding events (major, clinically significant nonmajor, and minor bleeding). The secondary outcomes included bleeding events, analyzed individually, and thrombotic events. Seven total bleeding events were observed between the 2 groups, with 1 minor bleeding event in the low-intensity group and 6 bleeding events in the high-intensity group. One thrombotic event occurred in the high-intensity group. No statistically significant differences were found between the primary and secondary outcomes. Future studies are necessary to guide heparin infusion intensity selection in patients with mechanical mitral valves.
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Affiliation(s)
- Megumi Olsen
- University of Michigan Health, Renown Regional Medical Center, Ann Arbor, MI; and
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2
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Johnston MG, Porter MA, Eppich KE, Gray CG, Scott DF. Evaluation of the Safety of Uninterrupted Warfarin Anticoagulation With Tranexamic Acid in Total Joint Arthroplasty. Orthopedics 2024; 47:211-216. [PMID: 38466825 DOI: 10.3928/01477447-20240304-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
BACKGROUND The continuation of long-term warfarin therapy is gaining acceptance in minor surgeries but maintaining therapeutic international normalized ratio (INR) values among patients during major orthopedic procedures raises concern. While bridging therapy with low-molecular-weight heparin is currently recommended for patients receiving anticoagulation, few studies have evaluated the safety of continuing warfarin during total joint arthroplasty. This study evaluated the safety and efficacy of continuous warfarin anticoagulation through total joint arthroplasty with and without prophylactic tranexamic acid (TXA). MATERIALS AND METHODS We conducted a retrospective, matched-pair analysis of two experimental groups of patients who underwent primary total hip arthroplasty or total knee arthroplasty performed by a single surgeon. Our first experimental group, warfarin plus TXA (warfarin+TXA), consisted of 21 patients who underwent arthroplasty while receiving therapeutic anticoagulation with warfarin (INR, 2.0-3.0) and who received prophylactic TXA. Our second experimental group, warfarin without TXA (warfarin-TXA), consisted of 40 patients who underwent arthroplasty while receiving therapeutic anticoagulation with warfarin (INR, 2.0-3.0) without prophylactic TXA. RESULTS The percent change in hemoglobin value after surgery, red blood cells transfused, surgical site infections, bleeding complications, and thrombotic complications were similar between both experimental and control groups. When comparing the historical group with the warfarin+TXA group, the addition of TXA resulted in a statistical decrease in mean red blood cells transfused and estimated blood loss, with no statistically significant increase in complications. CONCLUSION Many factors must be considered when choosing perioperative thromboembolic prophylaxis for arthroplasty candidates with medical comorbidities requiring long-term anticoagulation. This study presents data indicating that it could be safe and effective to continue therapeutic warfarin while using prophylactic TXA. [Orthopedics. 2024;47(4):211-216.].
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3
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Sweda R, Mannion AF, O'Riordan D, Haschtmann D, Loibl M, Kleinstück F, Jeszenszky D, Galbusera F, Fekete TF. A decade of experience in over 300 surgically treated spine patients with long-term oral anticoagulation: a propensity score matched cohort study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:1360-1368. [PMID: 38381387 DOI: 10.1007/s00586-024-08134-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 03/12/2023] [Accepted: 01/04/2024] [Indexed: 02/22/2024]
Abstract
PURPOSE The aim of this study was to investigate the risks and outcomes of patients with long-term oral anticoagulation (OAC) undergoing spine surgery. METHODS All patients on long-term OAC who underwent spine surgery between 01/2005 and 06/2015 were included. Data were prospectively collected within our in-house Spine Surgery registry and retrospectively supplemented with patient chart and administrative database information. A 1:1 propensity score-matched group of patients without OAC from the same time interval served as control. Primary outcomes were post-operative bleeding, wound complications and thromboembolic events up to 90 days post-surgery. Secondary outcomes included intraoperative blood loss, length of hospital stay, death and 3-month post-operative patient-rated outcomes. RESULTS In comparison with the control group, patients with OAC (n = 332) had a 3.4-fold (95%CI 1.3-9.0) higher risk for post-operative bleeding, whereas the risks for wound complications and thromboembolic events were comparable between groups. The higher bleeding risk was driven by a higher rate of extraspinal haematomas (3.3% vs. 0.6%; p = 0.001), while there was no difference in epidural haematomas and haematoma evacuations. Risk factors for adverse events among patients with OAC were mechanical heart valves, posterior neck surgery, blood loss > 1000 mL, age, female sex, BMI > 30 kg/m2 and post-operative PTT levels. At 3-month follow-up, most patients reported favourable outcomes with no difference between groups. CONCLUSION Although OAC patients have a higher risk for complications after spine surgery, the risk for major events is low and patients benefit similarly from surgery.
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Affiliation(s)
- Romy Sweda
- Spine Center, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anne F Mannion
- Spine Center, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - Dave O'Riordan
- Spine Center, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - Daniel Haschtmann
- Spine Center, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - Markus Loibl
- Spine Center, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - Frank Kleinstück
- Spine Center, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - Dezső Jeszenszky
- Spine Center, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - Fabio Galbusera
- Spine Center, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - Tamás F Fekete
- Spine Center, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland.
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4
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Balaji N, Olukayode O, Faiz F, Dixit P, Bhavsar V. Periprocedural Bridging Therapy in Patients With Mechanical Heart Valves. Cureus 2024; 16:e56465. [PMID: 38638777 PMCID: PMC11024885 DOI: 10.7759/cureus.56465] [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] [Accepted: 03/18/2024] [Indexed: 04/20/2024] Open
Abstract
Mechanical heart valves (MHVs) are thrombogenic and require lifelong anticoagulation with vitamin K antagonists (VKAs) such as warfarin. Periprocedural bridging with unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) aims to reduce the risk of thromboembolic events in patients. Currently, there are no definitive class I recommendations for anticoagulation management in patients with MHVs. In this report, we present the case of a 77-year-old female who was perioperatively bridged with enoxaparin and subsequently developed an acute thrombus.
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Affiliation(s)
- Nivedha Balaji
- Internal Medicine, Northeast Georgia Medical Center Gainesville, Gainesville, USA
| | - Oluwafemi Olukayode
- Internal Medicine, Northeast Georgia Medical Center Gainesville, Gainesville, USA
| | - Fardeen Faiz
- Cardiology, Northeast Georgia Medical Center Gainesville, Gainesville, USA
| | | | - Vedang Bhavsar
- Cardiology, Northeast Georgia Medical Center Gainesville, Gainesville, USA
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5
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Douketis JL, Schulman S. Potential for a Virtual Care Model in the Perioperative Management of Anticoagulant Therapy: A 5-Year Retrospective Clinic Review. TH OPEN 2023; 7:e184-e190. [PMID: 37415616 PMCID: PMC10322226 DOI: 10.1055/a-2098-6782] [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: 12/27/2022] [Accepted: 05/17/2023] [Indexed: 07/08/2023] Open
Abstract
Background With a trend toward greater virtual care in selected clinical settings, perioperative anticoagulant management appears well suited for this care delivery model. We explored the potential for virtual care among patients who are receiving anticoagulant therapy and require perioperative management around the time of an elective surgery/procedure. Methods We undertook a retrospective review of patients who were receiving anticoagulant therapy, either a direct oral anticoagulant (DOAC) or warfarin, assessed in a perioperative anticoagulation-bridging clinic over a 5-year period from 2016 to 2020. Using prespecified criteria, we determined the proportion of patients who likely would be suitable for virtual care (receiving a DOAC or warfarin and having a minimal- or low-/moderate-bleed-risk surgery/procedure), those who likely would be suitable for in-person care (receiving warfarin and requiring heparin bridging for a mechanical heart valve), and patients who would be suitable for either care delivery model (receiving a DOAC or warfarin, but not with a mechanical heart valve, and requiring a high-bleed-risk surgery/procedure). Results During the 5-year study period, there were 4,609 patients assessed for perioperative anticoagulant management in whom the most widely used anticoagulants were warfarin (37%), apixaban (30%), and rivaroxaban (24%). Within each year assessed, 4 to 20% of all patients were undergoing a minimal-bleed-risk procedure, 76 to 82% were undergoing a low-/moderate-bleed-risk surgery/procedure, and 10 to 39% were undergoing a high-bleed-risk surgery/procedure. The proportion of patients considered suitable for virtual, in-person, or either virtual or in-person management was 79.6, 7.1, and 13.3%, respectively. Conclusion In patients who were assessed in a perioperative anticoagulation clinic, there was a high proportion of patients in whom a virtual care model might be suitable.
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Affiliation(s)
- James Luke Douketis
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Sam Schulman
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
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6
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Parks AL, Fang MC. Periprocedural Anticoagulation. Ann Intern Med 2023; 176:ITC49-ITC64. [PMID: 37037035 DOI: 10.7326/aitc202304180] [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] [Indexed: 04/12/2023] Open
Abstract
Management of patients taking anticoagulants around the time of a procedure is a common and complex clinical scenario. Providing evidence-based care requires estimation of risk for thrombosis and bleeding, knowledge of commonly used medications, multidisciplinary communication and collaboration, and patient engagement and education. This review provides a standardized, evidence-based approach to periprocedural management of anticoagulation, based on current evidence and expert clinical guidelines.
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Affiliation(s)
- Anna L Parks
- University of Utah School of Medicine, Salt Lake City, Utah (A.L.P.)
| | - Margaret C Fang
- University of California, San Francisco, San Francisco, California (M.C.F.)
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7
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Sulfation of Birch Wood Microcrystalline Cellulose with Sulfamic Acid Using Ion-Exchange Resins as Catalysts. Polymers (Basel) 2023; 15:polym15051116. [PMID: 36904360 PMCID: PMC10007473 DOI: 10.3390/polym15051116] [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: 01/17/2023] [Revised: 02/17/2023] [Accepted: 02/20/2023] [Indexed: 02/25/2023] Open
Abstract
Cellulose sulfates are important biologically active substances with a wide range of useful properties. The development of new methods for the production of cellulose sulfates is an urgent task. In this work, we investigated ion-exchange resins as catalysts for the sulfation of cellulose with sulfamic acid. It has been shown that water-insoluble sulfated reaction products are formed in high yield in the presence of anion exchangers, while water-soluble products are formed in the presence of cation exchangers. The most effective catalyst is Amberlite IR 120. According to gel permeation chromatography, it was shown that the samples sulfated in the presence of the catalysts KU-2-8, Purolit s390 plus, and AN-31 SO42- underwent the greatest degradation. The molecular weight destribution profiles of these samples are noticeably shifted to the left towards low-molecular-weight compounds with an increase in fractions in the regions Mw ~2.100 g/mol and ~3.500 g/mol, indicating the growth of microcrystalline cellulose depolymerization products. The introduction of a sulfate group into the cellulose molecule is confirmed using FTIR spectroscopy by the appearance of absorption bands at 1245-1252 cm-1 and 800-809 cm-1, which correspond to the vibrations of the sulfate group. According to X-ray diffraction data, amorphization of the crystalline structure of cellulose is observed during sulfation. Thermal analysis has shown that with an increase in the content of sulfate groups in cellulose derivatives, thermal stability decreases.
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Hazkani I, Billings KR, Edwards E, Stein E, Bhat R, Lavin J. Perioperative management in chronically anticoagulated children undergoing tonsillectomy. Pediatr Int 2023; 65:e15438. [PMID: 36504262 DOI: 10.1111/ped.15438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 12/07/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND When undergoing tonsillectomy, patients at high risk of thrombosis who require chronic anticoagulation therapy pose a special challenge as bleeding may occur up to 2 weeks after surgery. Because of a lack of evidence-based data, there is no consensus on the best management for such patients. The objective of our study was to review perioperative anticoagulation bridging strategies in children undergoing tonsillectomy. METHODS The study group were a retrospective series of patients on chronic anticoagulation therapy at high risk of a thromboembolic event, who underwent tonsillectomy from 2010 to 2021. Patients whose anticoagulation treatment was discontinued because of a low risk of thromboembolic events were excluded. RESULTS Four patients met the inclusion criteria (age range, 1.5-16.1 years). All patients were admitted prior to surgery for bridging therapy with intravenous unfractionated heparin (UFH), drip-titrated to a therapeutic dose until 4-6 h prior to surgery. The estimated blood loss during surgery was minimal in all surgeries. Unfractionated heparin was readministered according to the hospital protocol on the night of surgery and titrated to a therapeutic dose. Warfarin was restarted within 2 days postsurgery for all patients. High-risk patients were kept in hospital until postoperative day 6-8 because of concern for delayed bleeding. One patient was noticed to have blood-tinged sputum requiring no intervention; none of the patients developed early or delayed hematemesis. CONCLUSIONS Our data show that bridging therapy with UFH has been successful in chronically anticoagulated patients undergoing tonsillectomy. These patients require multidisciplinary care for the management of their pre- and postoperative course.
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Affiliation(s)
- Inbal Hazkani
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Kathleen R Billings
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Evan Edwards
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Eli Stein
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Rukhmi Bhat
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Division of Hematology, Oncology, and Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Jennifer Lavin
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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9
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Douketis JD, Spyropoulos AC, Murad MH, Arcelus JI, Dager WE, Dunn AS, Fargo RA, Levy JH, Samama CM, Shah SH, Sherwood MW, Tafur AJ, Tang LV, Moores LK. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest 2022; 162:e207-e243. [PMID: 35964704 DOI: 10.1016/j.chest.2022.07.025] [Citation(s) in RCA: 93] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/10/2022] [Accepted: 07/11/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug. METHODS Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines. RESULTS A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures. CONCLUSIONS Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.
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Affiliation(s)
- James D Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton and McMaster University, Hamilton, ON, Canada.
| | - Alex C Spyropoulos
- Department of Medicine, Northwell Health at Lenox Hill Hospital, New York, NY; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Institute of Health Systems Science at The Feinstein Institutes for Medical Research, Manhasset, NY
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | - Juan I Arcelus
- Department of Surgery, Facultad de Medicina, University of Granada, Granada, Spain
| | - William E Dager
- Department of Pharmacy, University of California-Davis, Sacramento, CA
| | - Andrew S Dunn
- Division of Hospital Medicine, Department of Medicine, Mt. Sinai Health System, New York, NY
| | - Ramiz A Fargo
- Department of Internal Medicine, Loma Linda University Medical Center, Loma Linda, CA; Department of Internal Medicine, Riverside University Health System Medical Center, Moreno Valley, CA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, NC
| | - C Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP, Centre-Université Paris-Cité-Cochin Hospital, Paris, France
| | - Sahrish H Shah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | | | - Alfonso J Tafur
- Department of Medicine, Cardiovascular, NorthShore University HealthSystem, Evanston, IL
| | - Liang V Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong, University of Science and Technology, Wuhan, China
| | - Lisa K Moores
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
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10
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Briete LD, Towers WF, Bone R, Nair R, Steck M, Cutshall BT, Shah SP. Perioperative Anticoagulation Management. Crit Care Nurs Q 2022; 45:119-131. [PMID: 35212652 DOI: 10.1097/cnq.0000000000000395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Management of anticoagulation in individuals undergoing operative procedures is a complex situation. Each case should be assessed individually with proper risk assessment, monitoring, and plan for perioperative and postoperative anticoagulation. Clinical evidence for the management of these patients is relatively scarce, and clinicians are often assessing each individual case with minimal guidance. This review provides nurses with a summary of available literature on the assessment, laboratory monitoring, timing of adjusting anticoagulation, and bridging prior to procedures. In addition to general perioperative anticoagulation management, this review discusses perioperative management in special populations and provides a summary on principles when anticoagulation should be resumed following a procedure.
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Affiliation(s)
- Lauren D Briete
- Department of Pharmacy, Mississippi Baptist Medical Center, Jackson (Dr Briete); Department of Pharmacy, MD Anderson Cancer Center, Houston, Texas (Dr Towers); Department of Pharmacy, Methodist University Hospital, Memphis, Tennessee (Drs Bone and Cutshall); Department of Cardiothoracic Surgery, Stanford Healthcare, Stanford, California (Mr Nair); Department of Pharmacy, Indiana University Health Arnett Hospital, Lafayette (Dr Steck); and Department of Pharmacy, Mercy Health, Janesville, Wisconsin (Dr Shah)
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11
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Pacheco LD, Saade G, Shrivastava V, Shree R, Elkayam U. Society for Maternal-Fetal Medicine Consult Series #61: Anticoagulation in pregnant patients with cardiac disease. Am J Obstet Gynecol 2022; 227:B28-B43. [PMID: 35337804 DOI: 10.1016/j.ajog.2022.03.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pregnancy in individuals with a mechanical heart valve has been classified as very high risk because of a substantially increased risk of maternal mortality or severe morbidity. Lifelong therapeutic anticoagulation is a principal component of the medical management of mechanical heart valves to prevent valve thrombosis. Anticoagulation regimens indicated outside of pregnancy for patients with mechanical valves should be continued during pregnancy with the possibility of modifications based on the type of valve, the trimester of pregnancy, individual risk tolerance, and circumstances around the time of delivery. The purpose of this document is to provide recommendations regarding the management of anticoagulation for common cardiac conditions complicating pregnancy, including mechanical heart valves, atrial fibrillation, systolic heart failure, and congenital heart disease.
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Affiliation(s)
- Luis D Pacheco
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
| | - George Saade
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
| | - Vineet Shrivastava
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
| | - Raj Shree
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
| | - Uri Elkayam
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
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12
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Hata R, Yamashita Y, Morimoto T, Kadota K, Amano H, Murai R, Osakada K, Sano A, Takase T, Hiramori S, Kim K, Oi M, Akao M, Doi K, Kobayashi Y, Toyofuku M, Izumi T, Tada T, Chen PM, Murata K, Tsuyuki Y, Saga S, Nishimoto Y, Sasa T, Sakamoto J, Kinoshita M, Togi K, Mabuchi H, Takabayashi K, Tsujisaka Y, Seko Y, Matsushita K, Yoneda F, Kato T, Ono K, Kimura T. Periprocedural management and clinical outcomes of invasive procedures after venous thromboembolism: from the COMMAND VTE registry. J Thromb Thrombolysis 2021; 53:540-549. [PMID: 34524599 DOI: 10.1007/s11239-021-02564-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/31/2021] [Indexed: 02/02/2023]
Abstract
Anticoagulation therapy is prescribed for the prevention of recurrence in patients with venous thromboembolism, which could be temporarily interrupted during invasive procedures. The COMMAND VTE Registry is a multicenter registry enrolling 3027 consecutive patients with acute symptomatic VTE in Japan between January 2010 and August 2014. We identified patients who underwent invasive procedures during the entire follow-up period and evaluated periprocedural managements and clinical outcomes at 30 days after invasive procedures. During a median follow-up period of 1213 (IQR: 847-1764) days, 518 patients underwent invasive procedures with the cumulative incidences of 5.8% at 3 months, 11.1% at 1 year, and 24.0% at 5 years. Among 382 patients in high bleeding-risk category of invasive procedures, anticoagulation therapy had been discontinued already in 62 patients (16%) and interrupted temporarily in 288 patients (75%) during the invasive procedures with bridging anticoagulation therapy with heparin in 214 patients (56%). Among 80 patients in low bleeding-risk category, anticoagulation therapy had been already discontinued in 15 patients (19%) and interrupted temporarily in 31 patients (39%) during invasive procedure with bridging anticoagulation therapy with heparin in 17 patients (21%). At 30 days after the invasive procedures, 14 patients (2.7%) experienced recurrent VTE, while 28 patients (5.4%) had major bleeding. This study elucidated the real-world features of peri-procedural management and prognosis in patients with VTE who underwent invasive procedures during follow-up in the large multicenter VTE registry. The 30-day incidence rates of recurrent VTE and major bleeding events were 2.7% and 5.4%.
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Affiliation(s)
- Reo Hata
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.,Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kazushige Kadota
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Hidewo Amano
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Ryosuke Murai
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Kohei Osakada
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Arata Sano
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Toru Takase
- Department of Cardiology, Kinki University Hospital, Osaka, Japan
| | - Seiichi Hiramori
- Department of Cardiology, Kokura Memorial Hospital, Kokura, Japan
| | - Kitae Kim
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Maki Oi
- Department of Cardiology, Japanese Red Cross Otsu Hospital, Otsu, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Kosuke Doi
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yohei Kobayashi
- Department of Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan
| | - Mamoru Toyofuku
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Toshiaki Izumi
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Tomohisa Tada
- Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Po-Min Chen
- Department of Cardiology, Osaka Saiseikai Noe Hospital, Osaka, Japan
| | - Koichiro Murata
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Yoshiaki Tsuyuki
- Division of Cardiology, Shimada Municipal Hospital, Shimada, Japan
| | - Syunsuke Saga
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Yuji Nishimoto
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Tomoki Sasa
- Department of Cardiology, Kishiwada City Hospital, Kishiwada, Japan
| | - Jiro Sakamoto
- Department of Cardiology, Tenri Hospital, Tenri, Japan
| | | | - Kiyonori Togi
- Division of Cardiology, Faculty of Medicine, Nara Hospital, Kinki University, Ikoma, Japan
| | - Hiroshi Mabuchi
- Department of Cardiology, Koto Memorial Hospital, Higashiomi, Japan
| | | | - Yuta Tsujisaka
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yuta Seko
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kazuki Matsushita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Fumiya Yoneda
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Takao Kato
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Koh Ono
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
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Eljilany I, Elarref M, Shallik N, Elzouki AN, Bader L, El-Bardissy A, Abdelsamad O, Al-Badriyeh D, Cavallari LH, Elewa H. Genetic and Non-Genetic Factors Impact on INR Normalization in Preprocedural Warfarin Management. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2021; 14:1069-1080. [PMID: 34483679 PMCID: PMC8409603 DOI: 10.2147/pgpm.s322743] [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: 05/31/2021] [Accepted: 08/09/2021] [Indexed: 12/01/2022]
Abstract
Background Annually, 10% of warfarin patients will likely need to stop warfarin prior to elective surgery to achieve a baseline international normalization ratio (INR) level (INR ≤ 1.2) at the time of the procedure. This study explores the influence of genetic and non-genetic factors on INR normalization in the Arab (major part of Near Eastern) population in preprocedural warfarin management. Methods An observational prospective cohort study was designed to recruit Arab patients taking warfarin and scheduled for an elective procedure. Two INR readings were recorded. DNA extraction and genotyping of variants in CYP2C9*2, CYP2C9*3, CYP4F2*3, VKORC1*2, and FII (rs5896) and FVII (rs3093229) genes using real-time polymerase chain reaction were performed. Results Data from 116 patients were included in the analysis. CYP2C9 and VKORC1 genetic variants carriers required lower maintenance dose compared to non-carriers. The analysis showed that ciprofloxacin, antiplatelet medications, and INR index (INR at visit 1) are the only factors associated with the INR decline rate. Also, the proportion of CYP2C9*3 carriers with normal INR (≤1.2) on the day of surgery was significantly lower than those with wild-type genotype (28% vs 60%, p=0.013). In addition, heparin bridging, INR target, and Sudanese nationality are significant predictors of INR normalization (≤1.2) on the day of the procedure. Conclusion Despite the confirmed effect of genetic factors on warfarin maintenance dose, the study was not able to find a significant effect of any genetic factor on the rate of INR normalization possibly due to the small sample size. Index INR and interacting medications showed to be significant predictors of INR decline rate.
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Affiliation(s)
- Islam Eljilany
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Mohamed Elarref
- Department of Anesthesia, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Nabil Shallik
- Department of Anesthesia, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.,Department of Anesthesia, Faculty of Medicine, Tanta University, Tanta, Egypt.,Department of Clinical Anesthesia, College of Medicine, Qatar University, Doha, Qatar.,Department of Clinical Anesthesia, Weill Cornell Medical College, Doha, Qatar
| | - Abdel-Naser Elzouki
- Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.,Department of Internal Medicine, College of Medicine, Qatar University, Doha, Qatar.,Department of Internal Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Loulia Bader
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Ahmed El-Bardissy
- Department of Pharmacy, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Osama Abdelsamad
- Department of Pharmacy, Al Wakra Hospital, Hamad Medical Corporation, Doha, Qatar
| | | | - Larisa H Cavallari
- Department of Pharmacotherapy and Translation Research, Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Hazem Elewa
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar.,Department of Pharmacy, Al Wakra Hospital, Hamad Medical Corporation, Doha, Qatar.,Biomedical and Pharmaceutical Research Unit, QU Health, Qatar University, Doha, Qatar
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14
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Eljilany I, Elewa H, Abdelsamad O, Abdelgelil M, Mahfouz A, Anany RA, Yafei SA, Al-Badriyeh D. Bridging vs Non-Bridging with Warfarin Peri-Procedural Management: Cost and Cost-Effectiveness Analyses. Curr Probl Cardiol 2021; 46:100839. [PMID: 34059316 DOI: 10.1016/j.cpcardiol.2021.100839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 03/08/2021] [Indexed: 10/21/2022]
Abstract
The warfarin peri-procedural management in Qatar is predominantly based on bridging (63%), compared to non-bridging. This study sought to perform a first-time cost analysis of current warfarin peri-procedural management practices, including a cost-effectiveness analysis (CEA) of predominant bridging vs predominant non-bridging practices. From the hospital perspective, a one-year decision-analytic model followed the cost and success consequences of the peri-procedural warfarin in a hypothetical cohort of 10,000 atrial fibrillation patients. Success was defined as survival with no adverse events. Outcome measures were the cost and success consequences of the 63% bridging (vs not-bridging) practice in the study setting, ie, Hamad Medical Corporation, Qatar, and the incremental cost-effectiveness ratio (ICER, cost/success) of the warfarin therapy when predominantly bridging based vs when predominantly non-bridging based. The model was based on Monte Carlo simulation, and sensitivity analyses were performed to confirm the robustness of the study conclusions. As per 63% bridging practices, the mean overall cost of peri-procedural warfarin management per patient was USD 3,260 (QAR 11,900), associated with an overall success rate of 0.752. Based on the CEA, predominant bridging was dominant (lower cost, higher effect) over the predominant non-bridging practice in 62.2% of simulated cases, with a cost-saving of up to USD 2,001 (QAR 7,303) at an average of USD 272 (QAR 993) and was cost-effective in 36.9% of cases. Being between cost-saving and cost-effective, compared to predominant non-bridging practices, the predominant use of bridging with warfarin seems to be a favorable strategy in atrial fibrillation patients.
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Affiliation(s)
- Islam Eljilany
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Hazem Elewa
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar; Department of Pharmacy, Al Wakra Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Osama Abdelsamad
- Department of Pharmacy, Al Wakra Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Mohamed Abdelgelil
- Department of Pharmacy, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed Mahfouz
- Department of Pharmacy, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Rasha Al Anany
- Department of Pharmacy, Al Wakra Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Sumaya Al Yafei
- Department of Pharmacy, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
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15
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Siddiqui MU, Pasha AK, Rauf I, Lee JZ, Siddiqui MD, Yaacoub Y, Movahed MR. Efficacy and Safety of Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation Undergoing Elective Surgical Procedures: A Meta-analysis. Clin Med Res 2021; 19:19-25. [PMID: 33060109 PMCID: PMC7987095 DOI: 10.3121/cmr.2020.1546] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 03/26/2020] [Accepted: 09/11/2020] [Indexed: 01/15/2023]
Abstract
Objective: The study objective was to determine if peri-operative bridging anticoagulation in patients with atrial fibrillation is beneficial or harmful.Design: Systematic review and meta-analysis.Setting: Inpatient or in-hospital setting.Participants: Adults with atrial fibrillation having a CHADS2 score >1 undergoing elective surgical procedure on anticoagulation.Methods: A systemic search of multiple databases (Cochrane, Medline, PubMed) was performed regarding studies conducted on efficacy and safety of perioperative bridging anticoagulation in patients with atrial fibrillation. Studies identified were reviewed by two authors individually before inclusion. The results were then pooled using Review Manager to determine the combined effect. Stroke/systemic embolism was considered as the primary efficacy outcome. Major bleeding was the primary safety outcome.Results: The systematic search revealed 108 potential articles. The full texts of 28 articles were retrieved for assessment of eligibility. After full text review, 25 articles were excluded. Three articles met inclusion criteria. No significant difference in stroke/systemic embolism with bridging anticoagulation was noted (risk ratio, 1.25-95% confidence interval [CI], 0.55-2.85). Bridging was associated with significantly higher risk of major bleeding (risk ratio, 3.29-95% CI, 2.25-4.81).Conclusion: An individualized approach is required when initiating peri-operative bridging anticoagulation. There is certainly a higher risk of bleeding with bridging anticoagulation and no difference in stroke/systemic embolism. However, the results cannot be extrapolated to patients who have valvular atrial fibrillation or CHADS2 score of 5 or greater.
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Affiliation(s)
- Muhammad Umer Siddiqui
- Marshfield Clinic Health System, Eau Claire, Wisconsin, USA [Current affiliation: George Washington University, Washington, DC, USA
| | - Ahmed K Pasha
- Mayo Clinic Health System, Rochester, Minnesota, USA
| | - Ibtisam Rauf
- Northwestern University Feinberg School of Medicine, Department of Physical Therapy and Human Movement, Chicago, Illinois, USA
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16
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Tafur AJ, Clark NP, Spyropoulos AC, Li N, Kaplovitch E, MacDougall K, Schulman S, Caprini JA, Douketis J. Predictors of Bleeding in the Perioperative Anticoagulant Use for Surgery Evaluation Study. J Am Heart Assoc 2020; 9:e017316. [PMID: 32969288 PMCID: PMC7792425 DOI: 10.1161/jaha.120.017316] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background In the PAUSE (Perioperative Anticoagulant Use for Surgery Evaluation) Study, a simple, standardized, perioperative interruption strategy was provided for patients with nonvalvular atrial fibrillation taking direct oral anticoagulants (DOACs). Our objective was to define the factors associated with perioperative bleeding. Methods and Results We analyzed bleeding as the composite of major and clinically relevant nonmajor bleeding. Putative predictors of bleeding, and preoperative DOAC level were prospectively collected during recruitment. We used stratified logistic regression models for analysis. All statistical analyses were performed in R version 3.6.0. There were 3007 patients requiring perioperative DOAC interruption. More than one third of the included patients underwent a high bleeding risk procedure. The 30-day rates of major and clinically relevant nonmajor bleeding were 3.02% in apixaban (n=1257), 2.84% in dabigatran (n=668), and 4.16% for rivaroxaban (n=1082). Multivariate analysis stratified by region found more bleeding for hypertension (odds ratio [OR], 1.79; 95% CI 1.07-2.99; P=0.027), and prior bleeding (OR, 1.71; 95% CI, 1.08-2.71; P=0.021). Surgical bleed risk classification (high- versus low-risk) as a predictor of bleeding was only significant in the univariate analysis. The prediction model for major and clinically relevant nonmajor bleeding had an area under the curve of 0.71, and the preoperative DOAC level did not improve the area under the curve of the model. Conclusions In patients treated with DOACs who required an elective surgery/procedure and were managed with standardized DOAC interruption and resumption, there we did not find reversible risk factors for bleeding, suggesting that adjustment of the PAUSE management protocol to mitigate against bleeding is not needed.
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Affiliation(s)
- Alfonso J. Tafur
- Northshore University HealthSystemEvanstonIL
- University of ChicagoPritzker School of MedicineChicagoIL
| | | | - Alex C. Spyropoulos
- Zucker School of Medicine at Hofstra/NorthwellNorthwell Health at Lenox Hill HospitalNew YorkNY
| | - Na Li
- McMaster UniversityHamiltonONCanada
| | | | - Kira MacDougall
- Zucker School of Medicine at Hofstra/NorthwellNorthwell Health at Lenox Hill HospitalNew YorkNY
| | - Sam Schulman
- McMaster UniversityHamiltonONCanada
- Department of Obstetrics and GynecologyThe First I.M. Sechenov Moscow State Medical UniversityMoscowRussia
| | - Joseph A. Caprini
- Northshore University HealthSystemEvanstonIL
- University of ChicagoPritzker School of MedicineChicagoIL
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17
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Talari G, Demertzis ZD, Summey RD, Gill B, Kaatz S. Perioperative management of anticoagulation. Hosp Pract (1995) 2020; 48:231-240. [PMID: 32627607 DOI: 10.1080/21548331.2020.1792138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Periprocedural management of the anticoagulated patient can be as easy as continuing warfarin for a low bleeding risk procedure, holding a direct oral anticoagulant for 1 day prior and resuming 1 day later or as complex as emergent reversal with prothrombin complex concentrate, idarucizumab, or andexanet alfa. Patient-specific factors for thromboembolic risk and procedural bleeding risk determine timing of anticoagulation hold prior to and resumption after invasive procedures. Clinical trials and management studies in recent years have helped inform our approach to these patients, but much of the guidance is still based on expert consensus.
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Affiliation(s)
- Goutham Talari
- Division of Hospital Medicine, Henry Ford Hospital , Detroit, Michigan, USA
| | - Zachary D Demertzis
- Department of Internal Medicine, Henry Ford Hospital , Detroit, Michigan, USA
| | - Robert D Summey
- Division of Hospital Medicine, Henry Ford Hospital , Detroit, Michigan, USA
| | - Baljinder Gill
- Division of Hospital Medicine, Henry Ford Hospital , Detroit, Michigan, USA
| | - Scott Kaatz
- Division of Hospital Medicine, Henry Ford Hospital , Detroit, Michigan, USA
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18
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Gotoh S, Yasaka M, Nakamura A, Kuwashiro T, Okada Y. Management of Antithrombotic Agents During Surgery or Other Kinds of Medical Procedures With Bleeding: The MARK Study. J Am Heart Assoc 2020; 9:e012774. [PMID: 32079478 PMCID: PMC7335562 DOI: 10.1161/jaha.119.012774] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Optimal management of antithrombotic agents during surgery has yet to be established. We performed a prospective multicenter observational study to determine the current status of the management of antithrombotic agents during surgery or other medical procedures with bleeding (MARK [Management of Antithrombotic Agents During Surgery or Other Kinds of Medical Procedures With Bleeding] study) in Japan. Methods and Results The participants were 9700 patients who received oral antithrombotic agents and underwent scheduled medical procedures with bleeding at 59 National Hospital Organization institutions in Japan. Primary outcomes were thromboembolic events, bleeding events, and death within 2 weeks before and 4 weeks after the procedures. We investigated the relationships between each outcome and patient demographics, comorbidities, type of procedure, and management of antithrombotic therapy. With respect to the periprocedural management of antithrombotic agents, 3551 patients continued oral antithrombotic agents (36.6%, continuation group) and 6149 patients discontinued them (63.4%, discontinuation group). The incidence of any thromboembolic event (1.7% versus 0.6%, P<0.001), major bleeding (7.6% versus 0.4%, P<0.001), and death (0.8% versus 0.4%, P<0.001) was all greater in the discontinuation group than the continuation group. In multivariate analysis, even after adjusting for confounding factors, discontinuation of anticoagulant agents was significantly associated with higher risk for both thromboembolic events (odds ratio: 4.55; 95% CI, 1.67-12.4; P=0.003) and major bleeding (odds ratio: 11.1; 95% CI, 2.03-60.3; P=0.006) in procedures with low bleeding risk. In contrast, heparin bridging therapy was significantly associated with higher risk for both thromboembolic events (odds ratio: 2.03; 95% CI, 1.28-3.22; P=0.003) and major bleeding (odds ratio: 1.36; 95% CI, 1.10-1.68; P=0.005) in procedures with high bleeding risk. Conclusions Discontinuation of oral antithrombotic agents and addition of low-dose heparin bridging therapy appear to be significantly associated with adverse events in the periprocedural period.
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Affiliation(s)
- Seiji Gotoh
- Department of Cerebrovascular Medicine and Neurology Cerebrovascular Center and Clinical Research Institute National Hospital Organization Kyushu Medical Center Fukuoka Japan
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology Cerebrovascular Center and Clinical Research Institute National Hospital Organization Kyushu Medical Center Fukuoka Japan
| | - Asako Nakamura
- Department of Cerebrovascular Medicine and Neurology Cerebrovascular Center and Clinical Research Institute National Hospital Organization Kyushu Medical Center Fukuoka Japan
| | - Takahiro Kuwashiro
- Department of Cerebrovascular Medicine and Neurology Cerebrovascular Center and Clinical Research Institute National Hospital Organization Kyushu Medical Center Fukuoka Japan
| | - Yasushi Okada
- Department of Cerebrovascular Medicine and Neurology Cerebrovascular Center and Clinical Research Institute National Hospital Organization Kyushu Medical Center Fukuoka Japan
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19
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Nazha B, Pandya B, Cohen J, Zhang M, Lopes RD, Garcia DA, Sherwood MW, Spyropoulos AC. Periprocedural Outcomes of Direct Oral Anticoagulants Versus Warfarin in Nonvalvular Atrial Fibrillation. Circulation 2019; 138:1402-1411. [PMID: 29794081 DOI: 10.1161/circulationaha.117.031457] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are surpassing warfarin as the anticoagulant of choice for stroke prevention in nonvalvular atrial fibrillation. DOAC outcomes in elective periprocedural settings have not been well elucidated and remain a source of concern for clinicians. The aim of this meta-analysis was to evaluate the periprocedural safety and efficacy of DOACs versus warfarin in patients with nonvalvular atrial fibrillation. METHODS We reviewed the literature for data from phase III randomized controlled trials comparing DOACs with warfarin in the periprocedural period among patients with nonvalvular atrial fibrillation. Substudies from 4 trials (RE-LY [Randomized Evaluation of Long-Term Anticoagulation Therapy], ROCKET AF [Rivaroxaban Once Daily Oral Direct Factor Xa Inhibitor Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation], ARISTOTLE [Apixaban for the Prevention of Stroke in Subjects With Atrial Fibrillation], and ENGAGE-AF [Effective Anticoagulation With Factor xA Next Generation in Atrial Fibrillation]) were included in the meta-analysis. DOACs as a group and warfarin were compared in terms of the 30-day pooled risk for stroke/systemic embolism, major bleeding, and death, according to whether the study drug was interrupted or not periprocedurally. The overall relative risk (RR) was estimated with a random-effects model. The I2 test was used to assess heterogeneity in RR among the studies. RESULTS In the uninterrupted anticoagulant strategy, there were no differences in the rates of stroke/systemic embolism (pooled risk, 0.6% [29 events/4519 procedures] versus 1.1% [31/2971]; RR, 0.70; 95% confidence interval [CI], 0.41-1.18) and death (1.4% versus 1.8%; RR, 0.77; 95% CI, 0.53-1.12) between DOACs and warfarin and significantly fewer major bleeding events (2.0% versus 3.3%; RR, 0.62; 95% CI, 0.47-0.82) with DOACs compared to warfarin. Under an interrupted strategy, there was no significant difference between DOACs versus warfarin for stroke/systemic embolism (0.4% [41/9260] versus 0.5% [31/7168]; RR, 0.95; 95% CI, 0.59-1.55), major bleeding (2.1% versus 2.0%; RR, 1.05; 95% CI, 0.85-1.30), and death (0.7% versus 0.6%; RR, 1.24; 95% CI, 0.76-2.04). The studies were homogeneous ( I2=0.0%) for all calculated pooled associations except for the RR of death in the interrupted strategy ( I2=26.3%). CONCLUSIONS The short-term safety and efficacy of DOACs and warfarin are not different in patients with nonvalvular atrial fibrillation periprocedurally. Under an uninterrupted anticoagulation strategy, DOACs are associated with a 38% lower risk of major bleeding compared with warfarin.
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Affiliation(s)
- Bassel Nazha
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA (B.N.)
| | - Bhavi Pandya
- Division of Cardiology, Staten Island University Hospital-Northwell Health, NY (B.P.)
| | - Jessica Cohen
- Division of Hospital Medicine, Northwell Health at North Shore University Hospital, Manhasset, NY (J.C.)
| | - Meng Zhang
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, NY (M.Z., A.C.S.)
| | - Renato D Lopes
- Division of Cardiology, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (R.D.L.)
| | - David A Garcia
- Department of Medicine, Division of Hematology, University of Washington School of Medicine, Seattle (D.A.G.)
| | | | - Alex C Spyropoulos
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, NY (M.Z., A.C.S.).,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY (A.C.S.).,Department of Medicine, Anticoagulation and Clinical Thrombosis Service, Northwell Health at Lenox Hill Hospital, New York, NY (A.C.S.)
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20
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Guideline compliance for bridging anticoagulation use in vitamin-K antagonist patients; practice variation and factors associated with non-compliance. Thromb J 2019; 17:15. [PMID: 31391790 PMCID: PMC6681479 DOI: 10.1186/s12959-019-0204-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 06/26/2019] [Indexed: 12/18/2022] Open
Abstract
Background Bridging anticoagulation is used in vitamin-K antagonist (VKA) patients undergoing invasive procedures and involves complex risk assessment in order to prevent thromboembolic and bleeding outcomes. Objectives Our aim was to assess guideline compliance and identify factors associated with bridging and especially, non-compliant bridging. Methods A retrospective review of 256 patient records in 13 Dutch hospitals was performed. Demographic, clinical, surgical and care delivery characteristics were collected. Compliance to the American College of Chest Physicians ninth edition guideline (AT9) was assessed. Multilevel regression models were built to explain bridging use and predict non-compliance. Results Bridging use varied from 15.0 to 83.3% (mean = 41.8%) of patients per hospital, whereas guideline compliance varied from 20.0 to 88.2% (mean = 68.5%) per hospital. Both established thromboembolic risk factors and characteristics outside thromboembolic risk assessment were associated with bridging use. Predictors for overuse were gastrointestinal surgery (OR 14.85, 95% CI 2.69-81.99), vascular surgery (OR 13.01, 95% CI 1.83-92.30), non-elective surgery (OR 8.67, 95% CI 1.67-45.14), lowest 25th percentile socioeconomic status (OR 0.33, 95% CI 0.11-1.02) and use of VKA reversal agents (OR 0.22, 95% CI 0.04-1.16). Conclusion Bridging anticoagulation practice was not compliant with the AT9 in 31.5% of patients. The aggregated AT9 thromboembolic risk was inferior to individual thromboembolic risk factors and other characteristics in explaining bridging use. Therefor the AT9 risk seems less important for the decision making in everyday practice. Additionally, a heterogeneous implementation of the guideline between hospitals was found. Further research and interventions are needed to improve bridging anticoagulation practice in VKA patients.
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21
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Shaw JR, Douketis J, Le Gal G, Carrier M. Periprocedural interruption of anticoagulation in patients with cancer-associated venous thromboembolism: An analysis of thrombotic and bleeding outcomes. J Thromb Haemost 2019; 17:1171-1178. [PMID: 31038838 DOI: 10.1111/jth.14468] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 04/24/2019] [Indexed: 12/21/2022]
Abstract
Essentials Patients with cancer-associated VTE frequently undergo invasive procedures. Data on the perioperative interruption of anticoagulation for cancer-associated VTE are lacking. Patients with cancer-associated VTE experience high post-operative VTE and major bleeding rates. This patient population may warrant close follow-up after invasive procedures. BACKGROUND Patients with cancer are at high risk for venous thromboembolic events. Venous thromboembolism (VTE) can lead to significant morbidity among patients with cancer, and is estimated to be one of the leading causes of death among cancer patients. Patients with cancer often require invasive procedures for biopsy or therapeutic purposes. There is a lack of data on postoperative outcomes following interruption of anticoagulation in this population. OBJECTIVE To assess 30-day postoperative thromboembolic and major bleeding complication rates following the perioperative interruption of anticoagulation in patients with cancer-associated VTE. METHODS We conducted a retrospective self-controlled case series study with patients with cancer-associated VTE undergoing perioperative interruption of anticoagulation at a dedicated tertiary-care anticoagulation clinic for invasive procedures between January 2013 and March 2018. The primary efficacy and safety outcomes were the 30-day postoperative rates of VTE and major bleeding, respectively. The secondary outcomes included the 30-day rates of clinically relevant non-major bleeding (CRNMB) and overall mortality. Patients undergoing multiple perioperative anticoagulation interruptions were included. RESULTS One hundred and forty-six patients undergoing 171 periprocedural interruptions were included in our cohort. The 30-day rates of VTE and major bleeding were both 4.1% (95% confidence interval [CI] 2.0-8.2). The 30-day rate of CRNMB was 2.9% (95% CI 1.3-6.7) and the 30-day overall mortality rate was 0.6% (95% CI 0.1-3.4). There were no fatal postoperative VTE or major bleeding events. CONCLUSIONS The periprocedural interruption of anticoagulation in patients with cancer-associated VTE is associated with high postoperative rates of VTE and major bleeding. Patients with cancer-associated VTE may require closer follow-up for VTE and bleeding complications after invasive procedures.
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Affiliation(s)
- Joseph R Shaw
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Canada
| | - James Douketis
- Department of Medicine, Division of Hematology and Thromboembolism, McMaster University, Hamilton, Canada
| | - Gregoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Canada
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Canada
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Thomaschewski M, Beyer F, Thomaschewski M, Ellebrecht D, Jonczyk M, Schneider M, Keck T, Mentler T, Hummel R. Application-based management of perioperative anticoagulant therapy: description of POPACTApp. Langenbecks Arch Surg 2019; 404:633-645. [PMID: 31209561 DOI: 10.1007/s00423-019-01796-9] [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: 01/02/2019] [Accepted: 06/04/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Perioperative management of oral anticoagulation (OAC) is a constant challenge in interventional and surgical procedures. When deciding to discontinue OAC, the risk of thromboembolic events must be balanced against the risk of bleeding during and after the planned procedure. These risks differ across patients and must be considered individually. METHODS POPACTApp, an application for the perioperative or peri-interventional management of oral anticoagulants, was developed using a human-centered design process (ISO 9241-210:2010). The treatment concept developed here can be adapted to a patient's individual risk profile. POPACTApp provides recommendations based on guidelines, consensus statements, and study data. After entering patient-specific risk factors, the attending physician using POPACTApp receives a clear and direct presentation of a periprocedural treatment concept, which should enable the efficient use of the program in everyday clinical practice. The perioperative treatment concept is presented via a timeline, including (1) the decision on whether to interrupt OAC, (2) the timing of the last preoperative administration of OAC in cases of interruption, (3) the decision on whether and how to bridge with heparins, and (4) the decision about when to reinitiate anticoagulation. RESULTS A task-based survey to evaluate POPACTApp's usability conducted with 20 surgeons showed that all clinicians correctly interpreted the recommendations provided by the app. Further, a questionnaire using a 7-point Likert scale from - 3 (negative) to + 3 (positive) revealed the following results to three specific questions: (1) satisfaction with the current standard procedure in the respective unit of the participant (0.15; SD = 1.57), (2) individual satisfaction with the POPACTApp application (2.7; SD = 0.47), and (3) estimation of the usefulness of POPACTApp for clinical practice (2.7; SD = 0.47). CONCLUSIONS POPACTApp provides clinicians with an individual risk-optimized treatment concept for the perioperative or peri-interventional management of OAC based on current guidelines, consensus statements, and study data, enabling the standardized perioperative handling of OAC in daily clinical practice.
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Affiliation(s)
- Michael Thomaschewski
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Florens Beyer
- Institute for Multimedia and Interactive Systems, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Martin Thomaschewski
- Center for Nano Optics, University of Southern Denmark, Campusvej 55, 5230, Odense, Denmark
| | - David Ellebrecht
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Markus Jonczyk
- Department of Vascular Surgery, Academic Teaching Hospital St. Adolf-Stift, University of Hamburg, Hamburger Straße 41, 21465, Reinbek, Germany
| | - Matthias Schneider
- Department of Vascular Surgery, Academic Teaching Hospital St. Adolf-Stift, University of Hamburg, Hamburger Straße 41, 21465, Reinbek, Germany
| | - Tobias Keck
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Tilo Mentler
- Institute for Multimedia and Interactive Systems, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Richard Hummel
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
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Baumgartner C, de Kouchkovsky I, Whitaker E, Fang MC. Periprocedural Bridging in Patients with Venous Thromboembolism: A Systematic Review. Am J Med 2019; 132:722-732.e7. [PMID: 30659809 PMCID: PMC6588421 DOI: 10.1016/j.amjmed.2019.01.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 01/08/2019] [Accepted: 01/08/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Vitamin K antagonists (VKA) are the most widely used anticoagulants, and bridging is commonly administered during periprocedural VKA interruption. Given the unclear benefits and risks of periprocedural bridging in patients with previous venous thromboembolism, we aimed to assess recurrent venous thromboembolism and bleeding outcomes with and without bridging in this population. METHODS We performed a systematic review searching the PubMed and Embase databases from inception to December 7, 2017 for randomized and nonrandomized studies that included adults with previous venous thromboembolism requiring VKA interruption to undergo an elective procedure, and that reported venous thromboembolism or bleeding outcomes. Quality of evidence was graded by consensus. RESULTS We included 28 cohort studies (20 being single-arm cohorts) with, overall, 6915 procedures for analysis. In 27 studies reporting perioperative venous thromboembolism outcomes, the pooled incidence of recurrent venous thromboembolism with bridging was 0.7% (95% confidence interval [CI], 0.4%-1.2%) and 0.5% (95% CI, 0.3%-0.8%) without bridging. Eighteen studies reported major or nonmajor bleeding outcomes. The pooled incidence of any bleeding was 3.9% (95% CI, 2.0%-7.4%) with bridging and 0.4% (95% CI, 0.1%-1.7%) without bridging. In bridged patients at high thromboembolic risk, the pooled incidence for venous thromboembolism was 0.8% (95% CI, 0.3%-2.5%) and 7.5% (95% CI, 3.1%-17.4%) for any bleeding. Quality of available evidence was very low, primarily due to a high risk of bias of included studies. CONCLUSIONS Periprocedural bridging increases the risk of bleeding compared with VKA interruption without bridging, without a significant difference in periprocedural venous thromboembolism rates.
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Affiliation(s)
- Christine Baumgartner
- Division of Hospital Medicine, University of California, San Francisco; Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Evans Whitaker
- UCSF Medical Library, University of California, San Francisco
| | - Margaret C Fang
- Division of Hospital Medicine, University of California, San Francisco.
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Brainard BM, Buriko Y, Good J, Ralph AG, Rozanski EA. Consensus on the Rational Use of Antithrombotics in Veterinary Critical Care (CURATIVE): Domain 5-Discontinuation of anticoagulant therapy in small animals. J Vet Emerg Crit Care (San Antonio) 2019; 29:88-97. [PMID: 30654425 DOI: 10.1111/vec.12796] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 12/10/2018] [Accepted: 12/08/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To systematically evaluate the evidence supporting the timing and mechanisms of permanent or temporary discontinuation of antiplatelet or anticoagulant medications in small animals DESIGN: Standardized, systematic evaluation of the literature, categorization of relevant articles according to level of evidence and quality (poor, fair, or good), and development of consensus on conclusions via a Delphi-style survey for application of the concepts to clinical practice. SETTINGS Academic and referral veterinary medical centers. RESULTS Databases searched included Medline via PubMed and CAB abstracts. Two specific courses of inquiry were pursued, one focused on appropriate approaches to use for small animal patients receiving antiplatelet or anticoagulant drugs and requiring temporary discontinuation of this therapy for the purposes of invasive procedures (eg, surgery), and the other aimed at decision-making for the complete discontinuation of anticoagulant medications. In addition, the most appropriate methodology for discontinuation of heparins was addressed. CONCLUSIONS To better define specific patient groups, a risk stratification characterization was developed. It is recommended to continue anticoagulant therapy through invasive procedures in patients at high risk for thrombosis that are receiving anticoagulant therapy, while consideration for discontinuation in patients with low to moderate risk of thrombosis is reasonable. In patients with thrombosis in whom the underlying cause for thrombosis has resolved, indefinite treatment with anticoagulant medication is not recommended. If the underlying cause is unknown or untreatable, anticoagulant medication should be continued indefinitely. Unfractionated heparin therapy should be slowly tapered rather than discontinued abruptly.
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Affiliation(s)
- Benjamin M Brainard
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA
| | - Yekaterina Buriko
- Department of Clinical Studies, Philadelphia, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jennifer Good
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA
| | | | - Elizabeth A Rozanski
- Department of Clinical Sciences, Tufts Cummings School of Veterinary Medicine, North Grafton, MA
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Management of dental extractions in patients on warfarin and antiplatelet therapy. J Formos Med Assoc 2018; 117:979-986. [PMID: 30195969 DOI: 10.1016/j.jfma.2018.08.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 08/14/2018] [Accepted: 08/20/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND/PURPOSE Planning dental extractions for Taiwanese patients on antithrombotic therapy remains controversial. This study aimed to examine management of dental extraction in patients on warfarin and antiplatelet therapy. METHODS Subjects comprised 1331 patients, with (1) 60 on warfarin with intentional normalized ratio (INR) below 4.0 (warfarin continued: 28 patients/33 occasions; warfarin stopped and switched to heparin under hospitalization: 32 patients/37 occasions); (2) 183 on antiplatelet therapy (aspirin: 125 patients/185 occasions; clopidogrel: 42 patients/65 occasions; dual therapy: 16 patients/24 occasions); and (3) a control group of 1088 patients/1472 occasions without any antithrombotic therapy. The patient's clinico-demographic parameters, warfarin effectiveness (dose and INR levels) and antiplatelet therapy, number and type of dental extraction and incidence of postoperative bleeding were investigated. RESULTS Incidence of postoperative bleeding in the warfarinized group (warfarin continued: 9.1%; warfarin stopped: 8.1%) was higher than in the antiplatelet group (aspirin: 1.1%; clopidogrel: 3.1%; dual antiplatelet: 4.2%), and the control group (0.7%), but these differences were not significant and unrelated to INR or number and type of dental extraction. Postoperative hemorrhage was managed successfully by repacking with Gelfoam impregnated with tranexamic acid powder in most patients. CONCLUSION The study indicated that there is no need to interrupt warfarin (INR<4.0) and antiplatelet therapy before dental extractions in Taiwanese patients. A sufficient hemostasis could be obtained using local measures. This approach can save these individuals from becoming exposed to the risk of thromboembolism and the inconvenience of bridging anticoagulation with heparin.
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Johnson SA, LaBrin J. Periprocedural Bridging Anticoagulation. J Hosp Med 2018; 13:198-201. [PMID: 29364991 DOI: 10.12788/jhm.2899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Stacy A Johnson
- University of Utah Health Thrombosis Service, Salt Lake City, Utah, USA.
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Joshua LaBrin
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Boer C, Meesters MI, Milojevic M, Benedetto U, Bolliger D, von Heymann C, Jeppsson A, Koster A, Osnabrugge RL, Ranucci M, Ravn HB, Vonk AB, Wahba A, Pagano D. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. J Cardiothorac Vasc Anesth 2018; 32:88-120. [DOI: 10.1053/j.jvca.2017.06.026] [Citation(s) in RCA: 203] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Indexed: 01/28/2023]
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Safety of percutaneous nephrolithotomy in patients on chronic anticoagulant or antiplatelet therapy. Urolithiasis 2018; 46:581-585. [DOI: 10.1007/s00240-018-1034-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 01/10/2018] [Indexed: 12/23/2022]
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Feng L, Li Y, Li J, Yu B. Oral anticoagulation continuation compared with heparin bridging therapy among high risk patients undergoing implantation of cardiac rhythm devices. Thromb Haemost 2017; 108:1124-31. [DOI: 10.1160/th12-07-0498] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Accepted: 09/16/2012] [Indexed: 01/29/2023]
Abstract
SummaryIt was the objective of this study to systematically compare the effects of oral anticoagulation (OAC) with heparin bridging therapy among patients at high risk for thromboembolism undergoing implantation of cardiac rhythm devices. A systematic search of PubMed/MEDLINE, Ovid and Elsevier, and the Cochrane Library databases was conducted. Six trials that met our inclusion criteria were identified and included in the present study. The endpoints of this meta-analysis included pocket haematoma, severe haematoma requiring drainage/revision, thromboembolic events, and length of hospital stay. Data were expressed as odds ratios (ORs) and 95% confidence interval (CIs). There was a statistically significant reduction of pocket haematoma (OR 0.29, 95% CI: 0.17 to 0.49, p<0.00001) and haematoma drainage/revision (OR 0.15, 95%CI: 0.04 to 0.54, p=0.004), respectively, in the OAC continuation group versus the heparin bridging group. We did not detect any statistically sig- nificant differences of thromboembolic events (OR 0.48, 95%CI: 0.07 to 3.54, p=0.48) in the two groups. There was a trend that patients in bridging group had longer hospital stays. In conclusion, OAC continu- ation had a better risk-beneficial ratio and shorter length of hospital stay, and was more convenient to implement compared with heparin bridging therapy among patients at high risk for thromboembolism undergoing implantation of cardiac rhythm devices.
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Omran H, Bauersachs R, Rübenacker S, Goss F, Hammerstingl C. The HAS-BLED score predicts bleedings during bridging of chronic oral anticoagulation. Thromb Haemost 2017; 108:65-73. [PMID: 22534746 DOI: 10.1160/th11-12-0827] [Citation(s) in RCA: 128] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Accepted: 04/12/2012] [Indexed: 01/10/2023]
Abstract
SummaryPatients who receive long-term oral anticoagulant (OAC) therapy often require interruption of OAC for an elective invasive procedure. Current guidelines allow bridging therapy with either unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH). Apart from the risk of embolism, bleeding is an important complication in this setting and the optimal perioperative management of such patients is still under discussion. The aims of this prospective, observational, multicentre registry of patients treated by cardiologists were: 1) to evaluate current practice of perioperative management of OAC in a large outpatient cohort, 2) to document embolic and haemorrhagic events, and 3) to identify risk factors predicting adverse events. In the years 2009 and 2010, 1,000 invasive procedures (cardiac catheterisation n=533, pacemaker implantation n = 128, surgery n = 194, other n = 145) were performed in patients with OAC. Sixty- one (6.1%) of those patients did not receive bridging therapy during interruption of OAC, 937 (93.7%) patients were treated with LMWH, two patients (0.2%) received UFH. In 22 patients (2.2%) LMWHs were given in prophylactic dose, 727 patients (72.7%) were treated with halved therapeutic (i.e. weight-adapted) LMWH doses and 188 (18.8%) received full therapeutic LMWH doses. Four thromboembolic complications were observed during 30 days of follow-up (two retinal embolisms, one stroke, one myocardial infarction; 0.4%). One major bleeding (0.1%) and 35 clinically relevant bleedings (3.5%) occurred. Rehospitalisation after bleedings was necessary in 20 patients. Independent predictors for bleedings were history of mechanical heart valve replacement (MVR) (p=0.0002) and the HAS-BLED score (<0.0001), with a cut off value ≥3 being the most predictive variable for haemorrhage (hazard ratio 11.8, 95% confidence interval 5.6–24.9, p<0.0001). A total of 527 patients with atrial fibrillation and a CHADS2 score ≤2 received halved therapeutic or full therapeutic dosages of LMWH despite a low embolic risk, whereas 49 of the patients with heart valve replacement (51%) did not receive dosages of bridging therapy as recommended in guidelines. In conclusion, in this registry of patients treated by cardiologists, 94% of patients who required interruption of OAC before invasive procedures received LMWH as a bridging therapy, of whom 73% were treated with halved therapeutic LMWH-dosages. Guideline recommendations were followed in only 31% of cases. Importantly, 69% of patients with AF were over-treated while 51% of patients with heart valve replacement were under-treated with LMWHs. A HASB-BLED score ≥3 was highly predictive of bleeding events.
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Abstract
In patients with atrial fibrillation (AF), oral anticoagulation is used to prevent stroke and systemic embolism. In a common clinical scenario, AF patients frequently undergo invasive procedures requiring temporary interruption of oral anticoagulation, thereby potentially exposing such patients to increased risk of thromboembolism. Bridging anticoagulation has been used clinically to mitigate this perceived thromboembolic risk, though this practice may also increase risk of periprocedural bleeding. High-quality data has not previously existed to inform decision-making in this clinical situation of bridging anticoagulation. We discuss recent results from the BRIDGE trial and secondary analyses from recent phase 3 randomized clinical trials of direct-acting oral anticoagulant (DOAC) use in non-valvular AF, that inform periprocedural anticoagulation with bridging strategies in AF patients. Updated data from these current trials favor against a strategy of bridging anticoagulation for elective procedures in the majority of AF patients, low or moderate in thromboembolic risk. Bridging anticoagulation is associated with an increased risk of bleeding and no decreased risk of thromboembolism.
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Sousa-Uva M, Head SJ, Milojevic M, Collet JP, Landoni G, Castella M, Dunning J, Gudbjartsson T, Linker NJ, Sandoval E, Thielmann M, Jeppsson A, Landmesser U. 2017 EACTS Guidelines on perioperative medication in adult cardiac surgery. Eur J Cardiothorac Surg 2017; 53:5-33. [PMID: 29029110 DOI: 10.1093/ejcts/ezx314] [Citation(s) in RCA: 238] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Pagano D, Milojevic M, Meesters MI, Benedetto U, Bolliger D, von Heymann C, Jeppsson A, Koster A, Osnabrugge RL, Ranucci M, Ravn HB, Vonk ABA, Wahba A, Boer C. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. Eur J Cardiothorac Surg 2017; 53:79-111. [DOI: 10.1093/ejcts/ezx325] [Citation(s) in RCA: 192] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Cheng HYHH, Cheung VYT. Patients on Long-Term Warfarin Undergo Gynecological Surgeries: A 10-Year Review of Perioperative Anticoagulation. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 40:199-204. [PMID: 28821415 DOI: 10.1016/j.jogc.2017.05.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 05/30/2017] [Accepted: 05/31/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The aim of this study was to review our experience with patients having gynaecological surgeries while on long-term anticoagulation and to postulate a better guide for their perioperative management. MATERIAL AND METHODS A retrospective review of all women on long-term warfarin who underwent gynaecological surgeries from January 2003 to December 2012. Data from medical records including operation reports and inpatient and outpatient charts were reviewed and analyzed. RESULTS Sixty-seven cases from 58 patients were identified. Twenty and 38 patients underwent major and minor gynaecological surgeries, respectively. The incidence of postoperative bleeding was higher after major surgery (4 cases, 20%) than after minor surgery (1 case, 2.1%; P = 0.025). All bleeding complications occurred between postoperative day 3 and day 10. Three patients, who had resumption of warfarin at a lower dose and slowly stepped up, had no bleeding complications. None of our patients developed venous thromboembolic complications. There was one mortality due to septic shock. CONCLUSION Patients on long-term anticoagulation have a trend of increased bleeding complications after major gynaecological surgeries than in minor gynaecological surgeries. We suggest that delaying resumption of warfarin at a lower dose may have a role in reducing the risk of postoperative bleeding without increasing the risk of venous thromboembolism.
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Affiliation(s)
| | - Vincent Y T Cheung
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, Hong Kong
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Lum DJ, Ross PA, Bishop MA, Caetano ML, Malpani R, Streiff MB. Evaluation of a Standardized Perioperative Management Protocol in the Adult Hematology Anticoagulation Management Service. Ann Pharmacother 2017; 51:1077-1083. [PMID: 28677422 DOI: 10.1177/1060028017719505] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In North America, 250,000 patients on vitamin K antagonists require surgical procedures each year. Temporary interruption of oral anticoagulation and perioperative bridging therapy with unfractionated heparin or low-molecular-weight heparin are recommended by the American College of Chest Physicians 2012 for select patients. OBJECTIVES The study objectives are to evaluate adherence and nonadherence to the Johns Hopkins clinic guidelines for perioperative management of anticoagulation and identify bleeding or thromboembolic events during perioperative management of anticoagulation. METHODS This is a retrospective study of patients who required perioperative management of anticoagulation for an invasive procedure from May 2009 to March 2014. Individualized perioperative anticoagulation management plans were prospectively developed for each patient according to the standardized Johns Hopkins perioperative bridging recommendations and documented in the medical record. Adherence to these standardized Johns Hopkins clinic guidelines, the incidence of thromboembolic events, and bleeding and adverse events during perioperative management were retrieved from the medical record. RESULTS In 294 perioperative management cases, there was 1 (0.3%) thromboembolism, 3 (1%) major bleeds, and 21 (7%) minor bleeds. One patient experienced facial swelling after starting enoxaparin. There was no difference in thromboembolic (0 vs 1, P = 1.00), major (1 vs 2, P = 1.00), or minor bleeding (14 vs 7, P = 1.00) events in patients managed by providers who were adherent to guidelines when compared with providers who were nonadherent. CONCLUSION Our study shows that using a standardized guideline for perioperative management of anticoagulation to inform but not to dictate clinical practice leads to low rates of both thromboembolism and bleeding.
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Affiliation(s)
- Diane J Lum
- 1 The Johns Hopkins Hospital, Baltimore, MD, USA.,2 Stony Brook University Hospital, Stony Brook, NY, USA
| | | | | | | | | | - Michael B Streiff
- 1 The Johns Hopkins Hospital, Baltimore, MD, USA.,5 The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Hwang HG, Koo SM, Uh ST, Kim YK. The Perioperative Management of Antithrombotic Therapies Using Enoxaparin. J Korean Med Sci 2017; 32:942-947. [PMID: 28480651 PMCID: PMC5426250 DOI: 10.3346/jkms.2017.32.6.942] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 03/11/2017] [Indexed: 12/16/2022] Open
Abstract
Oral anticoagulant therapy is frequently and increasingly prescribed for patients at risk of arterial or venous thromboembolism (VTE). Although elective surgical or invasive procedures have necessitated temporary interruption of anticoagulants, managing these patients has been performed empirically and been poorly investigated. This study was designed to evaluate the adequacy of perioperative anticoagulation using enoxaparin. This was a retrospective, single-center study that evaluated the efficacy and safety of therapeutic-dose enoxaparin for bridging therapy in patients on long-term warfarin at Soonchunhyang University Hospital in Korea between August 2009 and July 2011. Warfarin was discontinued 5 days before surgery, and enoxaparin was administered twice daily by subcutaneous injection at a dose of 1 mg per kg from 3 days before the procedure to the last dose 24 hours before the procedure. Anticoagulation was restarted if proper hemostasis had been confirmed. There were 49 patients, of whom 25 (51%) were men, and the mean age was 63 years. Thirty-four (69%) received warfarin therapy for VTE, and 9 (18%) for atrial fibrillation. Twenty-nine patients (59%) underwent major surgery and 20 (41%) minor surgery. The mean postoperative duration of enoxaparin was 4 days. No patients had thromboembolic complications through 30 days after the procedure. The overall 30-day mortality rate was 0%. In conclusion, our findings demonstrate that bridging therapy with therapeutic-dose enoxaparin is feasible and associated with a low incidence of major bleeding and no thromboembolic complications. However, the optimal approach to managing patients perioperatively is uncertain and requires further evaluation.
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Affiliation(s)
- Hun Gyu Hwang
- Depertment of Internal Medicine, Soonchunhyang University Gumi Hospital, Gumi, Korea
| | - So My Koo
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Soo Taek Uh
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Yang Ki Kim
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea.
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Sánchez Fuentes D, Budiño Sánchez M, López Sánchez M. Use of oral anticoagulation for patients who undergo invasive procedures. Rev Clin Esp 2017. [DOI: 10.1016/j.rceng.2016.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Doherty JU, Gluckman TJ, Hucker WJ, Januzzi JL, Ortel TL, Saxonhouse SJ, Spinler SA. 2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation. J Am Coll Cardiol 2017; 69:871-898. [DOI: 10.1016/j.jacc.2016.11.024] [Citation(s) in RCA: 279] [Impact Index Per Article: 39.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Abstract
Periprocedural anticoagulation bridging is recommended to reduce the risk of thromboembolic events in patients at a higher risk of developing thromboembolism during the perioperative period. The optimal periprocedural anticoagulation strategy has not been established. Unfractionated heparin and low molecular heparin are used in preventing thromboembolism in the special population. Novel oral anticoagulants that directly inhibit thrombin (dabigatran) or factor Xa (rivaroxaban, apixaban) are shown as effective anticoagulants in preventing thromboembolism (venous thromboembolism) in various medical conditions. They have the advantage of having a faster onset, shorter half-lives, easier monitoring, and predicable doses. But there are disadvantages to newer anticoagulants such as the unavailability of definitive reversal agents and lack of data in patients with renal insufficiency. We review the latest evidence on the effects of newer oral anticoagulants in preventing thromboembolism and its bleeding risks.
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Results of surgery in general surgical patients receiving warfarin: retrospective analysis of 61 patients. Int Surg 2016; 100:225-32. [PMID: 25692422 DOI: 10.9738/intsurg-d-14-00139.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The aim of this study is to investigate postoperative complications, mortality rates, and to determine the factors affecting mortality on the patients receiving warfarin therapy preoperatively, as well as comparing the results obtained from emergency and elective surgeries. Surgical outcomes of 61 patients on long-term oral anticoagulation with warfarin who underwent surgery in our center were retrospectively reviewed over an 8-year period. Thirty-three (54.1%) patients were female, with a mean age of 53 years. Mitral valve replacement (62.3%) was the most frequent indication for chronic anticoagulation therapy. Twelve out of 61 (19.2%) patients underwent emergency surgery; 59 (96.7%) operations were classified as major surgery. We did not observe any thromboembolic events on patients receiving our bridging therapy protocol. Cardiopulmonary dysfunction (CPD; 19.7%) and hemorrhage (16.4%) were the most encountered postoperative complications. Presence of CPD, bleeding, endocarditis, and mortality were statistically significant for emergency surgeries when compared with the results obtained from elective surgeries. There were 5 (8.2%) deaths observed during follow-up. It was found that advanced age, prolonged duration of operations, and presence of CPD had a statistically significant effect on mortality (P < 0.05). The patients receiving oral anticoagulant had high postoperative complication and mortality rates. This case was more evident in emergency surgeries. It is recommendable that as mortality is more apparent in the patients who undergo emergency surgeries-being older, having long duration of operations as well as CPD. Therefore during the postoperative follow-up process, the patients should be closely monitored.
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Halaszynski TM. Administration of Coagulation-Altering Therapy in the Patient Presenting for Oral Health and Maxillofacial Surgery. Oral Maxillofac Surg Clin North Am 2016; 28:443-460. [PMID: 27745616 DOI: 10.1016/j.coms.2016.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Oral health care providers are concerned with how to manage patients prescribed coagulation-altering therapy during the perioperative/periprocedural period for dental and oral surgery interventions. Management and recommendation can be based on medication pharmacology and the clinical relevance of coagulation factor levels/deficiencies. Caution should be used with concurrent use of medications that affect other components of the clotting mechanisms; prompt diagnosis and any necessary intervention to optimize outcome is warranted. However, evidence-based data on management of anticoagulation therapy during oral and maxillofacial surgery/interventions is lacking. Therefore, clinical understanding and judgment are needed along with appropriate guidelines matching patient- and intervention-specific recommendations.
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Affiliation(s)
- Thomas M Halaszynski
- Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, TMP 3 Library, New Haven, CT 203 785-2804, USA.
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Sánchez Fuentes D, Budiño Sánchez MA, López Sánchez MP. Use of oral anticoagulation for patients who undergo invasive procedures. Rev Clin Esp 2016; 217:103-107. [PMID: 27457052 DOI: 10.1016/j.rce.2016.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 06/08/2016] [Indexed: 01/22/2023]
Abstract
The performance of invasive procedures in patients undergoing oral anticoagulation represents a risk. Without conclusive data on this issue, the recommendations on managing oral anticoagulation are generally weak, and its management is controversial and heterogeneous. We conducted a review of the evidence on the elective periprocedural management of oral anticoagulation following the publication of the 9th edition of the guidelines of the American College of Chest Physicians. Except for cases of procedures with minimal haemorrhagic risk, the use of oral anticoagulants is suspended with sufficient time so that it can be performed without a significant anticoagulant effect, which will depend on the half-life of the drug. For direct oral anticoagulants, the half-life is determined by the renal function. Recent studies have shown that the use of bridge therapy with heparin in patients who temporarily suspended the use of oral anticoagulation provided no benefits and increased the bleeding. However, there is no conclusive evidence against its use in patients with a high thromboembolic risk.
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Affiliation(s)
- D Sánchez Fuentes
- Servicio de Medicina Interna, Complejo Asistencial de Ávila , Ávila, España.
| | - M A Budiño Sánchez
- Servicio de Medicina Interna, Complejo Asistencial de Ávila , Ávila, España
| | - M P López Sánchez
- Medicina Familiar y Comunitaria, ABS Santa Coloma de Farnés, Gerona, España
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Risk stratification, perioperative and periprocedural management of the patient receiving anticoagulant therapy. J Clin Anesth 2016; 34:586-99. [PMID: 27687455 DOI: 10.1016/j.jclinane.2016.06.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 06/02/2016] [Accepted: 06/07/2016] [Indexed: 01/10/2023]
Abstract
As a result of the aging US population and the subsequent increase in the prevalence of coronary disease and atrial fibrillation, therapeutic use of anticoagulants has increased. Perioperative and periprocedural management of anticoagulated patients has become routine for anesthesiologists, who frequently mediate communication between the prescribing physician and the surgeon and assess the risks of both thromboembolic complications and hemorrhage. Data from randomized clinical trials on perioperative management of antithrombotic therapy are lacking. Therefore, clinical judgment is typically needed regarding decisions to continue, discontinue, bridge, or resume anticoagulation and regarding the time points when these events should occur in the perioperative period. In this review, we will discuss the most commonly used anticoagulants used in outpatient settings and discuss their management in the perioperative period. Special considerations for regional anesthesia and interventional pain procedures will also be reviewed.
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Spyropoulos AC, Al-Badri A, Sherwood MW, Douketis JD. Periprocedural management of patients receiving a vitamin K antagonist or a direct oral anticoagulant requiring an elective procedure or surgery. J Thromb Haemost 2016; 14:875-85. [PMID: 26988871 DOI: 10.1111/jth.13305] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 02/10/2016] [Indexed: 11/28/2022]
Abstract
The periprocedural management of patients receiving chronic therapy with oral anticoagulants (OACs), including vitamin K antagonists (VKAs) such as warfarin and direct OACs (DOACs), is a common clinical problem. The optimal perioperative management of patients receiving chronic OAC therapy is anchored on four key principles: (i) risk stratification of patient-related and procedure-related risks of thrombosis and bleeding; (ii) the clinical consequences of a thrombotic or bleeding event; (iii) discontinuation and reinitiation of OAC therapy on the basis of the pharmacokinetic properties of each agent; and (iv) whether aggressive management such as the use of periprocedural heparin bridging has advantages for the prevention of postoperative thromboembolism at the cost of a possible increase in bleeding risk. Recent data from randomized trials in patients receiving VKAs undergoing pacemaker/defibrillator implantation or using heparin bridging therapy for elective procedures or surgeries can now inform best practice. There are also emerging data on periprocedural outcomes in the DOAC trials for patients with non-valvular atrial fibrillation. This review summarizes the evidence for the periprocedural management of patients receiving chronic OAC therapy, focusing on recent randomized trials and large outcome studies, to address three key clinical scenarios: (i) can OAC therapy be safely continued for minor procedures or surgeries; (ii) if therapy with VKAs (especially warfarin) needs to be temporarily interrupted for an elective procedure/surgery, is heparin bridging necessary; and (iii) what is the optimal periprocedural management of the DOACs? In answering these questions, we aim to provide updated clinical guidance for the periprocedural management of patients receiving VKA or DOAC therapy, including the use of heparin bridging.
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Affiliation(s)
- A C Spyropoulos
- Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Hofstra North Shore/LIJ School of Medicine, North Shore/LIJ Health System, Manhasset, NY, USA
| | - A Al-Badri
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - M W Sherwood
- Durham VA Medical Center, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC, USA
| | - J D Douketis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Johnston S. An evidence summary of the management of the care of patients taking novel oral antiplatelet drugs undergoing dental surgery. J Am Dent Assoc 2016; 147:271-7. [DOI: 10.1016/j.adaj.2015.11.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 11/02/2015] [Accepted: 11/09/2015] [Indexed: 02/02/2023]
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Spencer RJ, Amerena JV. Rivaroxaban in the Prevention of Stroke and Systemic Embolism in Patients with Non-Valvular Atrial Fibrillation: Clinical Implications of the ROCKET AF Trial and Its Subanalyses. Am J Cardiovasc Drugs 2015; 15:395-401. [PMID: 26062914 DOI: 10.1007/s40256-015-0127-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Atrial fibrillation (AF) is an increasingly common cause of stroke and systemic embolism. While warfarin has been the mainstay of stroke prevention in patients with AF, newer novel oral anticoagulant medications are now available. Rivaroxaban, a direct factor Xa inhibitor with a rapid onset and offset after oral administration, offers potential advantages over warfarin, predominantly due to its predictable pharmacokinetics across wide patient populations. It requires no coagulation monitoring, and only two different doses are needed (20 mg daily for patients with normal renal function and 15 mg daily in those with reduced renal function). A large randomized trial (ROCKET AF) has shown non-inferiority to warfarin for preventing stroke or systemic embolism in the per-protocol population and superiority to warfarin in the on-treatment safety population. Several subanalyses confirm that the treatment effect of rivaroxaban is consistent across different patient subgroups, including those with reduced renal function. The tolerability of rivaroxaban appears similar to that of warfarin, with comparable overall bleeding rates in clinical trials. In ROCKET AF, significantly lower rates of fatal and intracranial bleeding were seen with rivaroxaban, while lower rates of gastrointestinal bleeding were seen with warfarin. Important contraindications to rivaroxaban include valvular AF, the presence of a prosthetic valve (mechanical or bioprosthetic) or valve repair, the need for concurrent dual antiplatelet therapy, and creatinine clearance <30 ml/min. Once-daily dosing and the lack of coagulation monitoring may increase utilization and adherence compared with warfarin, potentially decreasing the large burden of care associated with stroke secondary to AF. Overall, rivaroxaban offers a useful alternative to warfarin for stroke prevention in patients with AF.
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Haighton M, Kempen DHR, Wolterbeek N, Marting LN, van Dijk M, Veen RMR. Bridging therapy for oral anticoagulation increases the risk for bleeding-related complications in total joint arthroplasty. J Orthop Surg Res 2015; 10:145. [PMID: 26384316 PMCID: PMC4573310 DOI: 10.1186/s13018-015-0285-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 09/01/2015] [Indexed: 01/29/2023] Open
Abstract
Background Patients scheduled for elective surgery with a high risk of thromboembolism require anticoagulation bridging therapy perioperatively. The purpose of this study was to assess the risk of thromboembolic events and bleeding-related complications after total hip and knee arthroplasty in patients requiring bridging therapy for anticoagulants. Methods A retrospective cohort study of all patients with primary total hip or total knee replacement in a 4-year period was performed. Outcome measures were blood loss, thromboembolic and bleeding-related complications and hospital stay. Results Bridged patients had more blood loss and higher complication rates than the control group. Most complications were bleeding-related, and there were no thromboembolic events. Seven of the 14 (50 %) total hip patients bridged with unfractioned heparin required reoperation (three patients with ischial neuropraxia due to hematoma). There were two bleeding-related deaths in total hip patients bridged with low-molecular-weight heparin. Mean hospital stay was significantly longer in unfractioned heparin bridging. Conclusion In this study, there was a significant increase in bleeding-related complications in total joint replacement with bridging therapy compared to prophylaxis. This risk was highest in patients with total hip arthroplasty. There were no thromboembolic events in bridged patients.
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Affiliation(s)
- Martijn Haighton
- Department of Orthopaedic Surgery, St. Antonius Hospital, P.O. Box 2500, 3430, EM, Utrecht, The Netherlands.
| | - Diederik H R Kempen
- Department of Orthopaedic Surgery, OLVG Hospital, Oosterpark 9, 1091, AC, Amsterdam, The Netherlands.
| | - Nienke Wolterbeek
- Department of Orthopaedic Surgery, St. Antonius Hospital, P.O. Box 2500, 3430, EM, Utrecht, The Netherlands.
| | - Louis N Marting
- Department of Orthopaedic Surgery, St. Antonius Hospital, P.O. Box 2500, 3430, EM, Utrecht, The Netherlands.
| | - Martijn van Dijk
- Department of Orthopaedic Surgery, St. Antonius Hospital, P.O. Box 2500, 3430, EM, Utrecht, The Netherlands.
| | - Remmelt M R Veen
- Department of Orthopaedic Surgery, St. Antonius Hospital, P.O. Box 2500, 3430, EM, Utrecht, The Netherlands.
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Dundon JM, Trimba R, Bree KJ, Woods CJ, Laughlin RT. Recommendations for Perioperative Management of Patients on Existing Anticoagulation Therapy. JBJS Rev 2015; 3:01874474-201509000-00002. [PMID: 27490669 DOI: 10.2106/jbjs.rvw.n.00105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- John M Dundon
- Department of Orthopaedic Surgery, Sports Medicine & Rehabilitation, Boonshoft School of Medicine, Wright State University, 30 East Apple Street, Suite 2200, Dayton, OH 45409
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