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Hofer S, Schlimp CJ, Casu S, Grouzi E. Management of Coagulopathy in Bleeding Patients. J Clin Med 2021; 11:jcm11010001. [PMID: 35011742 PMCID: PMC8745606 DOI: 10.3390/jcm11010001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/10/2021] [Accepted: 12/14/2021] [Indexed: 02/06/2023] Open
Abstract
Early recognition of coagulopathy is necessary for its prompt correction and successful management. Novel approaches, such as point-of-care testing (POC) and administration of coagulation factor concentrates (CFCs), aim to tailor the haemostatic therapy to each patient and thus reduce the risks of over- or under-transfusion. CFCs are an effective alternative to ratio-based transfusion therapies for the correction of different types of coagulopathies. In case of major bleeding or urgent surgery in patients treated with vitamin K antagonist anticoagulants, prothrombin complex concentrate (PCC) can effectively reverse the effects of the anticoagulant drug. Evidence for PCC effectiveness in the treatment of direct oral anticoagulants-associated bleeding is also increasing and PCC is recommended in guidelines as an alternative to specific reversal agents. In trauma-induced coagulopathy, fibrinogen concentrate is the preferred first-line treatment for hypofibrinogenaemia. Goal-directed coagulation management algorithms based on POC results provide guidance on how to adjust the treatment to the needs of the patient. When POC is not available, concentrate-based management can be guided by other parameters, such as blood gas analysis, thus providing an important alternative. Overall, tailored haemostatic therapies offer a more targeted approach to increase the concentration of coagulation factors in bleeding patients than traditional transfusion protocols.
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Affiliation(s)
- Stefan Hofer
- Department of Anaesthesiology, Westpfalz-Klinikum Kaiserslautern, 67655 Kaiserlautern, Germany
- Correspondence: ; Tel.: +49-631-203-1030
| | - Christoph J. Schlimp
- Department of Anaesthesiology and Intensive Care, AUVA Trauma Hospital Linz, 4010 Linz, Austria;
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Center, 1200 Vienna, Austria
| | - Sebastian Casu
- Emergency Department, Asklepios Hospital Wandsbek, 22043 Hamburg, Germany;
| | - Elisavet Grouzi
- Transfusion Service and Clinical Hemostasis, Saint Savvas Oncology Hospital, 115 22 Athens, Greece;
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Hsu C, Hutt E, Bloomfield DM, Gailani D, Weitz JI. Factor XI Inhibition to Uncouple Thrombosis From Hemostasis: JACC Review Topic of the Week. J Am Coll Cardiol 2021; 78:625-631. [PMID: 34353538 DOI: 10.1016/j.jacc.2021.06.010] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/07/2021] [Accepted: 06/08/2021] [Indexed: 11/29/2022]
Abstract
Hemostasis and thrombosis are believed to be so intricately linked that any strategies that reduce thrombosis will have an inevitable impact on hemostasis. Consequently, bleeding is viewed as an unavoidable side effect of anticoagulant therapy. Emerging evidence suggests that factor XI is important for thrombosis but has a minor role in hemostasis. This information raises the possibility that anticoagulants that target factor XI will be safer than currently available agents. The authors provide a visual representation of the coagulation pathways that distinguishes between the steps involved in thrombosis and hemostasis to explain why factor XI inhibitors may serve as hemostasis-sparing anticoagulants. A safer class of anticoagulants would provide opportunities for treatment of a wider range of patients, including those at high risk for bleeding. Ongoing clinical studies will determine the extent to which factor XI inhibitors attenuate thrombosis without disruption of hemostasis.
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Affiliation(s)
- Charles Hsu
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jeffrey I Weitz
- Departments of Medicine and Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada.
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Pizzorno J, Pizzorno L. Commonly Prescribed and Over-the-Counter Drugs as Secondary Causes of Osteoporosis-Part Two. Integr Med (Encinitas) 2021; 20:8-14. [PMID: 34377095 PMCID: PMC8325506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
In this second of a 2-part editorial, we continue our discussion of the importance of being aware that some clinically important prescription drugs can impair bone metabolism. While obviously most critical for women (and men) with osteopenia or osteoporosis, the guidance here is directly relevant to all patients as many are already experiencing decreased bone regeneration even if not severe enough for a formal diagnosis. Part One covered aromatase inhibitors, gonadotropin-releasing hormone agonists, anticonvulsants, benzodiazepines, antidepressants, insulin sensitizers, and NSAIDs and acetaminophen. Part Two covers opioids, glucocorticoids, calcineurin inhibitors, gastric acid blockers, diuretics, anti-coagulants, thyroid hormone medications, and contraceptives.
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Quintas S, Zapata-Wainberg G, Arias-Rivas S, Ximénez-Carrillo Á, Castillo J, Benavente Fernández L, Masjuan Vallejo J, Freijó Guerrero MDM, Egido J, García Pastor A, Cardona P, Lago A, Castellanos Rodrigo M, Fuentes B, Sobrado M, Vivancos J. Time Trends in Intracerebral Hemorrhage Associated with Oral Anticoagulation and Its Risks Factors in Spain from 2008 to 2015. Eur Neurol 2020; 84:16-21. [PMID: 33321486 DOI: 10.1159/000511603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/08/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) is 7- to 10-fold higher in anticoagulated patients. Given the more extended use of oral anticoagulants, an increase in the prevalence of ICH associated with oral anticoagulation (ICH-OAC) could be expected. However, there is no previous study that assesses the time trends of ICH-OAC in Spain. METHODS We conducted a combined data analysis after creating a joint database of the 3 most important epidemiological studies on ICH-OAC of our country: the EPICES study (2008-2009), the TAC Registry (TR) study (2012-2013) and the TAC Registry 2 (TR2) study (2015). We finally included 65, 235, and 366 patients from the EPICES, TR, and TR2 studies, respectively. RESULTS We have observed a 3.73-fold increase in the crude annual incidence of ICH-OAC throughout the period of study, with proportion of ICH-OAC out of total ICH increasing from 8.4% in 2008 to 18.2% in 2015. Age, dyslipidemia, and prior antiplatelet treatment increased during the study, but we found no statistically significant differences in other risk factors for ICH-OAC. CONCLUSIONS The incidence of ICH-OAC is increasing in our country. It might at least be partly explained by aging of the population, with mean age at presentation being higher in the last years.
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Affiliation(s)
- Sonia Quintas
- Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria La Princesa, Madrid, Spain,
| | - Gustavo Zapata-Wainberg
- Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
| | | | - Álvaro Ximénez-Carrillo
- Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
| | - Jose Castillo
- Clinical Neurosciences Research Laboratory, Health Research Institute of Santiago de Compostela, Santiago de Compostela, Spain
| | | | - Jaime Masjuan Vallejo
- Servicio de Neurología, Hospital Universitario Ramón y Cajal, Departamento de Medicina, Facultad de Medicina, Universidad de Alcalá, IRYCIS, Madrid, Spain
| | | | - José Egido
- Hospital Clínico San Carlos, Madrid, Spain
| | | | - Pere Cardona
- Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Spain
| | - Aida Lago
- Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Mar Castellanos Rodrigo
- Complejo Hospitalario Universitario A Coruña, Instituto de Investigacion Biomédica A Coruña, Coruña, Spain
| | - Blanca Fuentes
- Instituto de Investigación Sanitaria La Paz, Departamento de Medicina, Hospital Universitario La Paz, Universidad Autónoma de Madrid, Madrid, Spain
| | - Mónica Sobrado
- Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
| | - Jose Vivancos
- Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
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Prognostic factors and analysis of mortality due to brain haemorrhages associated with vitamin K antagonist oral anticoagulants. Results from the TAC Registry. NEUROLOGÍA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.nrleng.2018.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Zapata-Wainberg G, Quintas S, Ximénez-Carrillo Rico A, Benavente Fernández L, Masjuan Vallejo J, Gállego Culleré J, Freijó Guerrero MDM, Egido J, Gómez Sánchez J, Martínez Domeño A, Purroy F, Vives Pastor B, Rodríguez Yáñez M, Vivancos J. Factores pronósticos y análisis de la mortalidad de las hemorragias cerebrales asociadas a anticoagulantes orales antagonistas de la vitamina K. Resultados del Estudio TAC Registry. Neurologia 2018; 33:419-426. [DOI: 10.1016/j.nrl.2016.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 07/06/2016] [Accepted: 07/12/2016] [Indexed: 10/21/2022] Open
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Quality of Chronic Anticoagulation Control in Patients with Intracranial Haemorrhage due to Vitamin K Antagonists. Stroke Res Treat 2018; 2018:5613103. [PMID: 30174820 PMCID: PMC6098890 DOI: 10.1155/2018/5613103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 06/27/2018] [Accepted: 07/12/2018] [Indexed: 01/09/2023] Open
Abstract
Introduction Patients treated with vitamin K antagonists (VKA) are at increased risk of intracranial haemorrhage (ICH). The purpose of our study was to determine the quality of previous anticoagulation control in patients with VKA-associated ICH. Materials and Methods We prospectively assessed every consecutive patient admitted to our stroke unit with VKA-associated ICH between 2013 and 2016. Demographic, clinical, and radiological variables, as well as consecutive international normalized ratios (INR) during 7 previous months, were extracted. Time in therapeutic range (TTR), time over range (TOR), time below range (TBR), and percentage of INR within range (PINRR) were calculated. Results and Discussion The study population comprised 53 patients. Mean age was 79 years; 42% were women. Forty-eight patients had atrial fibrillation (AF) and 5 mechanical prosthetic valves. Therapeutic or infratherapeutic INR on arrival was detected in 64.4% of patients (95% CI 2.7 to 3.2). TTR was 67.8% (95% CI: 60.2 to 75.6 %) and PINRR was 75% (95% CI: 49.9-100). TOR was 17.2% (95% CI: 10.4 to 23.9% ) and TBR was 17% (95% CI: 10.6 to 23.9%). Conclusion VKA-associated ICH happens usually in the context of good chronic anticoagulation control. Newer risk assessment methods are required.
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Masjuan J, Vera R. Anticoagulación tras una hemorragia cerebral. Med Clin (Barc) 2018. [DOI: 10.1016/s0025-7753(18)30667-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Zapata-Wainberg G, Quintas S, Ximénez-Carrillo Rico Á, Masjuán Vallejo J, Cardona P, Castellanos Rodrigo M, Benavente Fernández L, García Pastor A, Egido J, Maciñeiras J, Serena J, Freijo Guerrero MDM, Moniche F, Vivancos J. Epidemiology of Intracranial Hemorrhage Associated with Oral Anticoagulants in Spain: Trends in Anticoagulation Complications Registry - The TAC 2 Study. INTERVENTIONAL NEUROLOGY 2018; 7:284-295. [PMID: 29765398 DOI: 10.1159/000487518] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Objective Patients receiving treatment with oral anticoagulants (OACs) are at risk of intracranial hemorrhage (ICH). In this study, we describe the epidemiological and clinical characteristics of patients receiving OACs who experience ICH and compare those receiving vitamin K antagonists (ICH-VKAs) with those receiving direct OACs (ICH-DOACs). Methods We performed a national, multicenter, descriptive, observational, retrospective study of all adult patients receiving OACs who were admitted to the neurology department with ICH over a 1-year period. The study population was divided into 2 groups (ICH-VKAs and ICH-DOACs). Epidemiological, clinical, radiological, and therapy-related variables, as well as functional outcome, were compared at 3 months. A total of 366 cases were included (331 ICH-VKAs, 35 ICH- DOACs). Results The crude annual incidence of OAC-induced ICH was 3.8 (95% CI, 2.78-3.41) per 100,000 inhabitants/year. The mean (± SD) age was greater for ICH-DOACs (81.5 ± 8.3 vs. 77.7 ± 8.3 years; p = 0.012). The median (IQR) volume of the hemorrhage was lower for ICH-DOACs (11 [30.8] vs. 25 [50.7] mL; p = 0.03). The functional independence rate at 3 months (modified Rankin Scale, mRS < 3) was similar in both groups, although stroke-related mortality was greater in ICH-VKAs (40 vs. 72.7%; p = 0.02). The most frequently indicated poststroke antithrombotic therapy was DOACs (38.7%). Conclusion We found that the incidence of OAC-induced ICH was greater than in previous studies. Hemorrhage volume and mortality were lower in ICH-DOACs than in ICH-VKAs. After stroke, DOACs were the most frequently indicated antithrombotic treatment.
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Affiliation(s)
- Gustavo Zapata-Wainberg
- Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
| | - Sonia Quintas
- Hospital Universitario de La Princesa, Madrid, Spain
| | | | | | - Pere Cardona
- Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Spain
| | - Mar Castellanos Rodrigo
- Complejo Hospitalario Universitario A Coruña, Instituto de Investigacion Biomédica A Coruña, Coruña, Spain
| | | | | | - José Egido
- Hospital Clínico Universitario San Carlos, Madrid, Spain
| | | | | | | | | | - José Vivancos
- Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
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Frol S, Pretnar Oblak J. Early Outcome after Intracranial Hemorrhage Related to Non-Vitamin K Oral Anticoagulants. INTERVENTIONAL NEUROLOGY 2018; 7:19-25. [PMID: 29628941 PMCID: PMC5881142 DOI: 10.1159/000480524] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Intracranial hemorrhage (ICH) is a serious, life-threatening, but fortunately rare complication of non-vitamin K oral anticoagulant (NOAC) therapy. There are limited data on NOAC-related ICH prognosis. METHODS All consecutive patients admitted to a single center due to acute NOAC-related ICH from September 2012 until the beginning of 2017 were included. Risk factors, type of NOAC, and location of ICH were evaluated. Risk for ischemic and bleeding events and clinical status upon admission and at discharge were evaluated using standard scales. RESULTS Thirty-four patients aged 77.8 ± 8.3 years with NOAC-related ICH were included. The main predisposing risk factors were age and arterial hypertension. The median CHA2DS2-VASc score was 3.4 and the median HAS-BLED score was 1.8. Eighteen patients were treated with rivaroxaban, 11 with dabigatran, and 5 with apixaban. Ten patients (29%) had a favorable outcome with a modified Rankin Scale score ≤2 and 13 patients (38%) died. The location of the ICH was mainly intraparenchymal and subdural. CONCLUSIONS Our retrospective single-center study shows that the mortality rate with NOAC-related ICH is <40%, which makes it comparable to that with vitamin K antagonist-related ICH.
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Affiliation(s)
| | - Janja Pretnar Oblak
- Department of Vascular Neurology and Intensive Neurological Therapy, University Medical Center Ljubljana, Ljubljana, Slovenia
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