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Douketis JD, Yi Q, Bhatt DL, Muehlhofer E, Wang MK, Connolly S, Yusuf S, Maggioni AP, Eikelboom JW. Perioperative management and outcomes in patients receiving low-dose rivaroxaban and/or aspirin: a subanalysis of the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial. J Thromb Haemost 2024; 22:2227-2233. [PMID: 38729576 DOI: 10.1016/j.jtha.2024.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 03/11/2024] [Accepted: 03/27/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND No study has investigated the perioperative management and clinical outcomes in patients who are receiving rivaroxaban 2.5 mg twice a day and acetylsalicylic acid (ASA) 81 to 100 mg daily. OBJECTIVE To assess perioperative management and outcomes in patients who are receiving low-dose rivaroxaban, 2.5 mg twice-daily, and low-dose ASA, 81 to 100 mg daily. To assess perioperative management and outcomes in patients who are receiving low-dose rivaroxaban, 2.5 mg twice-daily, and low-dose ASA, 81 to 100 mg daily. METHODS Subanalysis of the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial was performed to assess perioperative management and clinical outcomes in patients with stable coronary or peripheral artery disease who were randomized to receive rivaroxaban 2.5 mg twice a day plus ASA 100 mg daily, rivaroxaban 5 mg twice a day, or ASA 100 mg daily. Patients studied required a surgery/procedure during the trial. The study outcomes, which included myocardial infarction, angina, stroke, acute limb ischemia, bleeding, and death, were assessed according to treatment allocation. RESULTS There were 2632 patients studied (mean age, 68 years; 80% male) who had a surgery/procedure, comprising percutaneous coronary interventions (∼43%), carotid or other arterial angioplasty (∼15%), pacemaker or internal cardiac defibrillator implantation (∼9%), and coronary artery bypass graft surgery (∼7%). Perioperative study drug management varied, with about one-third of patients not interrupting study drug and the remainder interrupting it between 1 and ≥10 days preprocedure. The incidences of adverse outcomes across treatment groups were 12.7% to 15.3% for myocardial ischemia, 0.8% to 1.2% for stroke, 0.1% to 0.2% for venous thromboembolism, and 3.1% to 4.2% for any bleeding. There was no statistically significant difference in outcome rates across treatment groups. CONCLUSION In patients in the COMPASS trial who required a surgery/procedure, there was no significant difference in perioperative adverse outcomes whether patients were receiving rivaroxaban 2.5 mg twice a day and ASA 100 mg daily, rivaroxaban 5 mg twice a day, or ASA alone.
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Affiliation(s)
- James D Douketis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada.
| | - Qilong Yi
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Deepak L Bhatt
- Mt. Sinai Fuster Heart Hospital, Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | | | - Michael K Wang
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Mt. Sinai Fuster Heart Hospital, Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | - Stuart Connolly
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Mt. Sinai Fuster Heart Hospital, Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | - Salim Yusuf
- Mt. Sinai Fuster Heart Hospital, Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | - Aldo P Maggioni
- Maria Cecilia Hospital, GVM Care and Research, Cotignola, Italy
| | - John W Eikelboom
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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Gunturu S, Chawla J, Karipineni S, Jayam C. Perioperative management of a patient with systemic lupus erythematosus-associated antiphospholipid syndrome undergoing mandibular third molar surgery. BMJ Case Rep 2024; 17:e259644. [PMID: 39074936 DOI: 10.1136/bcr-2024-259644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024] Open
Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune condition characterised by recurrent venous or arterial thrombosis and pregnancy complications, with persistent antiphospholipid autoantibodies. APS is often found in conjunction with other autoimmune diseases, such as systemic lupus erythematosus (SLE). SLE-associated APS patients may require dental procedures like tooth extractions. Due to the complex nature of this autoimmune disorder, perioperative management requires a comprehensive approach involving various medical specialists.These patients are frequently taking medications like anticoagulants, antiplatelet drugs, disease-modifying drugs and immunosuppressants. This medication regimen can increase their risk of postoperative complications, including bleeding, thrombosis, delayed healing and postoperative infections. Currently, there are no established guidelines for performing tooth extractions in individuals with SLE-associated APS.We report a case of SLE-associated APS with pericoronitis requiring surgical extraction. The purpose of this report is to offer practical recommendations for the perioperative management of dental procedures and alteration in medications used in such cases.
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Affiliation(s)
- Srikanth Gunturu
- Oral and Maxillofacial Surgery, Drs Sudha and Nageswara Rao Siddhartha Institute of Dental Sciences, Krishna, Andhra Pradesh, India
| | - Jitendra Chawla
- Dentistry, All India Institute of Medical Sciences Mangalagiri, Mangalagiri, Andhra Pradesh, India
| | - Swetha Karipineni
- Oral and Maxillofacial Surgery, Drs Sudha and Nageswara Rao Siddhartha Institute of Dental Sciences, Krishna, Andhra Pradesh, India
| | - Cheranjeevi Jayam
- Dentistry, All India Institute of Medical Sciences Mangalagiri, Mangalagiri, Andhra Pradesh, India
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Capiau A, De Vleeschauwer J, De Backer T, Gevaert S, Randon C, Mehuys E, Boussery K, Somers A. Optimizing anticoagulation therapy for in-hospital patients on direct oral anticoagulants: a single-centre modified Delphi study. Br J Clin Pharmacol 2024. [PMID: 38957976 DOI: 10.1111/bcp.16159] [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: 01/25/2024] [Revised: 05/23/2024] [Accepted: 06/09/2024] [Indexed: 07/04/2024] Open
Abstract
AIMS The management of patients treated with direct oral anticoagulants (DOACs) during hospitalization is a common challenge in clinical practice. Although bridging is generally not recommended, too often DOACs are switched to parenteral therapy with low molecular weight heparins. Our objectives were to update a local guideline for perioperative DOAC management and to develop a guideline for the anticoagulation management in non-surgical patients regarding temporary DOAC discontinuation. METHODS We executed a two-step modified Delphi study in a 1000-bed university hospital in Belgium. The Delphi questionnaires were developed based on a literature review and a telephone survey of prescribers. Two expert panels were established: one dedicated to perioperative DOAC management and the other to DOAC management in non-surgical patients. Both panels completed two rounds, commencing with an individual and online round, followed by a face-to-face group session. RESULTS After the two-round Delphi process, the updated perioperative guideline on DOAC management included reasons for delaying the resumption of DOACs following surgery, such as oral intake not possible, the probability of re-intervention within 3 days, and insufficient haemostasis (e.g. active clinically significant haematoma, haemorrhagic drains or wounds). Furthermore, a guideline for non-surgical hospitalized patients was developed, outlining possible reasons for interrupting DOAC therapy. Both guidelines offer clear anticoagulation therapy strategies corresponding to the identified scenarios. CONCLUSIONS We have updated and developed guidelines for DOAC management in surgical and non-surgical patients during hospitalization, which aim to support prescribers and to enhance targeted prescription review by hospital pharmacists.
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Affiliation(s)
- Andreas Capiau
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
| | | | - Tine De Backer
- Department of Cardiology, Heart Centre, Ghent University Hospital, Ghent, Belgium
- Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Sofie Gevaert
- Department of Cardiology, Heart Centre, Ghent University Hospital, Ghent, Belgium
- Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Caren Randon
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Els Mehuys
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Koen Boussery
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Annemie Somers
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
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Lyons MD, Pope B, Alexander J. Perioperative Management of Antithrombotic Therapy. JAMA 2024:2820286. [PMID: 38900436 DOI: 10.1001/jama.2024.5880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
This JAMA Clinical Guidelines Synopsis summarizes the American College of Chest Physicians’ 2022 guideline on perioperative management of patients taking oral anticoagulation or antiplatelet therapy who are undergoing an elective surgery or procedure.
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Affiliation(s)
- Maureen D Lyons
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
| | - Bailey Pope
- Department of Medicine, Division of Hospital Medicine, Oregon Health & Science University, Portland
| | - Jason Alexander
- Department of Medicine, Section of General Internal Medicine, University of Chicago, Chicago, Illinois
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Sachdev D, Khalil L, Gendi K, Brand J, Cominos N, Xie V, Mehran N. Perioperative Management of Traditional and Direct Oral Anticoagulants in Hip Fracture Patients. Orthop Rev (Pavia) 2024; 16:115605. [PMID: 38751452 PMCID: PMC11093752 DOI: 10.52965/001c.115605] [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: 08/15/2023] [Accepted: 02/05/2024] [Indexed: 05/18/2024] Open
Abstract
Hip fractures are an increasingly common injury in the senior population and almost always require surgical fixation or prosthetic replacement. These surgeries, according to the American Academy of Orthopaedic Surgeons, are considered high-risk for bleeding, especially in a population fraught with comorbidities and often presenting on anticoagulation medications. Direct oral anticoagulants represent a class of drugs that have been becoming more popular in use in this population, with many benefits over the historically used Warfarin. There are recommendations for preoperative discontinuation and postoperative resumption of these medications, which can be more readily managed for elective surgeries. However, there is a paucity of literature detailing best practice guidelines for the perioperative management of direct oral anticoagulants when a patient presents with a hip fracture. This review article summary of the periprocedural management of DOACs for hip surgery was developed by examining the American College of Chest Physicians evidence-based clinical practice guidelines, Perioperative Guidelines on Antiplatelet and Anticoagulant Agents written by anesthesiologists, various retrospective studies, and drug labels for pharmacokinetic data. These recommendations should be used as a guideline, along with the collaboration of multidisciplinary hospital teams during inpatient admission, to manage these complex patients.
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Affiliation(s)
| | - Lafi Khalil
- Department of Orthopaedic SurgeryMcLaren Flint
| | - Kirollos Gendi
- Department of Orthopaedic SurgeryMount Sinai Hospital (florida)
| | - Jordan Brand
- Department of Orthopaedic Surgery, Division of Traumatologyuniversity of maryland
| | | | | | - Nima Mehran
- Department of Orthopaedic SurgeryKaiser Permanente
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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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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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Lenga P, Dao Trong P, Papakonstantinou V, Unterberg AW, Krieg SM, Ishak B. Prospective insights into spinal surgery outcomes and adverse events: A comparative study between patients 65-79 years vs. ≥80 years from a German tertiary center. BRAIN & SPINE 2024; 4:102768. [PMID: 38510610 PMCID: PMC10951790 DOI: 10.1016/j.bas.2024.102768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 01/18/2024] [Accepted: 02/14/2024] [Indexed: 03/22/2024]
Abstract
Introduction In light of an aging global population, understanding adverse events (AEs) in surgeries for older adults is crucial for optimal outcomes and patient safety. Research question Our study compares surgical outcomes and AEs in patients aged 65-79 with those aged ≥80, focusing on clinical outcomes, morbidity and mortality rates, and age-related risk factors for AEs. Material and methods Our study, from January 2019 to December 2022, involved patients aged 65-79 and ≥ 80 undergoing spinal surgery. Each patient was evaluated for AEs post-discharge, defined as negative clinical outcomes within 30 days post-surgery. Patients were categorized based on primary spinal diagnoses: degenerative, oncological, traumatic, and infectious. Results We enrolled 546 patients aged 65-79 and 184 octogenarians. Degenerative diseases were most common in both groups, with higher infection and tumor rates in the younger cohort. Octogenarians had a higher Charlson Comorbidity Index and longer ICU/hospital stays. Surgery-related AE rates were 8.1% for 65-79-year-olds and 15.8% for octogenarians, with mortality around 2% in both groups. Discussion and conclusion Our prospective analysis shows octogenarians are more susceptible to surgical AEs, linked to greater health complexities. Despite higher AEs in older patients, low mortality rates across both age groups highlight the safety of spinal surgery. Tracking AEs is crucial for patient communication and impacts healthcare accreditation and funding.
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Affiliation(s)
- Pavlina Lenga
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Philip Dao Trong
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | | | | | - Sandro M. Krieg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Basem Ishak
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
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Ten Berg JM, Overduin DC, van Ginkel DJ. Best Oral Anticoagulant for Transcatheter Mitral Valve Replacement. J Am Coll Cardiol 2024; 83:347-349. [PMID: 38199712 DOI: 10.1016/j.jacc.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 11/06/2023] [Indexed: 01/12/2024]
Affiliation(s)
- Jurriën M Ten Berg
- Department of Cardiology, St Antonius Hospital, Nieuwegein, the Netherlands; Department of Cardiology, University Medical Center Maastricht, Maastricht University Center and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands.
| | - Daniël C Overduin
- Department of Cardiology, St Antonius Hospital, Nieuwegein, the Netherlands
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 192] [Impact Index Per Article: 192.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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11
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 57] [Impact Index Per Article: 57.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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12
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Tezuka F, Sakai T, Imagama S, Takahashi H, Takaso M, Aizawa T, Otani K, Okuda S, Kato S, Kanemura T, Kawaguchi Y, Konishi H, Suda K, Terai H, Nakanishi K, Nishida K, Machino M, Miyakoshi N, Murakami H, Yamato Y, Yukawa Y. Management of Antithrombotic Drugs before Elective Spine Surgery: A Nationwide Web-Based Questionnaire Survey in Japan. Spine Surg Relat Res 2023; 7:428-435. [PMID: 37841038 PMCID: PMC10569803 DOI: 10.22603/ssrr.2023-0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/13/2023] [Indexed: 10/17/2023] Open
Abstract
Introduction The number of patients on antithrombotic drugs for coronary heart disease or cerebrovascular disease has been increasing with the aging of society. We occasionally need to decide whether to continue or discontinue antithrombotic drugs before spine surgery. The purpose of this study is to understand the current perioperative management of antithrombotic drugs before elective spine surgery in Japan. Methods In 2021, members of the Japanese Society for Spine Surgery and Related Research (JSSR) were asked to complete a web-based questionnaire survey that included items concerning the respondents' surgical experience, their policy regarding discontinuation or continuation of antithrombotic drugs, their reasons for decisions concerning the management of antithrombotic drugs, and their experience of perioperative complications related to the continuation or discontinuation of these drugs. Results A total of 1,181 spine surgeons returned completed questionnaires, giving a response rate of 32.0%. JSSR board-certified spine surgeons comprised 75.1% of the respondents. Depending on the management policy regarding antithrombotic drugs for each comorbidity, approximately 73% of respondents discontinued these drugs before elective spine surgery, and about 80% also discontinued anticoagulants. Only 4%-5% of respondents reported continuing antiplatelet drugs, and 2.5% reported continuing anticoagulants. Among the respondents who discontinued antiplatelet drugs, 20.4% reported having encountered cerebral infarction and 3.7% reported encountering myocardial infarction; among those who discontinued anticoagulants, 13.6% reported encountering cerebral embolism and 5.4% reported encountering pulmonary embolism. However, among the respondents who continued antiplatelet drugs and those who continued anticoagulants, 26.3% and 27.2%, respectively, encountered an unexpected increase in intraoperative bleeding, and 10.3% and 8.7%, respectively, encountered postoperative spinal epidural hematoma requiring emergency surgery. Conclusions Our findings indicate that, in principle, >70% of JSSR members discontinue antithrombotic drugs before elective spine surgery. However, those with a discontinuation policy have encountered thrombotic complications, while those with a continuation policy have encountered hemorrhagic complications.
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Affiliation(s)
- Fumitake Tezuka
- Department of Orthopedics, Tokushima University, Tokushima, Japan
| | - Toshinori Sakai
- Department of Orthopedics, Tokushima University, Tokushima, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery/Rheumatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Takahashi
- Department of Orthopedic Surgery, Toho University School of Medicine, Tokyo, Japan
| | - Masashi Takaso
- Department of Orthopaedic Surgery, Kitasato University, School of Medicine, Kanagawa, Japan
| | - Toshimi Aizawa
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Koji Otani
- Department of Orthopedic Surgery, Fukushima Medical University, Fukushima, Japan
| | - Shinya Okuda
- Department of Orthopedics, Hoshigaoka Medical Center, Hirakata, Japan
| | - Satoshi Kato
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Tokumi Kanemura
- Department of Orthopaedic Surgery, Konan Kosei Hospital, Aichi, Japan
| | | | - Hiroaki Konishi
- Department of Orthopedics, Nagasaki Rosai Hospital, Sasebo, Japan
| | - Kota Suda
- Hokkaido Spinal Cord Injury Center, Bibai, Japan
| | - Hidetomi Terai
- Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Kazuo Nakanishi
- Department of Orthopedics, Traumatology and Spine Surgery, Kawasaki Medical School, Okayama, Japan
| | - Kotaro Nishida
- Department of Orthopedic Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Masaaki Machino
- Department of Orthopaedic Surgery/Rheumatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naohisa Miyakoshi
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Hideki Murakami
- Department of Orthopaedic Surgery, Nagoya City University, Nagoya, Japan
| | - Yu Yamato
- Division of Geriatric Musculoskeletal Health, Hamamatsu University School of Medicine, Shizuoka, Japan
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13
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Soler-Espejo E, Esteve-Pastor MA, Rivera-Caravaca JM, Roldan V, Marín F. Reducing bleeding risk in patients on oral anticoagulation therapy. Expert Rev Cardiovasc Ther 2023; 21:923-936. [PMID: 37905915 DOI: 10.1080/14779072.2023.2275662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/23/2023] [Indexed: 11/02/2023]
Abstract
INTRODUCTION Oral anticoagulation (OAC) significantly mitigates thromboembolism risks in atrial fibrillation (AF) and venous thromboembolism (VTE) patients yet concern about major bleeding events persist. In fact, clinically relevant hemorrhages can be life-threatening. Bleeding risk is dynamic and influenced by factors such as age, new comorbidities, and drug therapies, and should not be assessed solely based on static baseline factors. AREAS COVERED We comprehensively review the bleeding risk associated with OAC therapy. Emphasizing the importance of assessing both thromboembolic and bleeding risks, we present clinical tools for estimating stroke and systemic embolism (SSE) and bleeding risk in AF and VTE patients. We also address overlapping risk factors and the dynamic nature of bleeding risk. EXPERT OPINION The OAC management is undergoing constant transformation, motivated by the primary objective of mitigating thromboembolism and bleeding hazards, thereby amplifying patient safety throughout the course of treatment. The future of OAC embraces personalized approaches and innovative therapies, driven by advanced pathophysiological insights and technological progress. This holds promise for improving patient outcomes and revolutionizing anticoagulation practices.
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Affiliation(s)
- Eva Soler-Espejo
- Department of Hematology and Hemotherapy, Hospital General Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), Murcia, Spain
| | - María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), CIBERCV, Murcia, Spain
| | - José Miguel Rivera-Caravaca
- Faculty of Nursing, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), CIBERCV, Murcia, Spain
| | - Vanessa Roldan
- Department of Hematology and Hemotherapy, Hospital General Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), Murcia, Spain
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), CIBERCV, Murcia, Spain
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14
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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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15
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Douketis JD, Spyropoulos AC. Perioperative Management of Anticoagulant and Antiplatelet Therapy. NEJM EVIDENCE 2023; 2:EVIDra2200322. [PMID: 38320132 DOI: 10.1056/evidra2200322] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Anticoagulant and Antiplatelet Drug ManagementManagement of patients on an anticoagulant or antiplatelet drug who require surgery or an invasive procedure is a common clinical problem. Douketis and Spyropoulos provide an evidence-based but practical approach to managing anticoagulants and antiplatelet drugs in the perioperative setting.
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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, Anticoagulation and Clinical Thrombosis Service, Northwell Health at Lenox Hill Hospital, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Institute of Health Systems Science at The Feinstein Institutes for Medical Research, Manhasset, New York
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16
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Sugimoto M, Murata M, Kawai T. Assessment of delayed bleeding after endoscopic submucosal dissection of early-stage gastrointestinal tumors in patients receiving direct oral anticoagulants. World J Gastroenterol 2023; 29:2916-2931. [PMID: 37274799 PMCID: PMC10237096 DOI: 10.3748/wjg.v29.i19.2916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/03/2023] [Accepted: 04/24/2023] [Indexed: 05/16/2023] Open
Abstract
Delayed bleeding is a major and serious adverse event of endoscopic submucosal dissection (ESD) for early-stage gastrointestinal tumors. The rate of post-ESD bleeding for gastric cancer is higher (around 5%-8%) than that for esophagus, duodenum and colon cancer (around 2%-4%). Although investigations into the risk factors for post-ESD bleeding have identified several procedure-, lesion-, physician- and patient-related factors, use of antithrombotic drugs, especially anticoagulants [direct oral anticoagulants (DOACs) and warfarin], is thought to be the biggest risk factor for post-ESD bleeding. In fact, the post-ESD bleeding rate in patients receiving DOACs is 8.7%-20.8%, which is higher than that in patients not receiving anticoagulants. However, because clinical guidelines for management of ESD in patients receiving DOACs differ among countries, it is necessary for endoscopists to identify ways to prevent post-ESD delayed bleeding in clinical practice. Given that the pharmacokinetics (e.g., plasma DOAC level at both trough and Tmax) and pharmacodynamics (e.g., anti-factor Xa activity) of DOACs are related to risk of major bleeding, plasma DOAC level and anti-FXa activity may be useful parameters for monitoring the anti-coagulate effect and identifying DOAC patients at higher risk of post-ESD bleeding.
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Affiliation(s)
- Mitsushige Sugimoto
- Department of Gastroenterological Endoscopy, Tokyo Medical University Hospital, Tokyo 160-0023, Japan
| | - Masaki Murata
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan
| | - Takashi Kawai
- Department of Gastroenterological Endoscopy, Tokyo Medical University Hospital, Tokyo 160-0023, Japan
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17
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Kane WJ, Berry PS. Perioperative Assessment and Optimization in Major Colorectal Surgery: Medication Management. Clin Colon Rectal Surg 2023; 36:210-217. [PMID: 37113275 PMCID: PMC10125279 DOI: 10.1055/s-0043-1761156] [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: 04/29/2023]
Abstract
The colorectal surgeon is often faced with medications that can be challenging to manage in the perioperative period. In the era of novel agents for anticoagulation and immunotherapies for inflammatory bowel disease and malignancy, understanding how to advise patients about these medications has become increasingly complex. Here, we aim to provide clarity regarding the use of these agents and their perioperative management, with a particular focus on when to stop and restart them perioperatively. This review will begin with the management of both nonbiologic and biologic therapies used in the treatment of inflammatory bowel disease and malignancy. Then, discussion will shift to anticoagulant and antiplatelet medications, including their associated reversal agents. Upon finishing this review, the reader will have gained an increased familiarity with the management of common medications requiring modification by colorectal surgeons in the perioperative period.
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Affiliation(s)
- William J. Kane
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Puja Shah Berry
- Department of General and Colorectal Surgery, WellSpan Surgical Specialists, York, Pennsylvania
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18
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Lester W, Walker N, Bhatia K, Ciantar E, Banerjee A, Trinder J, Anderson J, Hodson K, Swan L, Bradbury C, Webster J, Tower C. British Society for Haematology guideline for anticoagulant management of pregnant individuals with mechanical heart valves. Br J Haematol 2023. [PMID: 37487690 DOI: 10.1111/bjh.18781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Affiliation(s)
- Will Lester
- Centre for Clinical Haematology, University Hospitals Birmingham NHS Foundation Trust Birmingham UK
| | - Niki Walker
- Department of Cardiology Golden Jubilee National Hospital West of Scotland Regional Heart and Lung Centre Clydebank UK
| | - Kailash Bhatia
- Department of Anaesthetics Manchester University NHS Foundation Trust Manchester UK
| | - Etienne Ciantar
- Department of Obstetrics & Gynaecology Leeds Teaching Hospitals NHS Trust Leeds UK
| | - Anita Banerjee
- Guy's and Saint Thomas' NHS Foundation Trust, Women's Services London UK
| | - Joanna Trinder
- Department of Obstetrics University Hospitals Bristol NHS Foundation Trust Bristol UK
| | | | - Kenneth Hodson
- Department of Maternity Newcastle Upon Tyne Hospitals NHS Foundation Trust Newcastle Upon Tyne UK
| | - Lorna Swan
- Department of Cardiology Golden Jubilee National Hospital West of Scotland Regional Heart and Lung Centre Clydebank UK
| | - Charlotte Bradbury
- Cellular and Molecular Medicine, University of Bristol Bristol UK
- Bristol Haematology and Oncology Centre Bristol UK
| | - Juliette Webster
- Department of Maternity Birmingham Women's and Children's NHS Foundation Trust Birmingham UK
| | - Clare Tower
- Department of Obstetric and Maternal and Fetal Medicine Manchester University NHS Foundation Trust Manchester UK
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19
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Boccatonda A, Frisone A, Lorusso F, Bugea C, Di Carmine M, Schiavone C, Cocco G, D’Ardes D, Scarano A, Guagnano MT. Perioperative Management of Antithrombotic Therapy in Patients Who Undergo Dental Procedures: A Systematic Review of the Literature and Network Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:5293. [PMID: 37047909 PMCID: PMC10093975 DOI: 10.3390/ijerph20075293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 03/10/2023] [Accepted: 03/14/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND The surgical dental treatment of subjects admitted for anticoagulants therapy represents a consistent risk for peri-operative bleeding. The aim of the present study was to investigate the clinical findings of dental surgery operative management of the patients under anticoagulants drugs protocol. METHODS The literature screening was performed using Pubmed/Medline, EMBASE and Cochrane library, considering only randomized clinical trials (RCTs) papers. No limitations about the publication's period, follow-up time or clinical parameters were considered. RESULTS A total of eight RCTs were included for the qualitative synthesis. No thromboembolic complications were reported in any studies. Several bleeding episodes associated with anticoagulant drugs in dental surgery were mild and generally happened on the first day after the treatment. CONCLUSIONS The use of local haemostatic measures is generally effective for bleeding control with no further pharmacological drug management or suspension.
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Affiliation(s)
- Andrea Boccatonda
- Internal Medicine, Bentivoglio Hospital, AUSL Bologna, 40010 Bentivoglio, Italy
| | - Alessio Frisone
- Department of Innovative Technologies in Medicine & Dentistry, University of Chieti-Pescara, Via Dei Vestini 31, 66100 Chieti, Italy
| | - Felice Lorusso
- Department of Innovative Technologies in Medicine & Dentistry, University of Chieti-Pescara, Via Dei Vestini 31, 66100 Chieti, Italy
| | - Calogero Bugea
- Department of Innovative Technologies in Medicine & Dentistry, University of Chieti-Pescara, Via Dei Vestini 31, 66100 Chieti, Italy
| | - Maristella Di Carmine
- Department of Innovative Technologies in Medicine & Dentistry, University of Chieti-Pescara, Via Dei Vestini 31, 66100 Chieti, Italy
| | - Cosima Schiavone
- Department of Medicine and Science of Aging, “G. d’Annunzio” University, 66100 Chieti, Italy
| | - Giulio Cocco
- Department of Medicine and Science of Aging, “G. d’Annunzio” University, 66100 Chieti, Italy
| | - Damiano D’Ardes
- Department of Medicine and Science of Aging, “G. d’Annunzio” University, 66100 Chieti, Italy
| | - Antonio Scarano
- Department of Innovative Technologies in Medicine & Dentistry, University of Chieti-Pescara, Via Dei Vestini 31, 66100 Chieti, Italy
- Department of Oral Implantology, Dental Research Division, College Ingà, UNINGÁ, Cachoeiro de Itapemirim 29312, ES, Brazil
| | - Maria Teresa Guagnano
- Department of Medicine and Science of Aging, “G. d’Annunzio” University, 66100 Chieti, Italy
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20
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Periprocedural Management of Patients With Atrial Fibrillation Receiving a Direct Oral Anticoagulant Undergoing a Digestive Endoscopy. Am J Gastroenterol 2023; 118:812-819. [PMID: 36434811 DOI: 10.14309/ajg.0000000000002076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 10/06/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The periprocedural management of patients with atrial fibrillation (AF) using a direct oral anticoagulant (DOAC) undergoing elective gastrointestinal (GI) endoscopic procedure remains uncertain. We investigated the safety of a standardized periprocedural DOAC management strategy. METHODS The Periprocedural Anticoagulation Use for Surgery Evaluation cohort study enrolled adult patients receiving a DOAC (apixaban, rivaroxaban, or dabigatran) for AF scheduled for an elective procedure or surgery. This analysis addresses patients undergoing digestive endoscopy. Standardized periprocedural management consisted of DOAC interruption 1 day preendoscopy with resumption 1 day after procedure at low-moderate risk of bleeding or 2 days in case of a high bleeding risk. Thirty-day outcomes included GI bleeding, thromboembolic events, and mortality. RESULTS Of 556 patients on a DOAC (mean [SD] age of 72.5 [8.6] years; 37.4% female; mean CHADS 2 score 1.7 [1.0]), 8.6% were also on American Society of Anesthesiology (ASA) and 0.7% on clopidogrel. Most of the patients underwent colonoscopies (63.3%) or gastroscopies (14.0%), with 18.9% having both on the same procedural day. The mean total duration of DOAC interruption was 3.9 ± 1.6 days. Four patients experienced an arterial thromboembolic event (0.7%, 0.3%-1.8%) within 24.2 ± 5.9 days of DOAC interruption. GI bleeding events occurred in 2.5% (1.4%-4.2%) within 11.1 ± 8.1 days (range: 0.6; 25.5 days) of endoscopy, with major GI bleeding in 0.9% (0.4%-2.1%). Three patients died (0.5%; 0.2%-1.6%) 15.6-22.3 days after the endoscopy. DISCUSSION After a contemporary standardized periprocedural management strategy, patients with AF undergoing DOAC therapy interruption for elective digestive endoscopy experienced low rates of arterial thromboembolism and major bleeding.
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21
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Micheletta F, Ferrara M, Bertozzi G, Volonnino G, Nasso M, La Russa R. Proactive Risk Assessment through Failure Mode and Effect Analysis (FMEA) for Perioperative Management Model of Oral Anticoagulant Therapy: A Pilot Project. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16430. [PMID: 36554313 PMCID: PMC9779206 DOI: 10.3390/ijerph192416430] [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: 10/06/2022] [Revised: 12/04/2022] [Accepted: 12/05/2022] [Indexed: 06/17/2023]
Abstract
INTRODUCTION Correct perioperative management of anticoagulant therapy is essential to prevent thromboembolic events and reduce the risk of bleeding. The lack of universally accepted guidelines makes perioperative anticoagulant therapy management difficult. The present study aims to identify the perioperative risks of oral anticoagulant therapy and to reduce adverse events through Failure Mode and Effect Analysis (FMEA). MATERIALS AND METHODS A multidisciplinary working group was set up, and four main phases of the process were identified. Each of these phases was divided into micro-activities to identify the related possible failure modes and their potential consequences. The Risk Priority Number was calculated for each failure mode. RESULTS AND DISCUSSION Seventeen failure modes were identified in the entire perioperative period; those with a higher priority of intervention concern the incorrect timing between therapy suspension and surgery, and the incorrect assessment of the bleeding risk related to the invasive procedure. CONCLUSION The FMEA method can help identify anticoagulant therapy perioperative failures and implement the management and patient safety of surgical procedures.
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Affiliation(s)
| | - Michela Ferrara
- Department of Anatomical, Histological, Forensic Medicine and Orthopedic Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Giuseppe Bertozzi
- Department of Clinical and Experimental Medicine, Section of Forensic Pathology, University of Foggia, 71122 Foggia, Italy
| | - Gianpietro Volonnino
- Department of Anatomical, Histological, Forensic Medicine and Orthopedic Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Maria Nasso
- Nuova Itor, Clinica accreditata, 00158 Rome, Italy
| | - Raffaele La Russa
- Department of Clinical and Experimental Medicine, Section of Forensic Pathology, University of Foggia, 71122 Foggia, Italy
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22
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Shah S, Nayfeh T, Hasan B, Urtecho M, Firwana M, Saadi S, Abd-Rabu R, Nanaa A, Flynn DN, Rajjoub NS, Hazem W, Seisa MO, Hassett LC, Spyropoulos AC, Douketis JD, Murad MH. Perioperative Management of Vitamin K Antagonists and Direct Oral Anticoagulants: A Systematic Review and Meta-analysis. Chest 2022; 163:1245-1257. [PMID: 36462533 DOI: 10.1016/j.chest.2022.11.032] [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] [Received: 06/03/2022] [Revised: 09/30/2022] [Accepted: 11/22/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The management of patients who are receiving chronic oral anticoagulation therapy and require an elective surgery or an invasive procedure is a common clinical scenario. RESAERCH QUESTION What is the best available evidence to support the development of American College of Chest Physicians guidelines on the perioperative management of patients who are receiving long-term vitamin K agonist (VKA) or direct oral anticoagulant (DOAC) and require elective surgery or procedures? STUDY DESIGH AND METHODS A literature search including multiple databases from database inception through July 16, 2020, was performed. Meta-analyses were conducted when appropriate. RESULTS In patients receiving VKA (warfarin) undergoing elective noncardiac surgery, shorter (< 5 days) VKA interruption is associated with an increased risk of major bleeding. In patients who required VKA interruption, heparin bridging (mostly with low-molecular-weight heparin [LMWH]) was associated with a statistically significant increased risk of major bleed (relative risk [RR], 9.1; 95% CI, 1.62-51.3), representing a very low certainty of evidence (COE). Compared with DOAC interruption 1 to 4 days before surgery, continuing DOACs was not associated with a statistically significant difference in the risk of bleeding, representing a very low COE. Continuing dabigatran was associated with a statistically significant increased risk of thromboembolism (RR, 2.2; 95% CI, 1.3-3.8), representing a low COE. In patients who needed DOAC interruption, bridging with LMWH was associated a with statistically significant increased risk of minor bleeding compared with no bridging (RR, 1.7; 95% CI, 1.13-2.7), representing a low COE. INTERPRETATION The certainty in the evidence supporting the perioperative management of anticoagulants remains limited. No high-quality evidence exists to support the practice of heparin bridging during the interruption of VKA or DOAC therapy for an elective surgery or procedure or for the practice of interrupting VKA therapy for minor procedures, including cardiac device implantation, or continuation of a DOAC vs short-term interruption of a DOAC (1-4 days) in the perioperative period.
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Affiliation(s)
- Sahrish Shah
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Tarek Nayfeh
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Bashar Hasan
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Meritxell Urtecho
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Mohammed Firwana
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Samer Saadi
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Rami Abd-Rabu
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Ahmad Nanaa
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - David N Flynn
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Noora S Rajjoub
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Walid Hazem
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Mohamed O Seisa
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | | | - Alex C Spyropoulos
- Institute of Health Systems Science-Feinstein Institutes for Medical Research and The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, and Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, NY
| | - James D Douketis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
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23
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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: 78] [Impact Index Per Article: 39.0] [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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Rivaroxaban after laparoscopic cancer surgery. Blood 2022; 140:804-805. [PMID: 36006673 DOI: 10.1182/blood.2022016866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 05/07/2022] [Indexed: 11/20/2022] Open
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Fensman SK, Grove EL, Johansen JB, Jørgensen OD, Frausing MHJP, Kirkfeldt RE, Nielsen JC. Predictors of pocket hematoma after cardiac implantable electronic device surgery: A nationwide cohort study. J Arrhythm 2022; 38:748-755. [PMID: 36237873 PMCID: PMC9535764 DOI: 10.1002/joa3.12769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 06/29/2022] [Accepted: 08/04/2022] [Indexed: 11/07/2022] Open
Abstract
Purpose Methods Results Conclusion
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Affiliation(s)
| | - Erik Lerkevang Grove
- Department of CardiologyAarhus University HospitalAarhusDenmark
- Department of Clinical Medicine, Faculty of HealthAarhus UniversityAarhusDenmark
| | - Jens Brock Johansen
- Department of CardiologyOdense University HospitalOdenseDenmark
- The Danish Pacemaker and ICD RegisterOdense UniversityOdenseDenmark
| | - Ole Dan Jørgensen
- The Danish Pacemaker and ICD RegisterOdense UniversityOdenseDenmark
- Department of Heart, Lung, and Vascular SurgeryOdense University HospitalOdenseDenmark
| | | | - Rikke Esberg Kirkfeldt
- Department of CardiologyAarhus University HospitalAarhusDenmark
- The Danish Pacemaker and ICD RegisterOdense UniversityOdenseDenmark
| | - Jens Cosedis Nielsen
- Department of CardiologyAarhus University HospitalAarhusDenmark
- Department of Clinical Medicine, Faculty of HealthAarhus UniversityAarhusDenmark
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Demir M, Özbek M, Polat N, Aktan A, Yıldırım B, Argun L, İldırımlı K, Dursun L, Öztürk C, Güzel T, Kılıç R, Toprak N. A comparison of postoperative complications following cardiac implantable electronic device procedures in patients treated with antithrombotic drugs. Pacing Clin Electrophysiol 2022; 45:733-741. [DOI: 10.1111/pace.14517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 04/20/2022] [Accepted: 05/02/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Muhammed Demir
- Department of Medicine Division of Cardiology Dicle University Heart Centre Diyarbakir Turkey
| | - Mehmet Özbek
- Department of Medicine Division of Cardiology Dicle University Heart Centre Diyarbakir Turkey
| | - Nihat Polat
- Department of Medicine Division of Cardiology Dicle University Heart Centre Diyarbakir Turkey
| | - Adem Aktan
- Department of Cardiology Mardin Training and Research Hospital Mardin Turkey
| | - Bünyamin Yıldırım
- Department of Medicine Division of Cardiology Dicle University Heart Centre Diyarbakir Turkey
| | - Lokman Argun
- Department of Medicine Division of Cardiology Dicle University Heart Centre Diyarbakir Turkey
| | - Kamran İldırımlı
- Department of Medicine Division of Cardiology Dicle University Heart Centre Diyarbakir Turkey
| | - Lezgin Dursun
- Division of Cardiology Bingöl State Hospital Bingöl Turkey
| | - Cansu Öztürk
- Department of Cardiology Gazi Yasargil Training and Research Hospital Diyarbakir Turkey
| | - Tuncay Güzel
- Department of Cardiology Gazi Yasargil Training and Research Hospital Diyarbakir Turkey
| | - Raif Kılıç
- Division of Cardiology Dagkapi Diyarlife Hospital Diyarbakir Turkey
| | - Nizamettin Toprak
- Department of Medicine Division of Cardiology Dicle University Heart Centre Diyarbakir Turkey
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Kim C, Pfeiffer ML, Chang JR, Burnstine MA. Perioperative Considerations for Antithrombotic Therapy in Oculofacial Surgery: A Review of Current Evidence and Practice Guidelines. Ophthalmic Plast Reconstr Surg 2022; 38:226-233. [PMID: 35019878 PMCID: PMC9093724 DOI: 10.1097/iop.0000000000002058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE Recent survey studies have demonstrated wide variability in practice patterns regarding the management of antithrombotic medications in oculofacial plastic surgery. Current evidence and consensus guidelines are reviewed to guide perioperative management of antithrombotic medications. METHODS Comprehensive literature review of PubMed database on perioperative use of antithrombotic medication. RESULTS/CONCLUSIONS Perioperative antithrombotic management is largely guided by retrospective studies, consensus recommendations, and trials in other surgical fields due to the limited number of studies in oculoplastic surgery. This review summarizes evidence-based recommendations from related medical specialties and provides context for surgeons to tailor antithrombotic medication management based on patient's individual risk. The decision to continue or cease antithrombotic medications prior to surgery requires a careful understanding of risk: risk of intraoperative or postoperative bleeding versus risk of a perioperative thromboembolic event. Cessation and resumption of antithrombotic medications after surgery should always be individualized based on the patient's thrombotic risk, surgical and postoperative risk of bleeding, and the particular drugs involved, in conjunction with the prescribing doctors. In general, we recommend that high thromboembolic risk patients undergoing high bleeding risk procedures (orbital or lacrimal surgery) may stop antiplatelet agents, direct oral anticoagulants, and warfarin including bridging warfarin with low-molecular weight heparin. Low-risk patients, regardless of type of procedure performed, may stop all agents. Decision on perioperative management of antithrombotic medications should be made in conjunction with patient's internist, cardiologist, hematologist, or other involved physicians which may limit the role of guidelines depending on patient risk and should be used on a case-by-case basis. Further studies are needed to provide oculofacial-specific evidence-based guidelines.
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Affiliation(s)
- Christian Kim
- Eyesthetica, Los Angeles, California
- Department of Ophthalmology, Loyola University Stritch School of Medicine, Chicago, Illinois
| | - Margaret L Pfeiffer
- Eyesthetica, Los Angeles, California
- USC Roski Eye Institute, University of Southern California Keck School of Medicine, Los Angeles, California, U.S.A
| | - Jessica R Chang
- USC Roski Eye Institute, University of Southern California Keck School of Medicine, Los Angeles, California, U.S.A
| | - Michael A Burnstine
- Eyesthetica, Los Angeles, California
- USC Roski Eye Institute, University of Southern California Keck School of Medicine, Los Angeles, California, U.S.A
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28
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Römer P, Heimes D, Pabst A, Becker P, Thiem DGE, Kämmerer PW. Bleeding disorders in implant dentistry: a narrative review and a treatment guide. Int J Implant Dent 2022; 8:20. [PMID: 35429255 PMCID: PMC9013394 DOI: 10.1186/s40729-022-00418-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/07/2022] [Indexed: 01/08/2023] Open
Abstract
Purpose Considering a high prevalence of congenital and especially acquired bleeding disorders, their heterogeneity and the multitude of possible treatments strategies, a review of the scientific data on this topic is needed to implement a treatment guide for healthcare professionals.
Methods A selective literature review was performed via PubMed for articles describing oral surgery / dental implant procedures in patients with congenital and acquired bleeding disorders. Out of the existing literature, potential treatment algorithms were extrapolated. Results In order to assess the susceptibility to bleeding, risk stratification can be used for both congenital and acquired coagulation disorders. This risk stratification, together with an appropriate therapeutic pathway, allows for an adequate and individualized therapy for each patient. A central point is the close interdisciplinary cooperation with specialists. In addition to the discontinuation or replacement of existing treatment modalities, local hemostyptic measures are of primary importance. If local measures are not sufficient, systemically administered substances such as desmopressin and blood products have to be used. Conclusions Despite the limited evidence, a treatment guide could be developed by means of this narrative review to improve safety for patients and practitioners. Prospective randomized controlled trials are needed to allow the implementation of official evidence-based guidelines.
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29
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American College of Gastroenterology-Canadian Association of Gastroenterology Clinical Practice Guideline: Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period. Am J Gastroenterol 2022; 117:542-558. [PMID: 35297395 PMCID: PMC8966740 DOI: 10.14309/ajg.0000000000001627] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/28/2021] [Indexed: 02/07/2023]
Abstract
We conducted systematic reviews of predefined clinical questions and used the Grading of Recommendations, Assessment, Development and Evaluations approach to develop recommendations for the periendoscopic management of anticoagulant and antiplatelet drugs during acute gastrointestinal (GI) bleeding and the elective endoscopic setting. The following recommendations target patients presenting with acute GI bleeding: For patients on warfarin, we suggest against giving fresh frozen plasma or vitamin K; if needed, we suggest prothrombin complex concentrate (PCC) compared with fresh frozen plasma administration; for patients on direct oral anticoagulants (DOACs), we suggest against PCC administration; if on dabigatran, we suggest against the administration of idarucizumab, and if on rivaroxaban or apixaban, we suggest against andexanet alfa administration; for patients on antiplatelet agents, we suggest against platelet transfusions; and for patients on cardiac acetylsalicylic acid (ASA) for secondary prevention, we suggest against holding it, but if the ASA has been interrupted, we suggest resumption on the day hemostasis is endoscopically confirmed. The following recommendations target patients in the elective (planned) endoscopy setting: For patients on warfarin, we suggest continuation as opposed to temporary interruption (1-7 days), but if it is held for procedures with high risk of GI bleeding, we suggest against bridging anticoagulation unless the patient has a mechanical heart valve; for patients on DOACs, we suggest temporarily interrupting rather than continuing these; for patients on dual antiplatelet therapy for secondary prevention, we suggest temporary interruption of the P2Y12 receptor inhibitor while continuing ASA; and if on cardiac ASA monotherapy for secondary prevention, we suggest against its interruption. Evidence was insufficient in the following settings to permit recommendations. With acute GI bleeding in patients on warfarin, we could not recommend for or against PCC administration when compared with placebo. In the elective periprocedural endoscopy setting, we could not recommend for or against temporary interruption of the P2Y12 receptor inhibitor for patients on a single P2Y12 inhibiting agent. We were also unable to make a recommendation regarding same-day resumption of the drug vs 1-7 days after the procedure among patients prescribed anticoagulants (warfarin or DOACs) or P2Y12 receptor inhibitor drugs because of insufficient evidence.
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30
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Gholami R, Khan R, Ramkissoon A, Alabdulqader A, Gimpaya N, Bansal R, Scaffidi MA, Prasad V, Detsky AS, Baker JP, Grover SC. Recommendation Reversals in Gastroenterology Clinical Practice Guidelines. J Can Assoc Gastroenterol 2022; 5:98-99. [PMID: 35368318 PMCID: PMC8972276 DOI: 10.1093/jcag/gwab040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 09/28/2021] [Indexed: 11/23/2022] Open
Abstract
Background Recommendations in clinical practice guidelines (CPGs) may be reversed when evidence emerges to show they are futile or unsafe. In this study, we identified and characterized recommendation reversals in gastroenterology CPGs. Methods We searched CPGs published by 20 gastroenterology societies from January 1990 to December 2019. We included guidelines which had at least two iterations of the same topic. We defined reversals as when (a) the more recent iteration of a CPG recommends against a specific practice that was previously recommend in an earlier iteration of a CPG from the same body, and (b) the recommendation in the previous iteration of the CPG is not replaced by a new diagnostic or therapeutic recommendation in the more recent iteration of the CPG. The primary outcome was the number of recommendation reversals. Secondary outcomes included the strength of recommendations and quality of evidence cited for reversals. Results Twenty societies published 1022 CPGs from 1990 to 2019. Our sample for analysis included 129 unique CPGs. There were 11 recommendation reversals from 10 guidelines. New evidence was presented for 10 recommendation reversals. Meta-analyses were cited for two reversals, and randomized controlled trials (RCTs) for seven reversals. Recommendations were stronger after the reversal for three cases, weaker in two cases, and of similar strength in three cases. We were unable to compare recommendation strengths for three reversals. Conclusion Recommendation reversals in gastroenterology CPGs are uncommon but highlight low value or harmful practices.
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Affiliation(s)
- Reza Gholami
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Rishad Khan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Anushka Ramkissoon
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | | | - Nikko Gimpaya
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Rishi Bansal
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Michael A Scaffidi
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Vinay Prasad
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California,USA
| | - Allan S Detsky
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada
| | - Jeffrey P Baker
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Samir C Grover
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
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Abraham NS, Barkun AN, Sauer BG, Douketis J, Laine L, Noseworthy PA, Telford JJ, Leontiadis GI. American College of Gastroenterology-Canadian Association of Gastroenterology Clinical Practice Guideline: Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period. J Can Assoc Gastroenterol 2022; 5:100-101. [DOI: 10.1093/jcag/gwac010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/28/2021] [Indexed: 11/14/2022] Open
Abstract
Abstract
We conducted systematic reviews of predefined clinical questions and used the Grading of Recommendations, Assessment, Development and Evaluations approach to develop recommendations for the periendoscopic management of anticoagulant and antiplatelet drugs during acute gastrointestinal (GI) bleeding and the elective endoscopic setting. The following recommendations target patients presenting with acute GI bleeding: For patients on warfarin, we suggest against giving fresh frozen plasma or vitamin K; if needed, we suggest prothrombin complex concentrate (PCC) compared with fresh frozen plasma administration; for patients on direct oral anticoagulants (DOACs), we suggest against PCC administration; if on dabigatran, we suggest against the administration of idarucizumab, and if on rivaroxaban or apixaban, we suggest against andexanet alfa administration; for patients on antiplatelet agents, we suggest against platelet transfusions; and for patients on cardiac acetylsalicylic acid (ASA) for secondary prevention, we suggest against holding it, but if the ASA has been interrupted, we suggest resumption on the day hemostasis is endoscopically confirmed. The following recommendations target patients in the elective (planned) endoscopy setting: For patients on warfarin, we suggest continuation as opposed to temporary interruption (1–7 days), but if it is held for procedures with high risk of GI bleeding, we suggest against bridging anticoagulation unless the patient has a mechanical heart valve; for patients on DOACs, we suggest temporarily interrupting rather than continuing these; for patients on dual antiplatelet therapy for secondary prevention, we suggest temporary interruption of the P2Y12 receptor inhibitor while continuing ASA; and if on cardiac ASA monotherapy for secondary prevention, we suggest against its interruption. Evidence was insufficient in the following settings to permit recommendations. With acute GI bleeding in patients on warfarin, we could not recommend for or against PCC administration when compared with placebo. In the elective periprocedural endoscopy setting, we could not recommend for or against temporary interruption of the P2Y12 receptor inhibitor for patients on a single P2Y12 inhibiting agent. We were also unable to make a recommendation regarding same-day resumption of the drug vs 1–7 days after the procedure among patients prescribed anticoagulants (warfarin or DOACs) or P2Y12 receptor inhibitor drugs because of insufficient evidence.
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Affiliation(s)
- Neena S Abraham
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Alan N Barkun
- Division of Gastroenterology, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Bryan G Sauer
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, USA
| | - James Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton and McMaster University, Hamilton, Ontario, Canada
| | - Loren Laine
- Yale School of Medicine, New Haven, Connecticut, USA
- Virginia Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Peter A Noseworthy
- Department of Cardiovascular Diseases, Electrophysiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jennifer J Telford
- Division of Gastroenterology, Department of Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Grigorios I Leontiadis
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Vondran M, von Aspern K, Garbade J, Lässing J, Kiefer P, Rastan AJ, Borger MA, Schroeter T. Is Implantable Cardioverter Defibrillator surgery in patients with an implanted left ventricular assist device safe under uninterrupted oral anticoagulation? Artif Organs 2022; 46:1564-1572. [PMID: 35192216 DOI: 10.1111/aor.14217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 12/27/2021] [Accepted: 02/03/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Implantable Cardioverter-Defibrillator (ICD) surgery in patients with implanted left ventricular assist devices (LVAD) is associated with an increased risk of bleeding complications because of the need to ensure that these patients are adequately anticoagulated. Our study aimed to evaluate the safety of our new strategy of uninterrupted oral anticoagulation compared to heparin-bridging during the surgical interval. METHODS Between 01/2009 and 01/2020, 116 patients with LVAD underwent ICD surgery. Since 01/2015, 60 patients were operated under continued sufficient oral anticoagulation with a vitamin k antagonist (VKA group). Fifty-six patients underwent a heparin-bridging regimen (heparin group). Demographics, perioperative data, complications, and mortality were analyzed. RESULTS Bleeding complications attributable to the surgical intervention occurred more often (19.6% vs. 10.0%, p=0.142) and at a higher rate of re-exploratory surgery (14.3 % vs. 5.0%, p=0.088) in the heparin group without reaching statistical significance. Moreover, the heparin group patients' postoperative total length of stay was 10 days longer. (17.8 ± 23.8 days vs. 8.3 ± 9.5 days, p=0.007). There were no procedure-related deaths, no thromboembolic events, and no LVAD-related thrombosis. CONCLUSION Our strategy of uninterrupted oral anticoagulation is safe and results in a reduction by more than half the number of days in hospital without an increase in adverse events.
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Affiliation(s)
- Maximilian Vondran
- University Department for Cardiac Surgery, Leipzig, Germany.,Department of Cardiac and Thoracic Vascular Surgery, Philipps-University Hospital Marburg, Marburg, Germany
| | | | - Jens Garbade
- University Department for Cardiac Surgery, Leipzig, Germany
| | - Johannes Lässing
- University Department for Cardiac Surgery, Leipzig, Germany.,Institute of Sports Medicine & Prevention, University of Leipzig Faculty of Medicine, Leipzig, Germany
| | - Philipp Kiefer
- University Department for Cardiac Surgery, Leipzig, Germany
| | - Ardawan Julian Rastan
- Department of Cardiac and Thoracic Vascular Surgery, Philipps-University Hospital Marburg, Marburg, Germany
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Chen AT, Patel M, Douketis JD. Perioperative management of antithrombotic therapy: a case-based narrative review. Intern Emerg Med 2022; 17:25-35. [PMID: 34652572 DOI: 10.1007/s11739-021-02866-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 10/03/2021] [Indexed: 11/30/2022]
Abstract
The periprocedural management of patients who are receiving vitamin K antagonists, direct oral anticoagulants and antiplatelet therapy is a common and challenging clinical scenario as the decision to interrupt or continue these medications is anchored on patient and procedure-related risks for bleeding and thrombosis. Adding to the complexity of clinical management is the fact that anticoagulants have varied pharmacokinetic and pharmacodynamic properties and indications for clinical use. In many minimal-bleed-risk procedures, anticoagulants can be safely continued, without interruption, whereas in cases where anticoagulants cannot be safely continued, the timing of interruption and resumption, as well as the need for heparin bridging requires consideration. Perioperative antithrombotic management scenarios occur most often in patients with atrial fibrillation, mechanical heart valves, coronary stents, and cerebrovascular disease as such patients are likely to be prescribed anticoagulant and/or antiplatelet therapy. The objective of this case-based narrative review is to provide a practical evidence-based approach to the perioperative management of patients on anticoagulation and antiplatelet therapy. Four clinical scenarios will be provided: (1) managing patients in whom anticoagulants can be continued; (2) perioperative management of direct oral anticoagulants; (3) management of patients on dual antiplatelet therapy; and (4) anticoagulant management for emergency or urgent surgery.
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Affiliation(s)
- Andrew Tiger Chen
- Department of Medicine, St. Joseph's Healthcare Hamilton, McMaster University, F-544, 50 Charlton Ave East, Hamilton, ON, L8N 4A6, Canada
| | - Matthew Patel
- Department of Medicine, St. Joseph's Healthcare Hamilton, McMaster University, F-544, 50 Charlton Ave East, Hamilton, ON, L8N 4A6, Canada
| | - James Demetrios Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton, McMaster University, F-544, 50 Charlton Ave East, Hamilton, ON, L8N 4A6, Canada.
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Bagur R, Ybarra LF, Israeli Z, Solomonica A, Taleb H, Savvoulidis P, Sanjoy SS, Lavi S. Postprocedural Radial Artery Compression Time In Chronic AnticoaguLated patients using StatSeal: The PRACTICAL-SEAL study. Int J Cardiol 2022; 346:14-17. [PMID: 34774642 DOI: 10.1016/j.ijcard.2021.11.011] [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: 09/08/2021] [Revised: 10/20/2021] [Accepted: 11/07/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients on uniterrupted chronic oral anticoagulation (OAC) therapy are at high-risk of bleeding during cardiac catheterization. We aimed to investigate the safety and efficacy of the StatSeal® disc for adjunct hemostasis in patients undergoing transradial coronary angiography under uninterrupted OAC therapy. METHODS Patients who underwent transradial cardiac catheterization without interrupted OAC therapy were included in this study. RESULTS Among 180 patients, 85 (47.2%) patients were on warfarin and 95 (52.8%) patients on novel oral anticoagulants (NOACs). Patients on NOACs were older (72.9 ± 9.6 versus 69.7 ± 10.8 years, P < 0.001) and had more atrial fibrillation/flutter (94.7% versus 62.4%, P < 0.001), whereas patients on Warfarin were more often women (43.5% versus 26.3%, P = 0.02) and had mechanical heart valves (27.1% versus 0%, P < 0.001). Intravenous unfractioned heparin (UFH) was administered in 96.5% of patients on warfarin (3799 ± 1342 units) and 93.7% patients on NOACs (4028 ± 1362 units), P = 0.27. There were no differences in terms of type and sheath size and the need for ad hoc coronary intervention. Time-to-first release of the hemostatic wristband was 56.2 ± 12.6 min and complete hemostasis was achieved in 71.1 ± 13.0 min, with shorter times among patients on NOACs (54.1 ± 11.7 and 58.5 ± 13.2 min, 68.9 ± 11.7 versus 73.6 ± 14.0 min, P = 0.02, for both). There were no significant differences in terms of bleeding. There was no radial artery occlusion among 112 participants who underwent color Doppler ultrasound. CONCLUSION The present study shows that in patients undergoing transradial coronary angiogram under contemporary uninterrupted OAC therapy and periprocedural administration of UFH, the use of StatSeal® disc for adjunctive hemostasis was associated with short times to complete hemostasis.
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Affiliation(s)
- Rodrigo Bagur
- London Health Sciences Centre, London, Ontario, Canada.
| | - Luiz F Ybarra
- London Health Sciences Centre, London, Ontario, Canada
| | - Zeev Israeli
- Division of Cardiology, Ziv Medical Center, Safed, Israel
| | - Amir Solomonica
- Interventional Cardiology Unit, Rambam Healthcare Campus, Haifa, Israel
| | - Hussein Taleb
- London Health Sciences Centre, London, Ontario, Canada
| | | | - Shubrandu S Sanjoy
- Research Department, Saskatchewan Health Authority, Regina, Saskatchewan, Canada
| | - Shahar Lavi
- London Health Sciences Centre, London, Ontario, Canada
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Risk of Bleeding after Colorectal Endoscopic Resection in Patients with Continued Warfarin Use Compared to Heparin Replacement: A Propensity Score Matching Analysis. Gastroenterol Res Pract 2021; 2021:9415387. [PMID: 34956362 PMCID: PMC8709771 DOI: 10.1155/2021/9415387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/28/2021] [Accepted: 11/19/2021] [Indexed: 12/28/2022] Open
Abstract
The Japan Gastroenterological Endoscopy Society (JGES) guidelines recommend continued warfarin treatment during gastroenterological endoscopic procedures with a high risk of bleeding as an alternative to heparin replacement in patients on warfarin therapy. However, there is insufficient evidence to support the use of warfarin in colorectal endoscopic resection (ER). The present study is aimed at verifying the risk of bleeding after ER for colorectal neoplasia (CRN) in patients with continued warfarin use. This was a single-center retrospective cohort study using clinical records. We assessed 126 consecutive patients with 159 CRNs who underwent ER (endoscopic mucosal resection, 146 cases; endoscopic submucosal dissection, 13 cases) at Hiroshima University Hospital between January 2014 and December 2019. Patients were divided into two groups: the heparin replacement group (79 patients with 79 CRNs) and the continued warfarin group (47 patients with 80 CRNs). One-to-one propensity score matching was performed to compare the bleeding rate after ER between the groups. The rate of bleeding after ER was significantly higher in the heparin replacement group than in the continued warfarin group for both before (10.1% vs. 1.3%, respectively; P = 0.0178) and after (11.9% vs. 0%, respectively; P = 0.0211) propensity score matching. None of the patients experienced thromboembolic events during the perioperative period. The risk of bleeding after colorectal ER was significantly lower in patients with continued warfarin use than in those with heparin replacement. Our data supports the recommendations of the latest JGES guidelines for patients receiving warfarin therapy.
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Burnett AE. Perioperative consultative hematology: can you clear my patient for a procedure? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:521-528. [PMID: 34889442 PMCID: PMC8791149 DOI: 10.1182/hematology.2021000287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Periprocedural management of antithrombotics is a common but challenging clinical scenario that renders patients vulnerable to potential adverse events such as bleeding and thrombosis. Over the past decade, periprocedural antithrombotic approaches have changed considerably with the advent of direct oral anticoagulants (DOACs), as well as a paradigm shift away from bridging in many warfarin patients. Successfully navigating this high-risk period relies on a number of individualized patient assessments conducted within a framework of standardized, systematic approaches. It also requires a thorough understanding of antithrombotic pharmacokinetics, multidisciplinary coordination of care, and comprehensive patient education and empowerment. In this article, we provide clinicians with a practical, stepwise approach to periprocedural management of antithrombotic agents through case-based examples of relevant clinical scenarios.
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Ble O, Bensmail D, Pérennou D, Parratte B, Joseph PA, Boyer FC, Michelon H, Lansaman T, Levy J. Management of antithrombotics for intramuscular injection of botulinum toxin for spasticity. A survey of real-life practice in France. Ann Phys Rehabil Med 2021; 64:101467. [PMID: 33316432 DOI: 10.1016/j.rehab.2020.101467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 11/11/2020] [Accepted: 11/18/2020] [Indexed: 10/20/2022]
Affiliation(s)
- Ozoua Ble
- Department of Physical and Rehabilitation Medicine, Raymond Poincaré Hospital, APHP, University Paris-Saclay, 92380 Garches, France.
| | - Djamel Bensmail
- U1179 Neuromuscular Handicap, Inserm, University of Versailles-St-Quentin-en-Yvelines, 78180 Montigny-le-Bretonneux, France
| | - Dominic Pérennou
- Department of Physical and Rehabilitation Medicine, Grenoble University Hospital, South Hospital, 38130 Echirolles, France
| | - Bernard Parratte
- Department of Physical and Rehabilitation Medicine, CHRU Jean Minjoz, Besançon-Franche-Comté University, 25000 Besançon, France
| | - Pierre-Alain Joseph
- Department of Physical and Rehabilitation Medicine, CHU de Bordeaux, 33000 Bordeaux, France
| | - François-Constant Boyer
- Department of Physical and Rehabilitation Medicine, University of Reims, CHU de Reims, 51100 Reims, France
| | - Hugues Michelon
- Pharmacy Department, Raymond Poincaré Hospital, APHP, University Paris-Saclay, 92380 Garches, France
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Eljilany I, El-Bardissy A, Nemir A, Elzouki AN, El Madhoun I, Al-Badriyeh D, Elewa H. Assessment of the attitude, awareness and practice of periprocedural warfarin management among health care professional in Qatar. A cross sectional survey. J Thromb Thrombolysis 2021; 50:957-968. [PMID: 32307632 PMCID: PMC7575475 DOI: 10.1007/s11239-020-02111-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
It is estimated that 10-15% of oral anticoagulant (OAC) patients, would need to hold their OAC for scheduled surgery. Especially for warfarin, this process is complex and requires multi-layer risk assessment and decisions across different specialties. Clinical guidelines deliver broad recommendations in the area of warfarin management before surgery which can lead to different trends and practices among practitioners. To evaluate the current attitude, awareness, and practice among health care providers (HCPs) on warfarin periprocedural management. A multiple-choice questionnaire was developed, containing questions on demographics and professional information and was completed by187 HCPs involved in warfarin periprocedural management. The awareness median (IQR) score was moderate [64.28% (21.43)]. The level of awareness was associated with the practitioner's specialty and degree of education (P = 0.009, 0.011 respectively). Practice leans to overestimate the need for warfarin discontinuation as well as the need for bridging. Participants expressed interest in using genetic tests to guide periprocedural warfarin management [median (IQR) score (out of 10) = 7 (5)]. In conclusion, the survey presented a wide variation in the clinical practice of warfarin periprocedural management. This study highlights that HCPs in Qatar have moderate awareness. We suggest tailoring an educational campaign or courses towards the identified gaps.
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Affiliation(s)
- Islam Eljilany
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Ahmed El-Bardissy
- Department of Pharmacy, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Arwa Nemir
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Abdel-Naser Elzouki
- Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.,College of Medicine, Qatar University & Weill Cornell Medical College- Qatar, Doha, Qatar
| | - Ihab El Madhoun
- Department of Medicine, Al Wakra Hospital Hamad Medical Corporation, Al Wakra, Qatar.,Weill Cornell Medical College, Al Wakra, Qatar
| | | | - Hazem Elewa
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar.
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Perioperative Care of Patients at High Risk for Stroke During or After Non-cardiac, Non-neurological Surgery: 2020 Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care. J Neurosurg Anesthesiol 2021; 32:210-226. [PMID: 32433102 DOI: 10.1097/ana.0000000000000686] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Perioperative stroke is associated with considerable morbidity and mortality. Stroke recognition and diagnosis are challenging perioperatively, and surgical patients receive therapeutic interventions less frequently compared with stroke patients in the outpatient setting. These updated guidelines from the Society for Neuroscience in Anesthesiology and Critical Care provide evidence-based recommendations regarding perioperative care of patients at high risk for stroke. Recommended areas for future investigation are also proposed.
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Hasan SM, Faluk M, Abdelmaseih R, Patel JD, Thakker R, Chacko JJ, Zayas D, Finer A, Albaeni A, Abusaada K. Incidence of Acute Ischemic Stroke in Hospitalized Patients With Atrial Fibrillation Who Had Anticoagulation Interruption: A Retrospective Study. Cardiol Res 2021; 12:225-230. [PMID: 34349863 PMCID: PMC8297036 DOI: 10.14740/cr1263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 06/11/2021] [Indexed: 12/02/2022] Open
Abstract
Background Atrial fibrillation (AF) is one of the leading causes of acute ischemic stroke requiring anticoagulation. Many patients experience treatment interruption in the hospital setting. The aim of this study was to evaluate the effect of anticoagulation interruption on short-term risk of ischemic stroke in hospitalized patients with AF. Methods We performed a retrospective medical record review using the Hospital Corporation of America (HCA) database. We included patients admitted to our institution between December 2015 and December 2018 who had a prior history of AF. Patients were excluded if they had ischemic stroke, hemorrhagic stroke, history venous thromboembolism or mechanical valve on admission. We compared the incidence of ischemic stroke in patients in whom anticoagulation was interrupted for more than 48 h to those who continued anticoagulation. Results A total of 2,277 patients with history of AF were included in the study. In this cohort, 79 patients (3.47%) had anticoagulation interruption of more than 48 h during their hospital stay. There was no difference in incidence of stroke between the interruption and no interruption groups (1.27% (n = 1) vs. 0.23% (n = 5), P = 0.19). Interruption of anticoagulation did not associate with a significant increase in the risk of in-hospital ischemic stroke. CHA2DS2VASc score was a strong predictor of in-hospital stroke risk regardless of anticoagulation interruption (odds ratio: 7.199, 95% confidence interval: 2.920 - 17.751). Conclusion In this study, the in-hospital incidence of ischemic stroke in patients with AF did not significantly increase by short-term anticoagulation interruption.
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Affiliation(s)
- Syed Mustajab Hasan
- University of Central Florida College of Medicine, Graduate Medical Education, Orlando, FL, USA.,Ocala Regional Medical Center, Internal Medicine Residency Program, Ocala, FL, USA
| | - Mohammed Faluk
- University of Central Florida College of Medicine, Graduate Medical Education, Orlando, FL, USA.,Ocala Regional Medical Center, Internal Medicine Residency Program, Ocala, FL, USA
| | - Ramy Abdelmaseih
- University of Central Florida College of Medicine, Graduate Medical Education, Orlando, FL, USA.,Ocala Regional Medical Center, Internal Medicine Residency Program, Ocala, FL, USA
| | - Jay D Patel
- University of Central Florida College of Medicine, Graduate Medical Education, Orlando, FL, USA.,Ocala Regional Medical Center, Internal Medicine Residency Program, Ocala, FL, USA
| | - Ravi Thakker
- University of Texas Medical Branch, Internal Medicine Residency Program Galveston, Galveston, TX, USA
| | - Jay J Chacko
- University of Central Florida College of Medicine, Graduate Medical Education, Orlando, FL, USA.,Ocala Regional Medical Center, Internal Medicine Residency Program, Ocala, FL, USA
| | - Dewid Zayas
- University of Central Florida College of Medicine, Graduate Medical Education, Orlando, FL, USA.,Ocala Regional Medical Center, Internal Medicine Residency Program, Ocala, FL, USA
| | - Alexis Finer
- Hospital Corporation of America Healthcare, Nashville, TN, USA
| | - Aiham Albaeni
- University of Central Florida College of Medicine, Graduate Medical Education, Orlando, FL, USA.,Ocala Regional Medical Center, Internal Medicine Residency Program, Ocala, FL, USA
| | - Khalid Abusaada
- University of Central Florida College of Medicine, Graduate Medical Education, Orlando, FL, USA.,Ocala Regional Medical Center, Internal Medicine Residency Program, Ocala, FL, USA
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Kovacs MJ, Wells PS, Anderson DR, Lazo-Langner A, Kearon C, Bates SM, Blostein M, Kahn SR, Schulman S, Sabri E, Solymoss S, Ramsay T, Yeo E, Rodger MA. Postoperative low molecular weight heparin bridging treatment for patients at high risk of arterial thromboembolism (PERIOP2): double blind randomised controlled trial. BMJ 2021; 373:n1205. [PMID: 34108229 PMCID: PMC8188228 DOI: 10.1136/bmj.n1205] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine the efficacy and safety of dalteparin postoperative bridging treatment versus placebo for patients with atrial fibrillation or mechanical heart valves when warfarin is temporarily interrupted for a planned procedure. DESIGN Prospective, double blind, randomised controlled trial. SETTING 10 thrombosis research sites in Canada and India between February 2007 and March 2016. PARTICIPANTS 1471 patients aged 18 years or older with atrial fibrillation or mechanical heart valves who required temporary interruption of warfarin for a procedure. INTERVENTION Random assignment to dalteparin (n=821; one patient withdrew consent immediately after randomisation) or placebo (n=650) after the procedure. MAIN OUTCOME MEASURES Major thromboembolism (stroke, transient ischaemic attack, proximal deep vein thrombosis, pulmonary embolism, myocardial infarction, peripheral embolism, or vascular death) and major bleeding according to the International Society on Thrombosis and Haemostasis criteria within 90 days of the procedure. RESULTS The rate of major thromboembolism within 90 days was 1.2% (eight events in 650 patients) for placebo and 1.0% (eight events in 820 patients) for dalteparin (P=0.64, risk difference -0.3%, 95% confidence interval -1.3 to 0.8). The rate of major bleeding was 2.0% (13 events in 650 patients) for placebo and 1.3% (11 events in 820 patients) for dalteparin (P=0.32, risk difference -0.7, 95% confidence interval -2.0 to 0.7). The results were consistent for the atrial fibrillation and mechanical heart valves groups. CONCLUSIONS In patients with atrial fibrillation or mechanical heart valves who had warfarin interrupted for a procedure, no significant benefit was found for postoperative dalteparin bridging to prevent major thromboembolism. TRIAL REGISTRATION Clinicaltrials.gov NCT00432796.
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Affiliation(s)
| | - Philip S Wells
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - David R Anderson
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | | | - Clive Kearon
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton ON, Canada
| | - Shannon M Bates
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton ON, Canada
| | - Mark Blostein
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Susan R Kahn
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Sam Schulman
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton ON, Canada
| | - Elham Sabri
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Susan Solymoss
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Tim Ramsay
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Erik Yeo
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Marc A Rodger
- Department of Medicine, McGill University, Montreal, QC, Canada
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Predictors of preprocedural direct oral anticoagulant levels in patients having an elective surgery or procedure. Blood Adv 2021; 4:3520-3527. [PMID: 32756938 DOI: 10.1182/bloodadvances.2020002335] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/01/2020] [Indexed: 12/21/2022] Open
Abstract
The Perioperative Anticoagulation Use for Surgery Evaluation (PAUSE) study prospectively evaluated a prespecified periprocedural-interruption strategy of direct oral anticoagulants (DOACs) among patients with atrial fibrillation. Logistic regression analyses were performed to identify clinical parameters associated with residual DOAC levels ≥30 ng/mL or ≥50 ng/mL. Patients undergoing low-bleed-risk procedures were more likely to have residual levels of ≥30 ng/mL and ≥50 ng/mL. For low-risk procedures, age ≥75 years, female sex, a creatinine clearance (CrCl) <50 mL/min, and an interruption of <36 hours were associated with a greater likelihood of levels ≥30 ng/mL, whereas age ≥75 years, female sex, a CrCl of <50 mL/min, and standard DOAC dosing were associated with levels ≥50 ng/mL. For high-risk procedures, weight of <70 kg, CrCl <50 mL/min, and standard DOAC dosing were associated with residual levels ≥30 ng/mL, whereas female sex was associated with levels ≥50 ng/mL. For low-risk procedures, apixaban was associated with a higher likelihood of levels ≥30 ng/mL as compared with dabigatran (P = .0019) and of levels ≥50 ng/mL when compared with rivaroxaban (P = .0003). For high-risk procedures, apixaban was marginally associated with a higher likelihood of residual levels ≥30 ng/mL when compared with dabigatran (P = .05), whereas rivaroxaban was associated with a higher likelihood of levels ≥30 ng/mL as compared with apixaban. Further study is required to determine whether adjustments to perioperative plans based on these clinical parameters could result in a lower risk of residual DOAC levels. The PAUSE trial was registered at www.clinicaltrials.gov as #NCT2228798.
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Ng AKY, Ng PY, Tam EWY, Siu CW, Fan K. Cardiac implantable electronic device surgery with interruption of warfarin forgoing post-operative bridging therapy in patients with moderate or high thromboembolic risks. Thromb J 2021; 19:28. [PMID: 33926467 PMCID: PMC8082611 DOI: 10.1186/s12959-021-00279-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 04/13/2021] [Indexed: 11/26/2022] Open
Abstract
Background For patients taking warfarin and undergoing pacemaker or implantable cardioverter-defibrillator surgery, clinical evidence and guidelines support continuation of warfarin therapy, as opposed to interruption of warfarin therapy with heparin bridging. Interruption of warfarin without post-operative bridging therapy may be a feasible alternative but data is sparse. Methods This is a single-arm observational study including adults who had interruption of warfarin therapy without post-operative bridging therapy for cardiac implantable electronic device (CIED) surgery performed between 2010 and 2019 in a tertiary referral hospital. The primary outcome was a composite of all-cause mortality, arterial or venous thromboembolic events. The secondary outcomes were clinically significant device-pocket hematoma and other procedural complications. Results Of the 411 patients analysed including 257 patients (62.5%) who had mechanical heart valves, the primary outcome developed in 5 (1.2%) patients within 30 days after surgery, including death in 3 (0.7%) patients, transient ischemic attack in 1 (0.2%) patient and non-CNS embolism in 1 (0.2%) patient. Clinically significant hematomas occurred in 24 (5.8%) patients, including 15 (3.7%) requiring additional interruption of anti-coagulation and 6 (1.5%) requiring clot evacuation. Other procedural complications and bleeding events were rare (< 1%). Conclusions Warfarin interruption without post-operative bridging therapy for CIED surgery was associated with low thromboembolic risks and acceptable bleeding risk. Randomized controlled trials are required to formulate an optimal approach to anti-coagulation management.
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Affiliation(s)
- Andrew Kei-Yan Ng
- Cardiac Medical Unit, Grantham Hospital, 125 Wong Chuk Hang Road, Hong Kong SAR, China.
| | - Pauline Yeung Ng
- Department of Adult Intensive Care, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong SAR, China.,Division of Respiratory and Critical Care Medicine, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Eva Wai-Ying Tam
- Cardiac Medical Unit, Grantham Hospital, 125 Wong Chuk Hang Road, Hong Kong SAR, China
| | - Chung-Wah Siu
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China
| | - Katherine Fan
- Cardiac Medical Unit, Grantham Hospital, 125 Wong Chuk Hang Road, Hong Kong SAR, China
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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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Update on the perioperative management of antiplatelets and anticoagulants in ophthalmic surgery. ARCHIVOS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGÍA 2021; 96:422-429. [PMID: 34340780 DOI: 10.1016/j.oftale.2020.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 11/06/2020] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Anti-thrombotic drugs (antiplatelets and anticoagulants) are widely used for different clinical reasons. This means that there are an increasing number of patients undergoing elective ophthalmic surgery that are being treated with these drugs. A better knowledge of their implications and their peri-operative use may help to prevent surgical and secondary adverse events. There is often no firm recommendation on how to manage certain drugs in certain surgeries. OBJECTIVE To review the recommendations in the scientific literature as regards managing anti-thrombotic agents during the peri-operative period of ophthalmic surgery. MATERIAL AND METHODS A review was made of the relevant guidelines and studies using an antiplatelet and anticoagulant drugs approach for cataract, vitreo-retinal, glaucoma, oculoplastic, and strabismus surgeries. RESULTS Recommendations about whether to continue or discontinue anti-thrombotic drugs in the peri-operative period of different ophthalmic surgical fields are presented. CONCLUSIONS There are only firm recommendations of maintaining anti-thrombotic drugs as regards cataract surgery using phacoemulsification with topical anaesthesia. In other surgical fields, ophthalmologists should balance the risk of thromboembolic events and risks of haemorrhagic complications in order to carry out a proper management. A multi-disciplinary approach is recommended for complex cases. Additional studies should be performed to better characterise the peri-operative use of anti-thrombotic agents in order to prepare clinical guidelines for ophthalmic surgery.
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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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Eljilany I, Elarref M, Shallik N, Elzouki AN, Mohammed A, Shoman B, Ibrahim S, Carr C, Al-Badriyeh D, Cavallari LH, Elewa H. Periprocedural Anticoagulation Management of Patients receiving Warfarin in Qatar: A Prospective Cohort Study. Curr Probl Cardiol 2021; 46:100816. [PMID: 33721568 DOI: 10.1016/j.cpcardiol.2021.100816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 02/01/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The use of anticoagulant bridging remains controversial. This study was conducted to evaluate our warfarin periprocedural management in Qatar and investigate the associated clinical outcomes with such management. METHODS A prospective cohort study was designed to describe the periprocedural clinical practice in warfarin patients in Qatar and to compare clinical safety and efficacy outcomes between anticoagulant bridging and nonbridging. RESULTS 103 patients were recruited. Bridging occurred in 82% of the participants. No thromboembolic events were observed, while 39.1% of patients experienced bleeding events during the study period. The incidence of overall bleeding and major bleeding were numerically higher for bridging group compared to nonbridging but did not reach statistical significance ([30.6% vs 22.2%, P = 0.478] and [12.9% vs 5.6%, P = 0.375], respectively). CONCLUSION Warfarin interruption and bridging are overwhelmingly used in warfarin-treated patients in Qatar. While bridging was numerically associated with increased bleeding events, there is no statistical difference in reported clinical events between bridging and nonbridging strategies.
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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; Weill Cornell Medical College, Doha, Qatar
| | - Abdel-Naser Elzouki
- Weill Cornell Medical College, Doha, Qatar; Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar; College of Medicine, Qatar University, Doha, Qatar
| | - AbdulMoqeeth Mohammed
- Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Bassam Shoman
- Department of Cardiothoracic Surgery, Heart Hospital, Hamad Medical corporation, Doha, Qatar
| | - Sami Ibrahim
- Department of anesthesia, Al Wakra Hospital, Hamad Medical corporation, Doha, Qatar; Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Cornelia Carr
- College of Medicine, Qatar University, Doha, Qatar; Department of Cardiothoracic Surgery, Heart 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, Florida, USA
| | - Hazem Elewa
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar; Biomedical and Pharmaceutical Research Unit, QU Health, Qatar University, Doha, Qatar.
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48
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Morris JA, Little M, Ashdown T, Clough OT, Packer T, Anakwe RE. Day case locked anterior plating for distal radial fractures is safe with uninterrupted antithrombotic therapy. J Hand Surg Eur Vol 2021; 46:172-175. [PMID: 33092452 DOI: 10.1177/1753193420966231] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We undertook a matched prospective cohort study over a 4-year period to examine the safety of continuing the administration of regular antithrombotic treatment with warfarin, clopidogrel or aspirin during day case surgical fixation of distal radial fractures. One hundred and one patients were identified and consented to participate in this study. There was only one reported complication: a superficial wound infection treated with antibiotics. No episodes of excessive bleeding were noted intraoperatively. All patients were discharged home on the day of surgery and there were no episodes of readmission, significant bleeding, haematoma requiring intervention, compartment syndrome or wound dehiscence. Complication rates were comparable with those of the matched cohort of patients undergoing the same procedure but who were not taking antithrombotic medications.Level of evidence: IV.
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Affiliation(s)
- James A Morris
- Department of Trauma and Orthopaedic Surgery, St Mary's Hospital Imperial College Healthcare NHS Trust, London, UK
| | - Max Little
- Department of Trauma and Orthopaedic Surgery, St Mary's Hospital Imperial College Healthcare NHS Trust, London, UK
| | - Thomas Ashdown
- Department of Trauma and Orthopaedic Surgery, St Mary's Hospital Imperial College Healthcare NHS Trust, London, UK
| | - Oliver T Clough
- Department of Trauma and Orthopaedic Surgery, St Mary's Hospital Imperial College Healthcare NHS Trust, London, UK
| | - Timothy Packer
- Department of Trauma and Orthopaedic Surgery, St Mary's Hospital Imperial College Healthcare NHS Trust, London, UK
| | - Raymond E Anakwe
- Department of Trauma and Orthopaedic Surgery, St Mary's Hospital Imperial College Healthcare NHS Trust, London, UK
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49
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Retrospective high volume comparative study suggests that patients on aspirin could have immediate surgery for hip fractures without significant blood loss. INTERNATIONAL ORTHOPAEDICS 2021; 45:543-549. [PMID: 33515330 DOI: 10.1007/s00264-021-04941-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 01/07/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE This study aimed to investigate the effects of aspirin on peri-operative hidden blood loss during hip fracture surgery by adjusting for possible factors affecting blood loss using a propensity score matching method. METHODS We retrospectively collected data from a cohort of isolated hip fracture patients (aged ≥ 65 years)who underwent surgery from January 2010 to December 2019. The study's primary outcome was blood loss from admission to the day after surgery in the aspirin and control groups. We estimated the hidden blood loss, calculated based on patient's blood volume, haemoglobin measurements, and blood transfusions. The secondary outcome focused on the requirement for blood transfusion. We adjusted for possible factors affecting blood loss using a propensity score matching method and statistically examined the effects of aspirin on hip fracture surgery. RESULTS We enrolled 806 patients of whom 271 (34%) were taking anticoagulant and antiplatelet drugs, while 114 (14%) were taking only aspirin (aspirin group). A total of 535 patients were not taking antiplatelets and anticoagulants (control group). In propensity score matching, 103 patients were matched. Aspirin was not associated with a significantly higher risk of hidden blood loss (aspirin group; median 598 mL [410-783 mL] vs control group; median 556 ml [321-741 mL], p = 0.14) and higher risk of blood transfusion requirement (aspirin group; 49 patients [48%] vs control group; 39 patients [38%], p = 0.21). CONCLUSION Aspirin did not affect peri-operative blood loss in hip fracture surgery. We concluded that patients taking aspirin can safely undergo hip fracture surgery without delay.
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50
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Influence of anticoagulants on the risk of delayed bleeding after gastric endoscopic submucosal dissection: a multicenter retrospective study. Gastric Cancer 2021; 24:179-189. [PMID: 32683602 DOI: 10.1007/s10120-020-01105-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 07/09/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Delayed bleeding after gastric endoscopic submucosal dissection (ESD) in patients receiving anticoagulants remains an unpreventable adverse event. Although direct-acting oral anticoagulants (DOACs) have superior efficacy in preventing thromboembolism, their effects on the occurrence of delayed bleeding remain unclear. This study aimed to elucidate the clinical effect of DOACs on delayed bleeding after gastric ESD. PATIENTS AND METHODS We retrospectively examined 728 patients who received anticoagulants and were treated for gastric neoplasms with ESD in 25 institutions across Japan. Overall, 261 patients received DOACs, including dabigatran (92), rivaroxaban (103), apixaban (45) and edoxaban (21), whereas 467 patients were treated with warfarin. RESULTS Delayed bleeding occurred in 14% of patients taking DOACs, which was not considerably different in patients receiving warfarin (18%). Delayed bleeding rate was significantly lower in patients receiving dabigatran than in those receiving warfarin and lower than that observed for other DOACs. Multivariate analysis showed that age ≥ 65, receiving multiple antithrombotic agents, resection of multiple lesions and lesion size ≥ 30 mm were independent risk factors, and that discontinuation of anticoagulants was associated with a decreased risk of bleeding. In multivariate analysis among patients taking DOACs, dabigatran therapy was associated with a significantly lower risk of delayed bleeding. CONCLUSIONS The effects of DOACs on delayed bleeding varied between agents, but dabigatran therapy was associated with the lowest risk of delayed bleeding. Switching oral anticoagulants to dabigatran during the perioperative period could be a reasonable option to reduce the risk of delayed bleeding after gastric ESD.
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