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Bücke P, Jung S, Kaesmacher J, Goeldlin MB, Horvath T, Prange U, Beyeler M, Fischer U, Arnold M, Seiffge DJ, Meinel TR. Intravenous thrombolysis in patients with recent intake of direct oral anticoagulants: A target trial analysis after the liberalization of institutional guidelines. Eur Stroke J 2024:23969873241252751. [PMID: 38738861 DOI: 10.1177/23969873241252751] [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: 05/14/2024] Open
Abstract
INTRODUCTION This study aimed to report the safety and efficacy of off-label intravenous thrombolysis (IVT) with alteplase after sequentially liberalizing our institutional guidelines allowing IVT for patients under direct oral anticoagulants (DOACs) regardless of plasma levels, time of last intake, and without prior anticoagulation reversal therapy. PATIENTS AND METHODS We utilized the target-trial methodology to emulate hypothetical criteria of a randomized controlled trial in our prospective stroke registry. Consecutive DOAC patients (06/2021-11/2023) otherwise qualifying for IVT were included. Safety and efficacy outcomes (symptomatic intracranial hemorrhage [ICH], any radiological ICH, major bleeding, 90-day mortality, 90-day good functional outcome [mRS 0-2 or return to baseline]) were assessed using inverse-probability-weighted regression-adjustment comparing patients with versus without IVT. RESULTS Ninety eight patients fulfilled the target-trial criteria. IVT was given in 49/98 (50%) patients at a median of 178 (interquartile range 134-285) min after symptom onset with median DOAC plasma level of 77 ng/ml (15 patients had plasma levels > 100 ng/ml; 25/49 [51%] were treated within 12 h after last DOAC ingestion). Endovascular therapy was more frequent in patients without IVT (73% vs 33%). Symptomatic ICH occurred in 0/49 patients receiving IVT and 2/49 patients without IVT (adjusted difference -2.5%; 95% CI -5.9 to 0.8). The rates of any radiological ICH were comparable. Patients receiving IVT were more likely to have good functional outcomes. DISCUSSION AND CONCLUSION After liberalizing our approach for IVT regardless of recent DOAC intake, we did not experience any safety concerns. The association of IVT with better functional outcomes warrants prospective randomized controlled trials.
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Affiliation(s)
- Philipp Bücke
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Simon Jung
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Stroke Research Center Bern, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Martina B Goeldlin
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Thomas Horvath
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Ulrike Prange
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Morin Beyeler
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Urs Fischer
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
- Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Marcel Arnold
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - David J Seiffge
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Thomas R Meinel
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
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Alyahya B, Alalshaikh A, Alkhulaif A, Al-Salamah T, Aldawood B, Alsubaie A, Alohali M, Alshenaifi S, Alohali A, Alzin MB, Almana A, Habib M, Hasanato R. Are We Overusing Coagulation Studies in the Emergency Department? Emerg Med Int 2024; 2024:8694183. [PMID: 38689634 PMCID: PMC11060872 DOI: 10.1155/2024/8694183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 03/28/2024] [Accepted: 04/01/2024] [Indexed: 05/02/2024] Open
Abstract
Methods This retrospective observational study, conducted in the ED of King Saud University Medical City (KSUMC) in Riyadh, Saudi Arabia, during July and August of 2021(2 months) examined coagulation profile requests. Patients' demographic data (age and gender), medical and clinical history (presenting complaint, comorbidities, and diagnosis), the use of antiplatelets or anticoagulant agents and laboratory values for PT, APTT, and INR were collected. We calculated the total cost of unnecessary coagulation profile testing based on the independent assessment of two ED consultants. Results Of 1,754 patients included in the study, 811 (46.2%) were males and 943 (53.8%) were females, with a mean age of 42.1 ± 18.5 years. There were 29 (1.7%) patients with liver disease and 21 (1.2%) patients had thromboembolic disease. The majority of the patients' results were within normal levels of PT (n = 1,409, 80.3%), APTT (n = 1,262, 71.9%), and INR (n = 1,711, 97.4%). Evidence of active bleeding was detected in 29 patients (1.7%). Among patients with bleeding only one had an abnormal INR (3.01) and was on warfarin. Forty-six (2.6%) patients had elevated INR level. Cohen's kappa between the two consultants was recorded at 0.681 (substantial agreement) in their assessment of the appropriateness of coagulation tests requests and both consultants believed that 1,051 tests (59.9%) were not indicated and were unnecessary. The expected annual cost saving if the unnecessary tests were removed would be around SAR 1,897,200 (approximately US$ 503,232) which is about SAR 180000 (US$ 48000)/1000 patients. Conclusion This study showed that coagulation tests are overused in the ED. More than half of coagulation profile tests in our study population were deemed unnecessary and associated with significant cost. Targeted testing based on specific patient presentation and medical history can guide physicians in wisely choosing who needs coagulation studies.
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Affiliation(s)
- Bader Alyahya
- Department of Emergency Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdulaziz Alalshaikh
- Department of Emergency Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ali Alkhulaif
- King Abdullah University Hospital, Riyadh, Saudi Arabia
| | - Tareq Al-Salamah
- Department of Emergency Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Badr Aldawood
- Department of Emergency Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Alwaleed Alsubaie
- Department of Emergency Medicine, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Meshal Alohali
- Medical Services Saudi Royal Guard, Riyadh, Saudi Arabia
| | - Saud Alshenaifi
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | | | - Majed B. Alzin
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdullah Almana
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mohammed Habib
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Rana Hasanato
- Laboratory Medicine Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Maegele M. Management of patients with proximal femur fractures under DOACs. Eur J Trauma Emerg Surg 2024; 50:359-366. [PMID: 38400927 PMCID: PMC11035399 DOI: 10.1007/s00068-024-02472-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 02/09/2024] [Indexed: 02/26/2024]
Abstract
PURPOSE In the past, preinjury direct oral anticoagulant (DOAC) intake has led to delays in time to surgery (TTS) in patients with proximal femur fractures and delays in surgery have been associated with impaired outcomes. Although healthcare institutions/federal committees have set rules for treatment within 24 h of injury, comprehensive guidelines for the perioperative management of these patients, in particular when on preinjury DOACs, are still lacking. This contribution aims to summarize the current evidence on the safe time window for surgery in patients with proximal femur fractures on preinjury DOACs and to outline therapeutic options if emergency DOAC reversal becomes necessary. METHODS Narrative review based upon selective review of the pertinent literature. RESULTS For the majority of patients with proximal femur fractures and on preinjury DOACs, early surgery appears safe as soon as medical clearance has been obtained. There may be an increase in the need for blood products but with data not yet conclusive. Work-up including assessment of remaining anticoagulant activity and potential reversal should be restricted to patients at risk for bleeding complications, in particular in the presence of renal/hepatic impairment. Methodology for rapid assessment of DOACs including quantitative/qualitative concentration levels is work in progress. In the case of bleeding, rapidly acting reversal agents are available. CONCLUSION Preinjury DOAC use should not routinely delay surgery in patients with proximal femur fractures.
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Affiliation(s)
- Marc Maegele
- Department for Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), Witten/Herdecke University, Campus Cologne-Merheim, Ostmerheimer Str. 200, 51109, Cologne, Germany.
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Campus Cologne-Merheim, Ostmerheimer Str. 200, 51109, Cologne, Germany.
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Mruthunjaya AKV, Chatelier RC, Torriero AAJ. Calibration-free electrochemical sensor to monitor factor-Xa inhibitors at the point-of-care anticoagulation therapy. Talanta 2024; 270:125593. [PMID: 38159356 DOI: 10.1016/j.talanta.2023.125593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/20/2023] [Accepted: 12/22/2023] [Indexed: 01/03/2024]
Abstract
This article presents a novel proof of concept for the blood plasma quantification of clinically relevant concentrations of direct oral anticoagulants, DOACs, including rivaroxaban and edoxaban, as well as low-molecular-weight heparins, LMWHs, such as enoxaparin and dalteparin, utilising a calibration-free disposable electrochemical sensor with co-facing electrodes. A dose-response curve was generated for rivaroxaban and edoxaban to demonstrate the sensor's ability to detect ≥9.00 ng mL-1 rivaroxaban and quantify it in the 11.0-140 ng mL-1 range. Similarly, the lower detection limit for edoxaban was 12.9 ng mL-1, with a quantification range of 16.8-140 ng mL-1. The significance of this sensor lies in its ability to quantify rivaroxaban and edoxaban below 30 ng mL-1, which is crucial in emergency care centres when patients undergoing DOAC therapy require emergency surgery or reversal of DOACs due to bleeding or ischemic stroke. Furthermore, the sensor can detect ≥0.016 IU mL-1 enoxaparin and ≥0.013 IU mL-1 dalteparin and quantify them in the 0.025-0.75 and 0.019-0.75 IU mL-1 range, respectively. Additionally, a dose-response curve was presented to demonstrate the potential ability of this sensor to quantify factor-Xa inhibitors independently of which DOACs or LMWHs are used. With the assay completed in less than 30 s using a minimal volume of 7 μL sample, the possibility to work at physiological pH and under calibration-free format makes this assay an excellent candidate for point-of-care testing.
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Affiliation(s)
- Ashwin K V Mruthunjaya
- School of Life and Environmental Sciences, Deakin University, Burwood, Victoria, 3125, Australia
| | - Ronald C Chatelier
- School of Life and Environmental Sciences, Deakin University, Burwood, Victoria, 3125, Australia
| | - Angel A J Torriero
- School of Life and Environmental Sciences, Deakin University, Burwood, Victoria, 3125, Australia.
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Brakta C, Stépanian A, Reiner P, Delrue M, Mazighi M, Curis E, Siguret V. Practical Nomogram Predicting Apixaban or Rivaroxaban Concentrations from Low-Molecular-Weight Heparin Anti-Xa Values: Special Interest in Acute Ischemic Stroke Patients. J Stroke 2023; 25:126-131. [PMID: 36592965 PMCID: PMC9911839 DOI: 10.5853/jos.2022.03034] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 11/23/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND AND PURPOSE In patients with acute ischemic stroke (AIS) using a direct oral factor-Xa anticoagulant (DOAC) during the last 48 hours, a fixed plasma heparin-calibrated anti-Xa activity (0.5 IU/mL) was proposed as a threshold below which patients could be eligible for thrombolysis and/or thrombectomy. Besides, specific DOAC-calibrated anti-Xa thresholds up to 50 ng/mL have been proposed. However, specific DOAC assays are not widely available contrarily to low-molecularweight heparin (LMWH) anti-Xa activity. We developed and validated a nomogram for predicting apixaban and rivaroxaban concentrations based on LMWH anti-Xa assay. METHODS Our prospective study included apixaban (n=325) and rivaroxaban (n=276) patients. On the same sample, we systematically measured specific DOAC concentration and LMWH anti-Xa activity, using STA®-Liquid-Anti-Xa (Stago) and specific DOAC- or LMWH-calibrators, respectively. The nomogram was built using quantifiable values for both assays on the derivation cohorts with a log-linear regression model. Model performances including sensitivity, specificity, and true positive rate for different thresholds were checked on the validation cohorts. RESULTS The models built from the derivation cohorts predicted that values <30 ng/mL and <50 ng/ mL DOAC thresholds corresponded to LMWH-anti-Xa values <0.10 IU/mL and <0.64 IU/mL for apixaban; <0.10 IU/mL and <0.71 IU/mL for rivaroxaban. The model accurately predicted apixaban/ rivaroxaban concentrations in the validation cohort. CONCLUSIONS This easy-to-use nomogram, developed with our reagent, allowed accurately predicting DOAC concentrations based on LMWH-anti-Xa results in emergency situations such as AIS when drug-specific assessments are not rapidly available. Using DOAC <50 ng/mL equivalent threshold, instead of the fixed LMWH <0.5 IU/mL one, would allow proposing thrombolysis to more patients.
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Affiliation(s)
- Charlyne Brakta
- Service d’hématologie – Hémostase clinique, Hôpital Lariboisière, APHP Nord, Paris, France
| | - Alain Stépanian
- Service d’hématologie – Hémostase clinique, Hôpital Lariboisière, APHP Nord, Paris, France,EA 3518, Université de Paris Cité, Paris, France
| | - Peggy Reiner
- Département de Neurologie, Unité Neuro-vasculaire, Hôpital Lariboisière, APHP Nord, Paris, France
| | - Maxime Delrue
- Service d’hématologie – Hémostase clinique, Hôpital Lariboisière, APHP Nord, Paris, France,Département de Neurologie, Unité Neuro-vasculaire, Hôpital Lariboisière, APHP Nord, Paris, France
| | - Mikaël Mazighi
- Département de Neurologie, Unité Neuro-vasculaire, Hôpital Lariboisière, APHP Nord, Paris, France
| | - Emmanuel Curis
- Service d’hématologie – Hémostase clinique, Hôpital Lariboisière, APHP Nord, Paris, France,UR 7537 BioSTM (Biostatistics), Faculté de Pharmacie de Paris, Université Paris Cité, Paris, France
| | - Virginie Siguret
- Service d’hématologie – Hémostase clinique, Hôpital Lariboisière, APHP Nord, Paris, France,INSERM UMRS-1140, Université de Paris Cité, Paris, France,Correspondence: Virginie Siguret Department of Hematology, Thrombosis Unit, Lariboisière Hospital (AP-HP), INSERM UMRS-1140, University Paris Cité, 2 rue Ambroise Paré 75010, Paris, France Tel: +33-6-63-53-37-55 Fax: +33-1-49-95-64-11 E-mail:
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Direct oral anticoagulants (DOACs): From the laboratory point of view. ACTA PHARMACEUTICA (ZAGREB, CROATIA) 2022; 72:459-482. [PMID: 36651369 DOI: 10.2478/acph-2022-0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/09/2022] [Indexed: 01/20/2023]
Abstract
Direct oral anticoagulants (DOACs) represent a new generation of drugs that have been increasingly used in the prevention and treatment of thromboembolic states. According to the mechanism of anticoagulant action, DOACs are divided into two groups: direct inhibitors of thrombin (dabigatran) and direct inhibitors of activated factor X (FXa) (rivaroxaban, apixaban, edoxaban, betrixaban). Compared to the vitamin K antagonists, DOACs are superior in terms of onset of action, pharmacokinetic and pharmacodynamics properties and fixed daily dose without the need for routine coagulation monitoring. Despite these advantages, there are clinical conditions in which laboratory measurement of DOACs should be performed. Although DOACs have an impact on screening haemostasis assays (prothrombin time, PT; activated partial thromboplastin time, aPTT; and thrombin time, TT), these tests are not appropriate for quantifying drug levels. Therefore, specific quantitative methods (LC-MS/MS as a gold standard method for all DOACs, coagulometric and chromogenic assays for dabigatran, and chromogenic anti-Xa assays with drug-specific calibrators for inhibitors of FXa) should only be used for determination of DOACs concentration. The aim of this review is to present all aspects of laboratory assessment of DOACs, including pre-analytical, analytical and post-analytical factors in the overall testing process with a special accent on the available specific quantitative methods for measurement of DOACs in circulation.
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Okada T, Yoshimoto T, Wada S, Yoshimura S, Chiba T, Egashira S, Kimura S, Shiozawa M, Inoue M, Ihara M, Toyoda K, Takashima H, Koga M. Intravenous Thrombolysis With Alteplase at 0.6 mg/kg in Patients With Ischemic Stroke Taking Direct Oral Anticoagulants. J Am Heart Assoc 2022; 11:e025809. [PMID: 36129032 PMCID: PMC9673692 DOI: 10.1161/jaha.122.025809] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background We elucidated the safety of treatment with alteplase at 0.6 mg/kg within 24 hours for patients on direct oral anticoagulants (DOACs) before ischemic stroke onset. Methods and Results Consecutive patients with acute ischemic stroke who underwent intravenous thrombolysis using alteplase at 0.6 mg/kg from 2011 to 2021 were enrolled from our single‐center prospective stroke registry. We compared outcomes between patients taking DOACs and those not taking oral anticoagulants within 48 hours of stroke onset. The primary safety outcome was the rate of symptomatic intracranial hemorrhage with a ≥4‐point increase on the National Institutes of Health Stroke Scale score from baseline. The efficacy outcome was defined as 3‐month modified Rankin Scale score of 0 to 2 after stroke onset. Of 915 patients with acute ischemic stroke who received intravenous thrombolysis (358 women; median age, 76 years; median National Institutes of Health Stroke Scale score, 10), 40 patients took DOACs (6 took dabigatran, 8 took rivaroxaban, 16 took apixaban, and 10 took edoxaban) within 24 hours of onset and 753 patients did not take any oral anticoagulants. The rate of symptomatic intracranial hemorrhage was comparable between patients on DOACs and those not on oral anticoagulants (2.5% versus 2.4%, P=0.95). The rate of favorable outcomes was comparable between the 2 groups (59.4% versus 58.2%, P=0.46), although the admission National Institutes of Health Stroke Scale score was higher in patients on DOACs. No significant differences showed in any intracranial hemorrhage within 36 hours or mortality at 3 months. Conclusions Intravenous thrombolysis would be safely performed for patients on DOACs following the recommendations of the Japanese guidelines. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02251665.
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Affiliation(s)
- Takashi Okada
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan.,Department of Neurology and Geriatrics Kagoshima University Graduate School of Medical and Dental Sciences Kagoshima Japan
| | - Takeshi Yoshimoto
- Department of Neurology National Cerebral and Cardiovascular Center Suita Japan
| | - Shinichi Wada
- Department of Medical and Health Information Management National Cerebral and Cardiovascular Center Suita Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Tetsuya Chiba
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Shuhei Egashira
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Shunsuke Kimura
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Manabu Inoue
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan.,Division of Stroke Care Unit National Cerebral and Cardiovascular Center Suita Japan
| | - Masafumi Ihara
- Department of Neurology National Cerebral and Cardiovascular Center Suita Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Hiroshi Takashima
- Department of Neurology and Geriatrics Kagoshima University Graduate School of Medical and Dental Sciences Kagoshima Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
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Seiffge DJ, Poli S, Meinel TR, Wu T, Wilson D, Purrucker JC. Intravenous thrombolysis in patients taking direct oral anticoagulants (ESO IVT guidelines comment). Eur Stroke J 2022; 6:445-446. [PMID: 35342810 DOI: 10.1177/23969873211050848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- David J Seiffge
- Department of Neurology, Inselspital University Hospital Bernand University of Bern, Switzerland
| | - Sven Poli
- Department of Neurology & Stroke, and Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Thomas R Meinel
- Department of Neurology, Inselspital University Hospital Bernand University of Bern, Switzerland
| | - Teddy Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand.,New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Duncan Wilson
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand.,New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Germany
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Farmakis D, Papakotoulas P, Angelopoulou E, Bischiniotis T, Giannakoulas G, Kliridis P, Richter D, Paraskevaidis I. Anticoagulation for atrial fibrillation in active cancer (Review). Oncol Lett 2022; 23:124. [PMID: 35261638 PMCID: PMC8867206 DOI: 10.3892/ol.2022.13244] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/02/2022] [Indexed: 11/17/2022] Open
Abstract
Atrial fibrillation (AF) may often pre-exist in patients with newly diagnosed cancer or occur with increased frequency shortly after cancer diagnosis. Patients with active cancer and AF have a particularly high risk of thromboembolic complications, as both conditions carry a risk of thrombosis. Thromboembolic risk is determined by several factors, including advanced age, sex (females), cancer histology (adenocarcinomas), location (e.g., pancreas, stomach), advanced stage, anticancer regimens (e.g., platinum compounds, anti-angiogenic therapies, immune modulators), comorbidities (e.g., obesity, kidney disease) and concurrent therapies (e.g., surgery, central catheters). Physicians are often reluctant to prescribe anticoagulants to patients with active cancer and AF, mainly due to fear of bleeding complications, which is partly related to the paucity of evidence in the field. Decision making regarding anticoagulation for the prevention of ischemic stroke and systemic embolism in patients with active cancer and AF may be challenging and should not simply rely on the risk prediction scores used in the general AF population. By contrast, the administration and choice of anticoagulants should be based on the comprehensive, individualized and periodic evaluation of thromboembolic and bleeding risk, drug-drug interactions, patient preferences and access to therapies.
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Affiliation(s)
- Dimitrios Farmakis
- Department of Physiology, University of Cyprus Medical School, Nicosia 2029, Cyprus
| | - Pavlos Papakotoulas
- First Department of Clinical Oncology, ‘Theagenio’ Anticancer Hospital, Thessaloniki 546 39, Greece
| | - Eleni Angelopoulou
- Department of Cardiology, ‘Agioi Anargyroi’ General Oncology Hospital, Athens 145 64, Greece
| | | | - George Giannakoulas
- Department of Cardiology, AHEPA General Hospital, Aristotle University of Thessaloniki, Thessaloniki 546 21, Greece
| | - Panagiotis Kliridis
- Department of Cardiology, ‘Agios Savvas’ General Anti‑Cancer Hospital, Athens 115 22, Greece
| | | | - Ioannis Paraskevaidis
- Department of Therapeutics, ‘Alexandra’ General Hospital, National and Kapodistrian University of Athens Medical School, Athens 115 28, Greece
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Harenberg J, Hetjens S, Weiss C. Patients' Plasma Activity of Heparin, low-Molecular-Weight Heparin or no Anticoagulants on Urine Based DOAC Test Strips. Clin Appl Thromb Hemost 2022; 28:10760296221083667. [PMID: 35275493 PMCID: PMC8921744 DOI: 10.1177/10760296221083667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
DOAC Dipstick determines specifically the presence and absence of direct oral anticoagulants (DOACs) from patients’ urine samples and handmade test strips performed as well as the commercial version. To compare plasma activity (chromogenic substrate assays) from plasma samples with results from urine samples (DOAC test strips) of patients treated with heparin, low-molecular weight heparin (LMWH) and without anticoagulation. Plasma anti-factor Xa (aXa) activity was determined by Coamatic chromogenic substrate assay and compared to the presence of anticoagulants in urine by DOAC test strips. Patients were treated for least 5 days and samples were taken 4 hrs after administration in comparison to no treatment with an anticoagulant (n = 42). A total of 100 patients were included treated with heparin (n = 29), LMWH nadroparin (n = 29) or no anticoagulants (n = 42). Plasma aXa levels of patients treated with heparin (2 × 7.500 IU daily subcutaneously, 12 male, age 67.4 ± 11.5 years) were 0,18 IU/ml ± 0,15 IU/ml (mean, standard deviation), with LMWH (1 × 3000 IU daily subcutaneously, 15 male, age 64.2 ± 14.1 years) 0,17 IU/ml ± 0,16 IU/l, and with no anticoagulants (28 male, age 64.2 ± 15.6 years) 0,02 IU/ml ± 0.01 IU/ml. All factor Xa and thrombin inhibitor pad results of test strips were negative. We conclude that DOAC Dipstick has a high probability of not detecting heparin and LMWH in patients on treatment as well as in urine samples of patients not treated with an anticoagulant.
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Affiliation(s)
- Job Harenberg
- DOASENSE GmbH, Heidelberg, Germany.,9144Ruprecht-Karls University Heidelberg, Heidelberg, Germany
| | - Svetlana Hetjens
- Medical Faculty Mannheim, Ruprecht-Karls University Heidelberg, Heidelberg, Germany
| | - Christel Weiss
- Medical Faculty Mannheim, Ruprecht-Karls University Heidelberg, Heidelberg, Germany
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12
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Kaaber AB, Jans Ø, Dziegiel MH, Stensballe J, Johansson PI. Managing patients on direct factor Xa inhibitors with rapid thrombelastography. Scandinavian Journal of Clinical and Laboratory Investigation 2021; 81:661-669. [PMID: 34807769 DOI: 10.1080/00365513.2021.2003855] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The use of direct factor Xa inhibitors rivaroxaban and apixaban (XABANs) has rapidly increased; however, there is no validated test available to monitor the effect on hemostasis. This study aims to assess how hemostatic management based on the Rapid Thromboelastography (R-TEG) variable activated clotting time (ACT) of XABAN patients with ongoing bleedings or in need for acute surgical intervention, affected patient outcome. A total of 343 XABAN patients were included in the main analysis together with 50 healthy volunteers to validate the reference value for ACT. An ACT >120 s (s) was defined as having XABAN-induced coagulopathy. Sixty-five percent of the XABAN patients presented with R-TEG ACT within the normal reference. Patients with XABAN-induced coagulopathy had a significantly increased risk of severe bleeding. Significantly more patients with extra-cerebral bleeding (ECB) and ACT above 120 s were transfused with five red blood cell (RBC) units or more compared to patients with ACT at 120 s or below (17% vs. 3%, p <.05). Significantly more XABAN-patients with ACT above 120 s received pro-hemostatic intervention with prothrombin complex concentrate (PCC) when compared to those with ACT at 120 s or below (ECB: 2% vs. 8%, p =.03, intracranial hemorrhage: 25% vs. 68%, p <.00). Patients who received PCC had a higher 30- and 90-day mortality compared to the rest of the cohort (16% vs. 6%, p = .02 and 21% vs. 7%, p =.00). Patients with XABAN-induced coagulopathy as evaluated by R-TEG ACT presented with more severe bleeding and higher transfusion requirements when compared to those with ACT in the normal range. This suggests that R-TEG ACT measurement in XABAN patients with active hemorrhage or in need for acute surgery may be of clinical value.
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Affiliation(s)
- Andrea Bak Kaaber
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Øivind Jans
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Denmark.,Department of Anesthesiology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Morten H Dziegiel
- Department of Clinical Immunology, Copenhagen University Hospital, Rigshospitalet, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jakob Stensballe
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Denmark.,Department of Anesthesiology, Center of Head and Orthopedics, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Pär I Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Denmark.,Department of Clinical Immunology, Copenhagen University Hospital, Rigshospitalet, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Abstract
From preoperative medications to intraoperative needs to postoperative thromboprophylaxis, anticoagulants are encountered throughout the perioperative period. This review focuses on coagulation testing clinicians utilize to monitor the effects of these medications.
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14
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Schäfer ST, Otto AC, Acevedo AC, Görlinger K, Massberg S, Kammerer T, Groene P. Point-of-care detection and differentiation of anticoagulant therapy - development of thromboelastometry-guided decision-making support algorithms. Thromb J 2021; 19:63. [PMID: 34493301 PMCID: PMC8425056 DOI: 10.1186/s12959-021-00313-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 08/14/2021] [Indexed: 03/25/2023] Open
Abstract
Background DOAC detection is challenging in emergency situations. Here, we demonstrated recently, that modified thromboelastometric tests can reliably detect and differentiate dabigatran and rivaroxaban. However, whether all DOACs can be detected and differentiated to other coagulopathies is unclear. Therefore, we now tested the hypothesis that a decision tree-based thromboelastometry algorithm enables detection and differentiation of all direct Xa-inhibitors (DXaIs), the direct thrombin inhibitor (DTI) dabigatran, as well as vitamin K antagonists (VKA) and dilutional coagulopathy (DIL) with high accuracy. Methods Following ethics committee approval (No 17–525-4), and registration by the German clinical trials database we conducted a prospective observational trial including 50 anticoagulated patients (n = 10 of either DOAC/VKA) and 20 healthy volunteers. Blood was drawn independent of last intake of coagulation inhibitor. Healthy volunteers served as controls and their blood was diluted to simulate a 50% dilution in vitro. Standard (extrinsic coagulation assay, fibrinogen assay, etc.) and modified thromboelastometric tests (ecarin assay and extrinsic coagulation assay with low tissue factor) were performed. Statistical analyzes included a decision tree analyzes, with depiction of accuracy, sensitivity and specificity, as well as receiver-operating-characteristics (ROC) curve analysis including optimal cut-off values (Youden-Index). Results First, standard thromboelastometric tests allow a good differentiation between DOACs and VKA, DIL and controls, however they fail to differentiate DXaIs, DTIs and VKAs reliably resulting in an overall accuracy of 78%. Second, adding modified thromboelastometric tests, 9/10 DTI and 28/30 DXaI patients were detected, resulting in an overall accuracy of 94%. Complex decision trees even increased overall accuracy to 98%. ROC curve analyses confirm the decision-tree-based results showing high sensitivity and specificity for detection and differentiation of DTI, DXaIs, VKA, DIL, and controls. Conclusions Decision tree-based machine-learning algorithms using standard and modified thromboelastometric tests allow reliable detection of DTI and DXaIs, and differentiation to VKA, DIL and controls. Trial registration Clinical trial number: German clinical trials database ID: DRKS00015704. Supplementary Information The online version contains supplementary material available at 10.1186/s12959-021-00313-7.
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Affiliation(s)
- Simon T Schäfer
- Department of Anaesthesiology, University Hospital Munich, LMU Munich, Munich, Germany
| | - Anne-Christine Otto
- Department of Anaesthesiology, University Hospital Munich, LMU Munich, Munich, Germany
| | | | | | - Steffen Massberg
- Department of Internal Medicine I - Cardiology, University Hospital Munich, LMU Munich, Munich, Germany
| | - Tobias Kammerer
- Department of Anaesthesiology, University Hospital Munich, LMU Munich, Munich, Germany.,Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Philipp Groene
- Department of Anaesthesiology, University Hospital Munich, LMU Munich, Munich, Germany. .,Klinikum der Universität München, Ludwig-Maximilians-Universität München, Marchioninistraße 15, 81377, Munich, Germany.
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15
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Cavaillez T, Weinmann L, Mouton C, Delassasseigne C, Sesay M, Biais M, James C, Roullet S. A retrospective study of indications and consequences of monitoring direct oral anticoagulant plasma concentrations on patient care in a university hospital: The Retro-AOD study. Thromb Res 2021; 206:76-83. [PMID: 34419866 DOI: 10.1016/j.thromres.2021.08.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 07/31/2021] [Accepted: 08/11/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The use of direct oral anticoagulants (DOAC) is increasing. Specific concentrations are available and have been proven to be reliable and reproducible in optimising patient care. This retrospective, monocentric study aimed to describe the indications and consequences of monitoring DOAC plasma levels on patient care. MATERIALS AND METHODS We collected data of patients hospitalised at the Bordeaux University Hospital between January 2017 and December 2018. These included demographics, indications, type, dose of DOAC, standard coagulation tests, creatinine clearance and DOAC plasma concentration using specifically calibrated rivaroxaban and apixaban anti-Xa and dabigatran anti-IIa assays. The date of last DOAC intake, the time between intake and plasma level measurement were also collected and analysed. RESULTS A total of 2197 DOAC assays in 1488 patients were obtained in various clinical situations: urgent or elective procedures, context of acute renal failure, suspicion or occurrence of ischemic strokes, intra-cranial and other bleeding sites. Interpretation of these assays led physicians to maintain, postpone or cancel invasive and high haemorrhagic risk procedures in 757, 261 and 56 cases respectively. The remaining 1123 assays were associated with no significant modification of patient care. DOAC plasma concentration was ≤30 ng ml-1 (sensitivity 85.4%, specificity 73.6%, positive predictive value 71.1%, negative predictive value 86.7%, AUC 0.81) after a last intake of at least 2 days. CONCLUSIONS Our study is, to date, the largest report of real-life measurement of specific DOAC plasma level at a single institution. Patient care was not modified in more than half of the assays.
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Affiliation(s)
- Thibaud Cavaillez
- CHU Bordeaux, Service d'Anesthésie-Réanimation Tripode, F-33000 Bordeaux, France
| | - Laurent Weinmann
- CHU Bordeaux, Laboratoire d'hématologie, F-33000 Bordeaux, France
| | - Christine Mouton
- CHU Bordeaux, Laboratoire d'hématologie, F-33000 Bordeaux, France
| | | | - Musa Sesay
- CHU Bordeaux, Service d'Anesthésie-Réanimation Tripode, F-33000 Bordeaux, France
| | - Matthieu Biais
- CHU Bordeaux, Service d'Anesthésie-Réanimation Tripode, F-33000 Bordeaux, France; Univ. Bordeaux, INSERM, Biologie des maladies cardiovasculaire, U1034, F-33600 Pessac, France
| | - Chloé James
- CHU Bordeaux, Laboratoire d'hématologie, F-33000 Bordeaux, France; Univ. Bordeaux, INSERM, Biologie des maladies cardiovasculaire, U1034, F-33600 Pessac, France
| | - Stéphanie Roullet
- CHU Bordeaux, Service d'Anesthésie-Réanimation Tripode, F-33000 Bordeaux, France; Univ. Bordeaux, INSERM, Biologie des maladies cardiovasculaire, U1034, F-33600 Pessac, France.
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16
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Zepeski AE, Faine BA, Merrill AE, Sutamtewagul G, Bhagavathi S. Utilization of anti-factor Xa levels to guide reversal of oral factor Xa inhibitors in the emergency department. Am J Health Syst Pharm 2021; 79:e20-e26. [PMID: 34363457 PMCID: PMC8385943 DOI: 10.1093/ajhp/zxab326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Purpose Oral factor Xa inhibitors (FXaIs) are increasingly utilized for outpatient anticoagulation therapy; however, laboratory monitoring is not routinely used to assess the safety and efficacy of these agents. We aimed to evaluate the role of chromogenic anti–factor Xa (anti-Xa) assays in the emergency department (ED) in the setting of patients with an acute bleed or requiring emergent procedures. Methods A retrospective review of anti-Xa levels obtained in the ED between June 1, 2019, and April 30, 2020, was completed. Data were collected to describe the clinical setting of anti-Xa level collection, oral FXaIs used before admission, administration of reversal agents, and patient disposition to further characterize the role of anti-Xa levels in the management of rivaroxaban and apixaban reversal. Results Thirty anti-Xa levels were included in the final analysis. The median time from sample collection to anti-Xa assay result was 45.9 minutes (interquartile range, 35.3-54.7 minutes). Eleven patients (37%) received anticoagulation reversal after their anti-Xa levels were determined. Anticoagulation reversal agents included either activated prothrombin complex concentrates (aPCCs) or prothrombin complex concentrates (PCCs). Anti-Xa levels were collected in 2 patients who had received PCCs before arrival at our ED. Of the patients with anti-Xa levels below 30 ng/mL, none received aPCCs or PCCs after their anti-Xa levels were determined. Anti-Xa assays were used to rule out the presence of FXaIs in 3 patients. Conclusion This study illustrates the novel role of anti-Xa levels in managing patients with an emergent need for reversal in the ED. The assay may be used to rule out the presence of oral FXaIs and avoid unnecessary administrations of anticoagulation reversal agents.
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Affiliation(s)
- Anne E Zepeski
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
- Department of Pharmacy Practice and Science, University of Iowa College of Pharmacy, Iowa City, IA, USA
- Address correspondence to Dr. Zepeski (). Twitter: @annezepeski
| | - Brett A Faine
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
- Department of Pharmacy Practice and Science, University of Iowa College of Pharmacy, Iowa City, IA, USA
| | - Anna E Merrill
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Grerk Sutamtewagul
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
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17
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Härtig F, Birschmann I, Peter A, Hörber S, Ebner M, Sonnleitner M, Spencer C, Bombach P, Stefanou MI, Kuhn J, Mengel A, Ziemann U, Poli S. Point-of-care testing of coagulation in patients treated with edoxaban. J Thromb Thrombolysis 2021; 50:632-639. [PMID: 32436010 PMCID: PMC7515947 DOI: 10.1007/s11239-020-02143-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Edoxaban, alongside other direct oral anticoagulants (DOAC), is increasingly used for prevention of thromboembolism, including stroke. Despite DOAC therapy, however, annual stroke rate in patients with atrial fibrillation remains 1–2%. Rapid exclusion of relevant anticoagulation is necessary to guide thrombolysis or reversal therapy but, so far, no data exists on the effect of edoxaban on available point-of-care test systems (POCT). To complete our previous investigation on global coagulation-POCT for the detection of DOAC, we evaluated whether CoaguChek®-INR (CC-INR) is capable of safely ruling out edoxaban concentrations above the current treatment thresholds of 30/50 ng/mL in a blood sample. We studied patients receiving a first dose of edoxaban; excluding subjects receiving other anticoagulants. Six blood samples were collected from each patient: before drug intake, 0.5, 1, 2 and 8 h after intake, and at trough (24 h). CC-INR and mass spectrometry for edoxaban concentrations were performed for each time-point. One hundred and twenty blood samples from 20 patients contained 0–302 ng/mL of edoxaban. CC-INR ranged from 0.9 to 2.3. Pearson’s correlation coefficient showed strong correlation between CC-INR and edoxaban concentrations (r = 0.73, p < 0.001). Edoxaban concentrations > 30 and > 50 ng/mL were ruled out by CC-INR ≤ 1.0 and ≤ 1.1, respectively, with high specificity (> 95%), and a sensitivity of 44% (95%-confidence interval: 30–59%) and 86% (74–93%), respectively. Our study represents the first evaluation of coagulation-POCT in edoxaban-treated patients. CC-POCT is suitable to safely exclude clinically relevant edoxaban concentrations prior to thrombolysis, or guide reversal therapy in stroke patients.
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Affiliation(s)
- Florian Härtig
- Department of Neurology & Stroke, and Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Tübingen, Germany
| | - Ingvild Birschmann
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Ruhr University, Bad Oeynhausen, Germany
| | - Andreas Peter
- Department for Diagnostic Laboratory Medicine, Institute for Clinical Chemistry and Pathobiochemistry, University Hospital Tuebingen, Tübingen, Germany
| | - Sebastian Hörber
- Department for Diagnostic Laboratory Medicine, Institute for Clinical Chemistry and Pathobiochemistry, University Hospital Tuebingen, Tübingen, Germany
| | - Matthias Ebner
- Department of Nephrology and Medical Intensive Care, Charité - University Medicine Berlin, Berlin, Germany
| | - Matthias Sonnleitner
- Department of Neurology & Stroke, and Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Tübingen, Germany
| | - Charlotte Spencer
- Department of Neurology & Stroke, and Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Tübingen, Germany
| | - Paula Bombach
- Department of Neurology & Stroke, and Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Tübingen, Germany
| | - Maria-Ioanna Stefanou
- Department of Neurology & Stroke, and Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Tübingen, Germany
| | - Joachim Kuhn
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Ruhr University, Bad Oeynhausen, Germany
| | - Annerose Mengel
- Department of Neurology & Stroke, and Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Tübingen, Germany
| | - Ulf Ziemann
- Department of Neurology & Stroke, and Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Tübingen, Germany
| | - Sven Poli
- Department of Neurology & Stroke, and Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Tübingen, Germany.
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18
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Fong AYY, Tiong LL, Tan SSN, Geruka D, Apil GG, Choo CW, Ong TK. Effect of Dabigatran on Clotting Time in the Clotpro Ecarin Clotting Assay: A Prospective, Single-Arm, Open-Label Study. Clin Appl Thromb Hemost 2021; 26:1076029620972473. [PMID: 33284050 PMCID: PMC7724398 DOI: 10.1177/1076029620972473] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Routine coagulation tests do not enable rapid, accurate determination of direct
oral anticoagulant (DOAC) therapy. The ecarin clotting assay (ECA), performed on
the ClotPro viscoelastic testing device, may enable sensitive and specific
detection of dabigatran. We assessed the association between trough plasma
dabigatran concentration and clotting time (CT) in the ClotPro ECA, in patients
with non-valvular atrial fibrillation (NVAF). Each patient provided a single
venous blood sample, ∼1 hour before dabigatran dosing. The study included 118
patients, of whom 64 were receiving dabigatran 110 mg twice daily and 54 were
receiving 150 mg twice daily. ECA CT was moderately correlated with trough
plasma dabigatran concentration (r = 0.80, p < 0.001).
Slight trends toward increased plasma dabigatran concentration and prolonged ECA
CT were apparent with 150 mg versus the 110 mg dose (differences not
statistically significant). Individuals with creatinine clearance below 50
mL/minute had significantly higher plasma dabigatran concentrations and
significantly prolonged ECA CT versus those with creatinine clearance ≥50
mL/minute. In conclusion, this preliminary study has demonstrated that CT in the
ClotPro ECA reflects the plasma concentration of dabigatran in patients with
NVAF. The ECA could potentially be used to assess the impact of dabigatran on a
patient’s coagulation status.
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Affiliation(s)
- Alan Yean Yip Fong
- Clinical Research Center, 58986Sarawak General Hospital, Institute for Clinical Research, National Institutes of Health, Shah Alam, Malaysia.,Department of Cardiology, Sarawak Heart Center, Kota Samarahan, Sarawak, Malaysia
| | - Lee Len Tiong
- Clinical Research Center, 58986Sarawak General Hospital, Institute for Clinical Research, National Institutes of Health, Shah Alam, Malaysia
| | - Shirley Siang Ning Tan
- Clinical Research Center, 58986Sarawak General Hospital, Institute for Clinical Research, National Institutes of Health, Shah Alam, Malaysia.,Department of Pharmacy, 58986Sarawak General Hospital, Kuching, Sarawak, Malaysia
| | - Dominic Geruka
- Clinical Research Center, 58986Sarawak General Hospital, Institute for Clinical Research, National Institutes of Health, Shah Alam, Malaysia
| | - Gerald Grino Apil
- Clinical Research Center, 58986Sarawak General Hospital, Institute for Clinical Research, National Institutes of Health, Shah Alam, Malaysia
| | - Chee Wei Choo
- Clinical Research Center, 58986Sarawak General Hospital, Institute for Clinical Research, National Institutes of Health, Shah Alam, Malaysia
| | - Tiong Kiam Ong
- Department of Cardiology, Sarawak Heart Center, Kota Samarahan, Sarawak, Malaysia
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19
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Dunois C. Laboratory Monitoring of Direct Oral Anticoagulants (DOACs). Biomedicines 2021; 9:biomedicines9050445. [PMID: 33919121 PMCID: PMC8143174 DOI: 10.3390/biomedicines9050445] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/08/2021] [Accepted: 04/13/2021] [Indexed: 11/16/2022] Open
Abstract
The introduction of direct oral anticoagulants (DOACs), such as dabigatran, rivaroxaban, apixaban, edoxaban, and betrixaban, provides safe and effective alternative to previous anticoagulant therapies. DOACs directly, selectively, and reversibly inhibit factors IIa or Xa. The coagulation effect follows the plasma concentration-time profile of the respective anticoagulant. The short half-life of a DOAC constrains the daily oral intake. Because DOACs have predictable pharmacokinetic and pharmacodynamic responses at a fixed dose, they do not require monitoring. However in specific clinical situations and for particular patient populations, testing may be helpful for patient management. The effect of DOACs on the screening coagulation assays such as prothrombin time (PT), activated partial thromboplastin time (APTT), and thrombin time (TT) is directly linked to reagent composition, and clotting time can be different from reagent to reagent, depending on the DOAC's reagent sensitivity. Liquid chromatography-mass spectrometry (LC-MS/MS) is considered the gold standard method for DOAC measurement, but it is time consuming and requires expensive equipment. The general consensus for the assessment of a DOAC is clotting or chromogenic assays using specific standard calibrators and controls. This review provides a short summary of DOAC properties and an update on laboratory methods for measuring DOACs.
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Affiliation(s)
- Claire Dunois
- HYPHEN BioMed, Sysmex Group, 95000 Neuville sur Oise, France
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20
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Harenberg J, Martini A, Du S, Krämer S, Weiss C, Hetjens S. Performance Characteristics of DOAC Dipstick in Determining Direct Oral Anticoagulants in Urine. Clin Appl Thromb Hemost 2021; 27:1076029621993550. [PMID: 33733904 PMCID: PMC7983466 DOI: 10.1177/1076029621993550] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Testing for direct oral anticoagulants (DOACs) in patient urine may facilitate medical treatment decisions. The aim of this study was to investigate interobserver variability by 2 independent observers compared to laboratory staff in the visual interpretation of factor Xa (DXI) and thrombin inhibitors (DTI) using the DOAC Dipstick test. We also examined whether test pads reacted to other anticoagulants and abnormal urine colors. The colors of the DOAC Dipstick direct factor Xa inhibitor and thrombin inhibitor pads were interpreted with 100% accuracy (95% confidence interval 0.862 to 1.000) for urine samples from persons treated with apixaban (n = 26), rivaroxaban (n = 24), and dabigatran (n = 29) and without anticoagulant therapy (n = 29). The factor Xa and thrombin inhibitor pads did not interact with heparin, nadroparin, fondaparinux, or coumadin. One µg/mL r-Hirudin and 6 µg/mL argatroban interacted with the DTI pad; however, this is unlikely to cause clinical problems because dabigatran is unlikely to be administered together with r-Hirudin and argatroban in clinical circumstances. Abnormal urine color was reliably detected by the urine color pad, so can prevent false interpretation of the DOAC Dipstick pad colors. In conclusion, we have demonstrated that interobserver variability when interpreting the DOAC Dipstick test strip is low and that factor Xa and thrombin inhibitor pads do not react to other anticoagulants such as heparins and coumadin. R-Hirudin and argatroban can be detected by the thrombin inhibitor pad and abnormal urine colors can be detected by the urine color pad to prevent false interpretation of the results in patient urine samples.
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Affiliation(s)
- Job Harenberg
- Ruprecht-Karls-University, Heidelberg, Germany.,DOASENSE GmbH, Heidelberg, Germany
| | - Andrea Martini
- Department of Medical Statistics, Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg, Mannheim, Germany
| | - Shanshan Du
- Ruprecht-Karls-University, Heidelberg, Germany
| | | | - Christel Weiss
- Department of Medical Statistics, Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg, Mannheim, Germany
| | - Svetlana Hetjens
- Department of Medical Statistics, Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg, Mannheim, Germany
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21
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Groene P, Wagner D, Kammerer T, Kellert L, Giebl A, Massberg S, Schäfer ST. Viscoelastometry for detecting oral anticoagulants. Thromb J 2021; 19:18. [PMID: 33726769 PMCID: PMC7962229 DOI: 10.1186/s12959-021-00267-w] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/01/2021] [Indexed: 12/26/2022] Open
Abstract
Background Determination of anticoagulant therapy is of pronounced interest in emergency situations. However, routine tests do not provide sufficient insight. This study was performed to investigate the impact of anticoagulants on the results of viscoelastometric assays using the ClotPro device. Methods This prospective, observational study was conducted in patients receiving dabigatran, factor Xa (FXa)-inhibitors, phenprocoumon, low molecular weight heparin (LMWH) or unfractionated heparin (UFH) (local ethics committee approval number: 17–525-4). Healthy volunteers served as controls. Viscoelastometric assays were performed, including the extrinsic test (EX-test), intrinsic test (IN-test) Russel’s viper venom test (RVV-test), ecarin test (ECA-test), and the tissue plasminogen activator test (TPA-test). Results 70 patients and 10 healthy volunteers were recruited. Clotting time in the EX-test (CTEX-test) was significantly prolonged versus controls by dabigatran, FXa inhibitors and phenprocoumon. CTIN-test was prolonged by dabigatran, FXa inhibitors and UFH. Dabigatran, FXa inhibitors and UFH significantly prolonged CTRVV-test in comparison with controls (median 200, 207 and 289 vs 63 s, respectively; all p < 0.0005). Only dabigatran elicited a significant increase in CTECA-test compared to controls (median 307 vs 73 s; p < 0.0001). CTECA-test correlated strongly with dabigatran plasma concentration (measured by anti-IIa activity; r = 0.9970; p < 0.0001) and provided 100% sensitivity and 100% specificity for detecting dabigatran. Plasma concentrations (anti-XA activity) of FXa inhibitors correlated with CTRVV-test (r = 0.7998; p < 0.0001), and CTRVV-test provided 83% sensitivity and 64% specificity for detecting FXa inhibitors. Conclusions In emergency situations, ClotPro viscoelastometric assessment of whole-blood samples may help towards determining the presence and type of anticoagulant class that a patient is taking. Trial registration German clinical trials database ID: DRKS00015302. Supplementary Information The online version contains supplementary material available at 10.1186/s12959-021-00267-w.
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Affiliation(s)
- Philipp Groene
- Department of Anaesthesiology, University Hospital Munich, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany.
| | - Daniela Wagner
- Department of Anaesthesiology, University Hospital Munich, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Tobias Kammerer
- Department of Anaesthesiology, University Hospital Munich, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany.,Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Lars Kellert
- Department of Neurology, University Hospital Munich, LMU Munich, Munich, Germany
| | - Andreas Giebl
- Department of Transfusion Medicine and Hemostaseology, University Hospital Augsburg, Augsburg, Germany
| | - Steffen Massberg
- Department of Internal Medicine I - Cardiology, University Hospital Munich, LMU Munich, Munich, Germany
| | - Simon Thomas Schäfer
- Department of Anaesthesiology, University Hospital Munich, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
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Real-World Data on Characteristics and Management of Community Patients Receiving Anticoagulation Therapy Who Presented with Acute Bleeding to the Emergency Department at a Regional Australian Hospital: A Prospective Observational Study. Mediterr J Hematol Infect Dis 2021; 13:e2021017. [PMID: 33747398 PMCID: PMC7938926 DOI: 10.4084/mjhid.2021.017] [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: 11/04/2020] [Accepted: 02/05/2021] [Indexed: 11/08/2022] Open
Abstract
Objective To study patients receiving anticoagulants with or without antiplatelet therapy presenting at a regional Australian hospital with bleeding. The main aims are to explore: (1) patients' characteristics and management provided; (2) association between the type of anticoagulant and antiplatelet agent used and the requirement of reversal; (3) and the length of hospital stay (LoS) in conjunction with bleeding episode and management. Methods A prospective cross-sectional review of medical records of all patients who presented at a tertiary referral centre with bleeding while receiving anticoagulation therapy between January 2016 and June 2018. Data included: patients, demographics, investigations (kidney and liver function tests, coagulation profile, FBC), LoS, bleeding site, type of and reason for anticoagulation therapy, and management provided. Data analysis included descriptive statistics, χ2 association, and regression models. Results Among the 144 eligible patients, 75 (52.1%) were male, and the mean age was 76 years (SD=11.1). Gastrointestinal tract bleeding was the most common (n=48, 33.3%), followed by epistaxis (n=32, 22.2%). Atrial fibrillation was the commonest reason for anticoagulation therapy (n=65, 45.1%). Warfarin was commonly used (n=74, 51.4%), followed by aspirin (n=29, 20.1%), rivaroxaban (n=26, 18.1%), and apixaban (n=12, 8.3%). The majority had increased blood urea nitrogen (n=67, 46.5%), while 58 (40.3%) had an elevated serum creatinine level, and 59 (41.0%) had a mild reduction in eGFR. Thirty-five of the warfarinised patients (47.3%) had an INR above their condition's target range despite normal liver function. Severe anaemia (Hb<80g/L) was reported in 88 patients (61.1%). DOACs were associated with a reduced likelihood of receiving reversal (B= -1.7, P=<.001), and with a shorter LoS (B= -4.1, P=.046) when compared with warfarin, LMWH, and antiplatelet therapy. Conclusion Warfarin use was common among patients who presented with acute bleeding, and the INR in many warfarinised patients exceeded the target for their condition. DOACs were associated with a reduced likelihood of receiving reversal and a shorter LoS than warfarin, LMWH, which might support a broader application of DOACs into community practice.
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23
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Härtig F, Birschmann I, Peter A, Hörber S, Ebner M, Sonnleitner M, Spencer C, Bombach P, Stefanou MI, Tünnerhoff J, Mengel A, Kuhn J, Ziemann U, Poli S. Point-of-care testing for emergency assessment of coagulation in patients treated with direct oral anticoagulants including edoxaban. Neurol Res Pract 2021; 3:9. [PMID: 33641678 PMCID: PMC7919064 DOI: 10.1186/s42466-021-00105-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 01/11/2021] [Indexed: 01/31/2023] Open
Abstract
Background Direct oral anticoagulants (DOAC) including edoxaban are increasingly used for stroke prevention in atrial fibrillation. Despite treatment, annual stroke rate in these patients remains 1–2%. Rapid assessment of coagulation would be useful to guide thrombolysis or reversal therapy in this growing population of DOAC/edoxaban-treated stroke patients. Employing the Hemochron™ Signature Elite point-of-care test system (HC-POCT), clinically relevant plasma concentrations of dabigatran and rivaroxaban can be excluded in a blood sample. However, no data exists on the effect of edoxaban on HC-POCT results. We evaluated whether edoxaban plasma concentrations above the current treatment thresholds for thrombolysis or anticoagulation reversal (i.e., 30 and 50 ng/mL) can be ruled out with the HC-POCT. Methods We prospectively studied patients receiving a first dose of edoxaban. Six blood samples were collected from each patient: before, 0.5, 1, 2, 8, and 24 h after drug intake. HC-POCT-based INR (HC-INR), activated clotting time (HC-ACT+ and HC-ACT-LR), activated partial thromboplastin time (HC-aPTT), and mass spectrometry for edoxaban plasma concentrations were performed at each time-point. We calculated correlations, receiver operating characteristics (ROC) and test-specific cut-offs for ruling out edoxaban concentrations > 30 and > 50 ng/mL in a blood sample. Results One hundred twenty blood samples from 20 edoxaban-treated patients were analyzed. Edoxaban plasma concentrations ranged from 0 to 512 ng/mL. HC-INR/HC-ACT+/HC-ACT-LR/HC-aPTT ranged from 0.7–8.3/78–310 s/65–215 s/19–93 s, and Pearson’s correlation coefficients showed moderate to very strong correlations with edoxaban concentrations (r = 0.95/0.79/0.70/0.60). With areas under the ROC curve of 0.997 (95% confidence interval: 0.991–0.971) and 0.989 (0.975–1.000), HC-INR most reliably ruled out edoxaban concentrations > 30 and > 50 ng/mL, respectively, and HC-INR results ≤1.5 and ≤ 2.1 provided specificity/sensitivity of 98.6% (91.2–99.9)/98.0% (88.0–99.9) and 96.8% (88.0–99.4)/96.5% (86.8–99.4). Conclusions Our study represents the first systematic evaluation of the HC-POCT in edoxaban-treated patients. Applying sufficiently low assay-specific cut-offs, the HC-POCT may not only be used to reliably rule out dabigatran and rivaroxaban, but also very low edoxaban concentrations in a blood sample. Because the assay-specific cut-offs were retrospectively defined, further investigation is warranted. Trial registration ClinicalTrials.gov, registration number: NCT02825394, registered on: 07/07/2016, URL Supplementary Information The online version contains supplementary material available at 10.1186/s42466-021-00105-4.
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Affiliation(s)
- Florian Härtig
- Department of Neurology & Stroke, University Hospital, Eberhard-Karls University Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Ingvild Birschmann
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Ruhr University, Bad Oeynhausen, Germany
| | - Andreas Peter
- Department of Diagnostic Laboratory Medicine, Institue for Clinical Chemistry and Pathobiochemistry, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Sebastian Hörber
- Department of Diagnostic Laboratory Medicine, Institue for Clinical Chemistry and Pathobiochemistry, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Matthias Ebner
- Department of Nephrology and Medical Intensive Care, Charité University Medicine, Berlin, Germany
| | - Matthias Sonnleitner
- Department of Neurology & Stroke, University Hospital, Eberhard-Karls University Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Charlotte Spencer
- Department of Neurology & Stroke, University Hospital, Eberhard-Karls University Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Paula Bombach
- Department of Neurology & Stroke, University Hospital, Eberhard-Karls University Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Maria-Ioanna Stefanou
- Department of Neurology & Stroke, University Hospital, Eberhard-Karls University Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Johannes Tünnerhoff
- Department of Neurology & Stroke, University Hospital, Eberhard-Karls University Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Annerose Mengel
- Department of Neurology & Stroke, University Hospital, Eberhard-Karls University Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Joachim Kuhn
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Ruhr University, Bad Oeynhausen, Germany
| | - Ulf Ziemann
- Department of Neurology & Stroke, University Hospital, Eberhard-Karls University Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Sven Poli
- Department of Neurology & Stroke, University Hospital, Eberhard-Karls University Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany. .,Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany.
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24
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Olsen LN, Fischer M, Evans PA, Gliemann L, Hellsten Y. Does Exercise Influence the Susceptibility to Arterial Thrombosis? An Integrative Perspective. Front Physiol 2021; 12:636027. [PMID: 33708141 PMCID: PMC7940832 DOI: 10.3389/fphys.2021.636027] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/01/2021] [Indexed: 12/14/2022] Open
Abstract
Arterial thrombosis is the primary cause of death worldwide, with the most important risk factors being smoking, unhealthy diet, and physical inactivity. However, although there are clear indications in the literature of beneficial effects of physical activity in lowering the risk of cardiovascular events, exercise can be considered a double-edged sword in that physical exertion can induce an immediate pro-thrombotic environment. Epidemiological studies show an increased risk of cardiovascular events after acute exercise, a risk, which appear to be particularly apparent in individuals with lifestyle-related disease. Factors that cause the increased susceptibility to arterial thrombosis with exercise are both chemical and mechanical in nature and include circulating catecholamines and vascular shear stress. Exercise intensity plays a marked role on such parameters, and evidence in the literature accordingly points at a greater susceptibility to thrombus formation at high compared to light and moderate intensity exercise. Of importance is, however, that the susceptibility to arterial thrombosis appears to be lower in exercise-conditioned individuals compared to sedentary individuals. There is currently limited data on the role of acute and chronic exercise on the susceptibility to arterial thrombosis, and many studies include incomplete assessments of thrombogenic clotting profile. Thus, further studies on the role of exercise, involving valid biomarkers, are clearly warranted.
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Affiliation(s)
- Line Nørregaard Olsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Mads Fischer
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Phillip Adrian Evans
- Haemostasis Biomedical Research Unit, Welsh Centre for Emergency Medicine Research, Morriston Hospital, SBU Health Board, Swansea, United Kingdom.,College of Medicine, Swansea University, Swansea, United Kingdom
| | - Lasse Gliemann
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Ylva Hellsten
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
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25
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Younis SE, El-Nahass SA, Elkhatib MA, Soliman SA, Youssef RM. Gradient HPLC-DAD method for quantification of novel oral anticoagulant “Edoxaban” in plasma: Its selective determination in presence of sixteen co-administered drugs. J Chromatogr B Analyt Technol Biomed Life Sci 2020; 1160:122386. [DOI: 10.1016/j.jchromb.2020.122386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 08/20/2020] [Accepted: 09/08/2020] [Indexed: 10/23/2022]
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26
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Strickland SW, Palkimas S, Acker M, Bazydlo LAL. A Novel Laboratory Assay to Monitor Unfractionated Heparin Dosing in Patients Taking Apixaban Prior to Hospital Admission. J Appl Lab Med 2020; 6:378-386. [PMID: 32995844 DOI: 10.1093/jalm/jfaa084] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 04/09/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION When monitoring heparin, anti-Xa assays are susceptible to interference from apixaban taken before admission and can result in inappropriate dose adjustments that can negatively affect patient care. METHODS We derived a novel assay, termed corrected heparin (CH), using quantified values from a chromogenic anti-Xa assay with heparin calibrators before and after heparinase treatment to eliminate any interference from apixaban within the patient sample. We retrospectively assessed 469 specimens from 72 patients at our institution who had their unfractionated heparin infusion monitored using the CH assay because of known apixaban use. These patients were included in the study if they had detectable apixaban levels (>0.1 IU/mL by anti-Xa). RESULTS The analytical performance of the assay was evaluated, and precision was found to be 8.8% within 1 day and 13.3% over multiple days, with acceptable linearity (R2 = 0.997). Evaluation of clinical performance was compared with the partial thromboplastin time (PTT), showing a lack of correlation similar to comparisons between the PTT and anti-Xa assay (Blood Coagul Fibrinolysis 1993;4:635-8). The mean time to a therapeutic result in this cohort was 10 hours and 10 minutes. The CH assay was used to determine how long the apixaban was detected by the anti-Xa assay. The majority of patients (80%) still had measurable anti-Xa assay interference from apixaban at 24 hours after the last apixaban dose. CONCLUSIONS We have developed and evaluated an assay capable of quantifying heparin in the presence of apixaban. This assay showed acceptable performance in both analytical and clinical performance.
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Affiliation(s)
- Sydney W Strickland
- Department of Pathology, University of Virginia Health System, Charlottesville, VA
| | - Surabhi Palkimas
- Department of Pharmacy, University of Virginia Health System, Charlottesville, VA.,Department of Pharmacy, University of Colorado Health, Charlottesville, VA
| | - Mary Acker
- Medical Laboratories, University of Virginia Health System, Charlottesville, VA
| | - Lindsay A L Bazydlo
- Department of Pathology, University of Virginia Health System, Charlottesville, VA
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Oberladstätter D, Voelckel W, Schlimp C, Zipperle J, Ziegler B, Grottke O, Schöchl H. A prospective observational study of the rapid detection of clinically-relevant plasma direct oral anticoagulant levels following acute traumatic injury. Anaesthesia 2020; 76:373-380. [PMID: 32946123 DOI: 10.1111/anae.15254] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2020] [Indexed: 12/15/2022]
Abstract
In urgent clinical situations, such as trauma, urgent surgery or before thrombolysis, rapid quantification of direct oral anticoagulant plasma drug levels is warranted. Using the ClotPro® analyser, we assessed two novel viscoelastic tests for detection of clinically-relevant plasma drug levels in trauma patients. The ecarin clotting time was used to assess the plasma concentration of dabigatran and Russell´s viper venom clotting time to determine the plasma concentration of direct factor Xa inhibitors. In parallel, plasma concentrations were analysed using plasma-based chromogenic assays. A total of 203 simultaneous measurements were performed. Strong to very strong linear correlations were detected between ecarin clotting time and plasma concentration of dabigatran (r = 0.9693), and between Russell´s viper venom clotting time and plasma concentrations of apixaban (r = 0.7391), edoxaban (r = 0.9251) and rivaroxaban (r = 0.8792), all p < 0.001. An ecarin clotting time ≥ 189 seconds provided 100% sensitivity and 90% specificity for detecting plasma dabigatran concentrations ≥ 50 ng.ml-1 . Corresponding Russell´s viper venom clotting time cut-off values were ≥ 136 seconds for apixaban (80% sensitivity, 88% specificity), ≥ 168 seconds for edoxaban (100% sensitivity, 100% specificity) and ≥ 177 seconds for rivaroxaban (90% sensitivity, 100% specificity). Detection of drug levels ≥ 100 ng.ml-1 was also investigated: for dabigatran, an ecarin clotting time ≥ 315 seconds yielded 92% sensitivity and 100% specificity; while Russell´s viper venom clotting time cut-offs of 191, 188 and 196 seconds were calculated for apixaban (67% sensitivity, 88% specificity), edoxaban (100% sensitivity, 75% specificity) and rivaroxaban (100% sensitivity, 91% specificity), respectively. We have demonstrated strong positive correlations between plasma drug levels and clotting time values in the specific ClotPro assays. Cut-off values for detecting clinically-relevant drug levels showed high levels of sensitivity and specificity.
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Affiliation(s)
- D Oberladstätter
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University Salzburg, Salzburg, Austria.,Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria
| | - W Voelckel
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University Salzburg, Salzburg, Austria
| | - C Schlimp
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University Salzburg, Salzburg, Austria.,Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria
| | - J Zipperle
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria
| | - B Ziegler
- Department of Anaesthesiology and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - O Grottke
- Department of Anaesthesiology, University Hospital of the RWTH Aachen, Aachen, Germany
| | - H Schöchl
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University Salzburg, Salzburg, Austria.,Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria
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28
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Zhang H, Liu Z, Mu G, Wang Z, Zhou S, Xie Q, Ma L, Wang Z, Hu K, Gong Y, Jiang J, Xiang Q, Cui Y. Diagnostic performance of coagulation indices for direct oral anticoagulant concentration. Thromb Res 2020; 195:171-179. [PMID: 32711233 DOI: 10.1016/j.thromres.2020.07.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 07/10/2020] [Accepted: 07/14/2020] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Different coagulation indices for direct oral anticoagulants (DOACs) exist in clinical practice, but limited data are available for the diagnostic power of these indices. This review and meta-analysis aims to explore the diagnostic value of coagulation indices for DOACs. MATERIALS AND METHODS PubMed, Web of Science, EMBASE, Clinical Trials.gov, and the Cochrane Library were searched from inception of each database to 15 February 2020. Studies reporting a relationship between coagulation indices and the gold standard (liquid chromatography/tandem mass spectrometry) were included in the analysis. RESULTS Sixteen articles from 9169 citations evaluating the performance of coagulation indices were included in this review. A total of 236, 273, 273 rivaroxaban samples were included to assess the diagnostic power of anti-Xa activity (AXA), prothrombin time (PT), combined PT and activated partial thromboplastin time, respectively. A total of 268 dabigatran samples were included to assess the diagnostic performance of diluted thromboplastin time (dTT). AXA calibrated by rivaroxaban showed a sensitivity of 0.98 (95% confidence interval (CI): 0.91-0.99) and a specificity of 0.98 (95% CI: 0.94-0.99) at the threshold of 30 ng/mL. For dabigatran, the combined sensitivity of dTT was 0.76 (95% CI: 0.66-0.84) and combined specificity was 0.97 (95% CI: 0.92-0.99). CONCLUSIONS DOAC-specific calibrated AXA was a good index to indicate concentration for rivaroxaban and apixaban. More studies on edoxaban and betrixaban are in need. Diluted TT, thrombin inhibitor assay, and ecarin-based assays were potential to measure dabigatran concentration. Due to the limited data, results should be validated in the future.
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Affiliation(s)
- Hanxu Zhang
- Department of Pharmacy, Peking University First Hospital, Beijing, China; School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Zhiyan Liu
- Department of Pharmacy, Peking University First Hospital, Beijing, China; School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Guangyan Mu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zhe Wang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Shuang Zhou
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Qiufen Xie
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Lingyue Ma
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zining Wang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Kun Hu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Yanjun Gong
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Jie Jiang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Qian Xiang
- Department of Pharmacy, Peking University First Hospital, Beijing, China.
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, Beijing, China; School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China.
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Metze M, Pfrepper C, Klöter T, Stöbe S, Siegemund R, Siegemund T, Edel E, Laufs U, Petros S. Inhibition of thrombin generation 12 hours after intake of direct oral anticoagulants. Res Pract Thromb Haemost 2020; 4:610-618. [PMID: 32548560 PMCID: PMC7292666 DOI: 10.1002/rth2.12332] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 01/12/2020] [Accepted: 02/02/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The residual antithrombotic activity 12 hours after intake of direct oral anticoagulants (DOACs) is of clinical relevance in the setting of bleeding or urgent surgery. OBJECTIVE To evaluate the effects of DOACs on thrombin generation 12 hours after DOAC intake in comparison to baseline and a healthy control group. METHODS Eighty patients were recruited, 20 patients for each approved DOAC: apixaban, edoxaban, rivaroxaban, and dabigatran. The patients were either to be put on anticoagulation for the first time or had stopped taking oral anticoagulation for at least 48 hours. Blood plasma was sampled before (baseline) and 12 hours after starting DOAC for quantification of drug levels and thrombin generation assayed using an automated system (ST Genesia). Sixty-one blood donors served as control group. RESULTS The factor Xa inhibitors significantly increased lag time (137%-219%) and reduced thrombin peak (47%-76%) and velocity index (17%-44%) after 12 hours compared to baseline. Dabigatran showed prolongation of lag time to 133% and time to peak to 119%. All patients had residual antithrombotic activity, with reduced thrombin generation parameters 12 hours after DOAC intake compared to baseline and to the healthy control group. This effect remained significant in patients with low residual DOAC plasma levels <50 ng/mL. CONCLUSION Thrombin generation remains reduced 12 hours after DOAC intake. While thrombin peak is particularly modified by factor Xa inhibitors, all DOACs prolong the lag time and time to thrombin peak. In the setting of bleeding or urgent surgery, the automated thrombin generation assay may assist in decision making and antidote administration.
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Affiliation(s)
- Michael Metze
- Department of CardiologyMedical Department IVUniversity Hospital LeipzigLeipzigGermany
| | - Christian Pfrepper
- Division of HemostaseologyMedical Department IUniversity Hospital LeipzigLeipzigGermany
| | - Tristan Klöter
- Department of CardiologyMedical Department IVUniversity Hospital LeipzigLeipzigGermany
| | - Stephan Stöbe
- Department of CardiologyMedical Department IVUniversity Hospital LeipzigLeipzigGermany
| | - Roland Siegemund
- Division of HemostaseologyMedical Department IUniversity Hospital LeipzigLeipzigGermany
| | - Thomas Siegemund
- Division of HemostaseologyMedical Department IUniversity Hospital LeipzigLeipzigGermany
| | - Elvira Edel
- Institute of Transfusion MedicineUniversity Hospital LeipzigLeipzigGermany
| | - Ulrich Laufs
- Department of CardiologyMedical Department IVUniversity Hospital LeipzigLeipzigGermany
| | - Sirak Petros
- Division of HemostaseologyMedical Department IUniversity Hospital LeipzigLeipzigGermany
- Medical ICUUniversity Hospital LeipzigLeipzigGermany
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30
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Sorigue M, Cañamero E, Siguenza P, Nomdedeu M, López-Núñez JJ. Recent developments and persisting challenges in the prevention and treatment of venous thromboembolism in patients with hematological malignancies. Leuk Lymphoma 2020; 61:1277-1291. [DOI: 10.1080/10428194.2020.1713321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Marc Sorigue
- Laboratory of Hematology, ICO-Hospital Germans Trias i Pujol, IJC, UAB, Badalona, Spain
| | - Eloi Cañamero
- Laboratory of Hematology, ICO-Hospital Germans Trias i Pujol, IJC, UAB, Badalona, Spain
| | - Patricia Siguenza
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Meritxell Nomdedeu
- Laboratory of Hematology, ICO-Hospital Germans Trias i Pujol, IJC, UAB, Badalona, Spain
| | - Juan J. López-Núñez
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Spain
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31
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Ebner M, Birschmann I, Peter A, Härtig F, Spencer C, Kuhn J, Rupp A, Blumenstock G, Zuern CS, Ziemann U, Poli S. Limitations of Specific Coagulation Tests for Direct Oral Anticoagulants: A Critical Analysis. J Am Heart Assoc 2019; 7:e009807. [PMID: 30371316 PMCID: PMC6404908 DOI: 10.1161/jaha.118.009807] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background During treatment with direct oral anticoagulants (DOAC), coagulation assessment is required before thrombolysis, surgery, and if anticoagulation reversal is evaluated. Limited data support the accuracy of DOAC‐specific coagulation assays around the current safe‐for‐treatment threshold of 30 ng/mL. Methods and Results In 481 samples obtained from 96 patients enrolled at a single center, DOAC concentrations were measured using Hemoclot direct thrombin inhibitor assay, Biophen direct thrombin inhibitor assay or ecarin clotting time for dabigatran, chromogenic anti‐Xa assay (AXA) for factor Xa inhibitors (rivaroxaban, apixaban) and ultraperformance liquid chromatography–tandem mass spectrometry as reference. All dabigatran‐specific assays had high sensitivity to concentrations >30 ng/mL, but specificity was lower for Hemoclot direct thrombin inhibitor assay (78.2%) than for Biophen direct thrombin inhibitor assay (98.9%) and ecarin clotting time (94.6%). AXA provided high sensitivity and specificity for rivaroxaban, but low sensitivity for apixaban (73.8%; concentrations up to 82 ng/mL were misclassified as <30 ng/mL). If no DOAC‐specific calibration for AXA is available, results 2‐fold above the upper limit of normal indicate relevant rivaroxaban concentrations. For apixaban, all elevated results should raise suspicion of relevant anticoagulation. Conclusions DOAC‐specific tests differ considerably in diagnostic performance for concentrations close to the currently accepted safe‐for‐treatment threshold. Compared with Biophen direct thrombin inhibitor assay and ecarin clotting time, limited specificity of Hemoclot direct thrombin inhibitor assay poses a high risk of unnecessary anticoagulation reversal or treatment delays in patients on dabigatran. While AXA accurately detected rivaroxaban, the impact of low apixaban levels on the assay was weak. Hence, AXA results need to be interpreted with extreme caution when used to assess hemostatic function in patients on apixaban. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifiers: NCT02371044, NCT02371070.
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Affiliation(s)
- Matthias Ebner
- 1 Department of Internal Medicine and Cardiology Charité University Medicine Berlin Campus Virchow Klinikum Berlin Germany.,2 Department of Neurology with Focus on Neurovascular Diseases and Neurooncology and Hertie Institute for Clinical Brain Research University Hospital Tübingen Germany
| | - Ingvild Birschmann
- 3 Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center Ruhr University Bad Oeynhausen Germany
| | - Andreas Peter
- 4 Division of Endocrinology, Diabetology, Angiology, Nephrology and Clinical Chemistry Department of Internal Medicine University Hospital Tübingen Germany.,5 Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Centre Munich University of Tübingen Germany.,6 German Centre for Diabetes Research (DZD) Neuherberg Germany
| | - Florian Härtig
- 2 Department of Neurology with Focus on Neurovascular Diseases and Neurooncology and Hertie Institute for Clinical Brain Research University Hospital Tübingen Germany
| | - Charlotte Spencer
- 2 Department of Neurology with Focus on Neurovascular Diseases and Neurooncology and Hertie Institute for Clinical Brain Research University Hospital Tübingen Germany
| | - Joachim Kuhn
- 3 Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center Ruhr University Bad Oeynhausen Germany
| | - André Rupp
- 7 Department of Neurology University Hospital Heidelberg Heidelberg Germany
| | - Gunnar Blumenstock
- 8 Department of Clinical Epidemiology and Applied Biometry University of Tübingen Germany
| | - Christine S Zuern
- 9 Department of Cardiology and Cardiovascular Medicine University Hospital Tübingen Germany.,10 Department of Cardiology and Cardiovascular Research Institute Basel (CRIB) University Hospital Basel Switzerland
| | - Ulf Ziemann
- 2 Department of Neurology with Focus on Neurovascular Diseases and Neurooncology and Hertie Institute for Clinical Brain Research University Hospital Tübingen Germany
| | - Sven Poli
- 2 Department of Neurology with Focus on Neurovascular Diseases and Neurooncology and Hertie Institute for Clinical Brain Research University Hospital Tübingen Germany
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DTI/DXI interferences with global coagulation tests in emergency hospital admissions - Results of the prospective Dresden NOAC Registry (NCT01588119). Thromb Res 2019; 182:101-109. [DOI: 10.1016/j.thromres.2019.08.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 07/19/2019] [Accepted: 08/19/2019] [Indexed: 01/06/2023]
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Frydman GH, Ellett F, Van Cott EM, Hayden D, Majmudar M, Vanderburg CR, Dalzell H, Padmanabhan DL, Davis N, Jorgensen J, Toner M, Fox JG, Tompkins RG. A New Test for the Detection of Direct Oral Anticoagulants (Rivaroxaban and Apixaban) in the Emergency Room Setting. Crit Care Explor 2019; 1:e0024. [PMID: 32166266 PMCID: PMC7063952 DOI: 10.1097/cce.0000000000000024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Determining whether a patient has taken a direct oral anticoagulant (DOAC) is critical during the periprocedural and preoperative period in the emergency department. However, the inaccessibility of complete medical records, along with the generally inconsistent sensitivity of conventional coagulation tests to these drugs, complicates clinical decision making and puts patients at risk of uncontrollable bleeding. In this study, we evaluate the utility of inhibitor-II-X (i-II-X), a novel, microfluidics-based diagnostic assay for the detection and identification of Factor Xa inhibitors (FXa-Is) in an acute care setting. DESIGN First-in-human, 91-patient, single-center retrospective pilot study. SETTING Emergency room. PATIENTS Adult patients admitted into the emergency department, which received any clinician-ordered coagulation test requiring a 3.2% buffered sodium citrate blood collection tube. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Plasma samples from patients admitted to the emergency department were screened for the use of FXa-Is, including apixaban and rivaroxaban, within the past 24 hours using our new i-II-X microfluidic test. i-II-X results were then compared with results from conventional coagulation tests, including prothrombin time (PT) and international normalized ratio (INR), which were ordered by treating clinicians, and an anti-Xa assay for rivaroxaban. The i-II-X test detected DOACs in samples collected from the emergency department with 95.20% sensitivity and 100.00% specificity. Unlike PT and INR, i-II-X reliably identified patients who had prolonged clotting times secondary to the presence of a FXa-I. CONCLUSIONS The i-II-X test overcomes the limitations of currently available coagulation tests and could be a useful tool by which to routinely screen patients for DOACs in emergency and critical care settings. Our new diagnostic approach is particularly relevant in clinical situations where medical records may be unavailable, or where precautions need to be taken prior to invasive interventions, such as specific reversal agent administration.
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Affiliation(s)
- Galit H Frydman
- Division of Comparative Medicine, Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA
- BioMEMS Resource Center, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Felix Ellett
- BioMEMS Resource Center, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | | | - Douglas Hayden
- Department of Biostatistics, Massachusetts General Hospital, Boston, MA
| | - Maulik Majmudar
- Department of Cardiology, Massachusetts General Hospital, Boston, MA
| | | | - Haley Dalzell
- Department of Cardiology, Massachusetts General Hospital, Boston, MA
| | | | - Nick Davis
- Division of Comparative Medicine, Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA
| | - Julianne Jorgensen
- BioMEMS Resource Center, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Mehmet Toner
- BioMEMS Resource Center, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - James G Fox
- Division of Comparative Medicine, Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA
| | - Ronald G Tompkins
- BioMEMS Resource Center, Department of Surgery, Massachusetts General Hospital, Boston, MA
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Abstract
PURPOSE OF REVIEW Despite the increasing use of NOACs, there is still uncertainty on how to treat NOAC patients presenting with neurological emergencies. Initial assessment of coagulation status is challenging but essential in these patients to provide best-possible treatment in case of ischemic or hemorrhagic stroke. Meanwhile, anticoagulation reversal strategies have been suggested; yet, the optimal management is still unestablished. The current review aims to provide up-to-date information on (i) how to identify patients with NOAC intake, (ii) which therapies are feasible in the setting of ischemic and hemorrhagic stroke as well as traumatic intracranial hemorrhage, and (iii) how to proceed with patients requiring emergency lumbar puncture. RECENT FINDINGS Despite several expert opinions, there is still an ongoing debate which NOAC patients presenting with ischemic stroke may benefit from recanalizing strategies and whether these treatment approaches can be performed safely. Results from two phase IV trials investigating the efficacy of NOAC-specific reversal agents in case of major bleeding seem promising with regard to hemostatic parameters, but these antidotes have not been verified to clinically benefit patients, and approval by authorities in parts is still pending. Specific reversal agents are on the way and will provide new treatment options in patients with NOAC-related ischemic and hemorrhagic stroke. Up to now, the decision which patients should undergo recanalizing treatment for ischemic stroke, or which specific pharmacological reversal treatment in hemorrhagic stroke should be initiated, has to be made cautiously on an individual basis after assessing hemostatic parameters.
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Affiliation(s)
- Stefan T Gerner
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany.
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[Atypical intracerebral hemorrhage-etiology and acute management]. DER NERVENARZT 2019; 90:423-441. [PMID: 30915485 DOI: 10.1007/s00115-019-0695-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Acute management as well as establishing the etiology of an intracerebral hemorrhage is still a challenge for clinicians. The location of the intracerebral hemorrhage alone should not be used to determine the cause because atypically located hemorrhages can be caused by long-standing arterial hypertension and typically located hemorrhages can occur due to non-hypertensive causes. Besides discussing the classification of intracerebral hemorrhages, this article focuses on a diagnostic algorithm as well as the presentation of potential (rarer) causes of non-traumatic intracerebral hemorrhages. Furthermore, the acute treatment of intracerebral hemorrhage with respect to recent data on blood pressure management as well as the management of bleeding under oral anticoagulant treatment are described.
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Winther-Larsen A, Hvas AM. Clinical impact of direct oral anticoagulant measuring in a real-life setting. Thromb Res 2019; 175:40-45. [DOI: 10.1016/j.thromres.2019.01.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 01/16/2019] [Accepted: 01/23/2019] [Indexed: 01/27/2023]
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