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Balachandren N, Seshadri S, Yasmin E, Saab W, Gates C, Sayar Z, Cohen H, Webber L. Venous thromboembolism associated with medically assisted reproduction (MAR): British fertility society policy and practice guidance for assessment and prevention. HUM FERTIL 2024; 27:2352387. [PMID: 38804228 DOI: 10.1080/14647273.2024.2352387] [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: 12/27/2023] [Accepted: 04/25/2024] [Indexed: 05/29/2024]
Abstract
The association between Medically Assisted Reproduction (MAR) and thromboembolic complications has been reported widely in multiple published studies. Although venous thromboembolism (VTE) is not thought to be a common complication of MAR, it is associated with high morbidity and is often preventable. Since VTE usually occurs after completion of MAR treatment and is often managed outside of the treating fertility unit, these complications are likely to be underreported and there may be limited awareness of the risks among clinicians. As we continue to see a rise in the total number of MAR treatment cycles, particularly in women over 40 years of age, along with a steady increase in the number of fertility preservation cycles for both medical and social indications, it is likely that we will see an increase in absolute numbers of VTE complications. Currently, there is a lack of management guidance and reporting of VTE events associated with assisted conception treatment. The aim of this guidance is to provide clinicians with information on VTE risk factors, guidance on assessing VTE risk and the best practice recommendations on risk reducing strategies for individuals at risk of VTE undergoing ovarian stimulation and embryo transfer cycles.
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Affiliation(s)
| | | | - Ephia Yasmin
- Reproductive Medicine Unit, University College London Hospital, London, UK
| | - Wael Saab
- The Centre for Reproductive & Genetic Health, London, UK
| | - Carolyn Gates
- Department of Haematology, University College London Hospital, London, UK
| | - Zara Sayar
- Department of Haematology, University College London Hospital, London, UK
- Department of Haematology, Whittington Health NHS Trust, London, UK
| | - Hannah Cohen
- Department of Haematology, University College London Hospital, London, UK
| | - Lisa Webber
- Gynaecology & Reproductive Medicine, Imperial College Healthcare NHS Trust, St Mary's Hospital, London, W2 1NY and Department of Obstetrics & Gynaecology, Singapore General Hospital, Singapore, Singapore
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O'Glasser AY, Manjarrez EC. Perioperative Care of Heart Failure, Arrhythmias, and Valvular Heart Disease. Med Clin North Am 2024; 108:1053-1064. [PMID: 39341613 DOI: 10.1016/j.mcna.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2024]
Abstract
Frequently, the question of whether or not a patient is stable for surgery boils down to the question, "Does this patient need a preoperative stress test?" However, coronary artery disease and ischemic heart disease are only some of the many cardiac conditions that patients present with preoperatively-and that can negatively impact their intraoperative management and postoperative outcomes. This article will explore the evidence based, patient centered best practices surrounding the perioperative evaluation and management of heart failure, arrhythmias, and valvular heart disease.
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Affiliation(s)
- Avital Y O'Glasser
- Department of Medicine, Division of Hospital Medicine, Oregon Health and Science University, 3485 Southwest Bond Avenue, CHH2 8008, Portland, OR 97239, USA; Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, 3485 Southwest Bond Avenue, CHH2 8008, Portland, OR 97239, USA.
| | - Efrén C Manjarrez
- Department of Medicine, Division of Hospital Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
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Dubois-Silva Á, Bikdeli B. Anticoagulant Therapy in Patients Undergoing Acute Pulmonary Embolism Interventions. Interv Cardiol Clin 2024; 13:561-575. [PMID: 39245555 DOI: 10.1016/j.iccl.2024.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2024]
Abstract
Catheter-based interventions and surgical embolectomy represent alternatives to systemic fibrinolysis for patients with high-risk pulmonary embolism (PE) or those with intermediate-high-risk PE who deteriorate hemodynamically. They are indicated when systemic fibrinolysis is contraindicated or ineffective, or if obstructive shock is imminent. Extracorporeal membrane oxygenation can be added to reperfusion therapies or used alone for severe right ventricular dysfunction and cardiogenic shock. These advanced therapies complement but do not replace anticoagulation, which remains the cornerstone in PE management. This review summarizes the evidence and shares practical recommendations for the use of anticoagulant therapy before, during, and after acute PE interventions.
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Affiliation(s)
- Álvaro Dubois-Silva
- Venous Thromboembolism Unit, Department of Internal Medicine, Complexo Hospitalario Universitario de A Coruña (CHUAC), A Coruña, Spain; Universidade da Coruña (UDC), A Coruña, Spain; Hospital at Home and Palliative Care Department, Complexo Hospitalario Universitario de A Coruña (CHUAC), A Coruña, Spain
| | - Behnood Bikdeli
- Division of Cardiovascular Medicine and the Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA.
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Schulman S, Bhagirath V, Chan N, Germini F, Ikesaka R, Iorio A, Mithoowani S, Weitz JI, Gross PL. Prothrombin complex concentrate for emergency surgery in patients on oral Xa-inhibitors. J Thromb Haemost 2024; 22:2761-2766. [PMID: 39002730 DOI: 10.1016/j.jtha.2024.07.002] [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: 04/25/2024] [Revised: 06/18/2024] [Accepted: 07/03/2024] [Indexed: 07/15/2024]
Abstract
BACKGROUND It is uncertain whether prothrombin complex concentrate (PCC) improves hemostasis in patients on treatment with oral factor Xa-inhibitors (XaI) who require emergency surgery. OBJECTIVES To evaluate whether, in patients with therapeutic levels of oral XaI, preoperative PCC prevents excessive bleeding during and after emergency surgery and is not associated with thrombotic complications. METHODS We conducted a prospective cohort study wherein a fixed 2000 IU dose of 4-factor PCC was given to patients taking oral XaI with plasma XaI levels of at least 75 ng/mL before the emergency surgery with an expected blood loss of at least 50 mL. Patients were followed for 30 days. The primary efficacy outcome was the incidence of normal or mildly abnormal surgical hemostasis, as assessed by the surgeon; primary safety outcome was the incidence of thromboembolic events within 7 days. RESULTS We included 20 patients, of which 50% were female, on apixaban (75%) or rivaroxaban (25%) with median XaI level of 128 ng/mL (range, 77-497 ng/mL). The median duration of surgery was 2 hours 42 minutes (range, 15 minutes to 8 hours 17 minutes). Normal or mildly abnormal hemostasis was observed in 16 patients (80%); 2 patients had moderately abnormal and 2 had severely abnormal hemostasis, 1 each of those was considered due to local or technical factors. There were 4 deaths (20%) secondary to underlying disease and 1 incidental pulmonary embolism in a patient with cancer. CONCLUSION A fixed dose of PCC appears to control hemostasis in patients with therapeutic plasma levels of apixaban or rivaroxaban requiring emergency surgery.
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Affiliation(s)
- Sam Schulman
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada; Department of Obstetrics and Gynecology and Perinatal Medicine, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia.
| | - Vinai Bhagirath
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada
| | - Noel Chan
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada
| | - Federico Germini
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada; Clinical Epidemiology and Research Center, Istituto di Ricovero e Cura a Carattere Scientifico Humanitas Research Hospital, Milan, Italy
| | - Rick Ikesaka
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Alfonso Iorio
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Siraj Mithoowani
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Jeff I Weitz
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Peter L Gross
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
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Douketis JD, Spyropoulos AC. Perioperative Management of Patients Taking Direct Oral Anticoagulants: A Review. JAMA 2024; 332:825-834. [PMID: 39133476 DOI: 10.1001/jama.2024.12708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
Importance Direct oral anticoagulants (DOACs), comprising apixaban, rivaroxaban, edoxaban, and dabigatran, are commonly used medications to treat patients with atrial fibrillation and venous thromboembolism. Decisions about how to manage DOACs in patients undergoing a surgical or nonsurgical procedure are important to decrease the risks of bleeding and thromboembolism. Observations For elective surgical or nonsurgical procedures, a standardized approach to perioperative DOAC management involves classifying the risk of procedure-related bleeding as minimal (eg, minor dental or skin procedures), low to moderate (eg, cholecystectomy, inguinal hernia repair), or high risk (eg, major cancer or joint replacement procedures). For patients undergoing minimal bleeding risk procedures, DOACs may be continued, or if there is concern about excessive bleeding, DOACs may be discontinued on the day of the procedure. Patients undergoing a low to moderate bleeding risk procedure should typically discontinue DOACs 1 day before the operation and restart DOACs 1 day after. Patients undergoing a high bleeding risk procedure should stop DOACs 2 days prior to the operation and restart DOACs 2 days after. With this perioperative DOAC management strategy, rates of thromboembolism (0.2%-0.4%) and major bleeding (1%-2%) are low and delays or cancellations of surgical and nonsurgical procedures are infrequent. Patients taking DOACs who need emergent (<6 hours after presentation) or urgent surgical procedures (6-24 hours after presentation) experience bleeding rates up to 23% and thromboembolism as high as 11%. Laboratory testing to measure preoperative DOAC levels may be useful to determine whether patients should receive a DOAC reversal agent (eg, prothrombin complex concentrates, idarucizumab, or andexanet-α) prior to an emergent or urgent procedure. Conclusions and Relevance When patients who are taking a DOAC require an elective surgical or nonsurgical procedure, standardized management protocols can be applied that do not require testing DOAC levels or heparin bridging. When patients taking a DOAC require an emergent, urgent, or semiurgent surgical procedure, anticoagulant reversal agents may be appropriate when DOAC levels are elevated or not available.
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Affiliation(s)
- James D Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton, and McMaster University, Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Alex C Spyropoulos
- Department of Medicine, Anticoagulation and Clinical Thrombosis Service, Northwell Health at Lenox Hill Hospital, New York, New York
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Institute of Health System Science at the Feinstein Institutes for Medical Research, Manhasset, New York
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Tamminen A, Aaltonen RI, Ristola MT. Postoperative bleeding complications in breast conserving surgery and the role of antithrombotic medications: retrospective analysis of 4712 operations. World J Surg Oncol 2024; 22:234. [PMID: 39232775 PMCID: PMC11375840 DOI: 10.1186/s12957-024-03511-5] [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: 06/17/2024] [Accepted: 08/27/2024] [Indexed: 09/06/2024] Open
Abstract
BACKGROUND This study aimed to evaluate the risk and timing of postoperative bleeding complications following breast-conserving surgery (BCS), with or without axillary surgery, especially in relation to perioperative management of antithrombotic medications. METHODS Data from all patients who underwent BCS for breast cancer between 2010 and 2022 at a single university hospital were collected. Medical records were reviewed for reoperations, unplanned admissions, and patient characteristics. RESULTS In total, 4712 breast-conserving surgeries and 3631 axillary surgeries were performed on 3838 patients. The risk of any bleeding complication was 1.1% (40/3571) in breast-conserving surgery, 0.3% (9/2847) in sentinel lymph node biopsy, and 0.5% (4/779) in axillary lymph node dissection. Upon arrival for treatment, 645 (17%) patients were taking antithrombotic medications. The risk of bleeding complications was not elevated in patients whose medication was discontinued at least a day before the surgery (OR 0.84, p = 0.76); but it was almost four-fold (OR 3.61, p = 0.026) in patients whose antithrombotic medication was continued. However, the absolute risk for bleeding complication was low in these patients as well (2.0%, 15/751). The majority of bleeding complications (85%, 47/55) occurred within 24 h after the surgery. CONCLUSION The risk for bleeding complications was elevated, but still low, after BCS with or without axillary surgery, when antithrombotic medications were continued through the surgical period. Discontinuing antithrombotic medications is not obligatory in these patients.
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Affiliation(s)
- Anselm Tamminen
- Department of Plastic and General Surgery, Turku University Hospital, Turku, Finland.
- University of Turku, Turku, Finland.
| | - Riitta I Aaltonen
- Department of Plastic and General Surgery, Turku University Hospital, Turku, Finland
- University of Turku, Turku, Finland
| | - Marko T Ristola
- Department of Plastic and General Surgery, Turku University Hospital, Turku, Finland
- University of Turku, Turku, Finland
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Ezzat B, Rossitto CP, Kalagara R, Ali M, Vasa D, Dedhia M, Asfaw Z, Arora A, Schuldt B, Smith C, Bose J, Mocco J, Kellner CP. Antithrombotics alter intracerebral hemorrhage presentation without affecting minimally invasive endoscopic evacuation. J Stroke Cerebrovasc Dis 2024; 33:107878. [PMID: 39025249 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107878] [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: 02/10/2024] [Revised: 07/05/2024] [Accepted: 07/15/2024] [Indexed: 07/20/2024] Open
Abstract
OBJECTIVES Intracerebral hemorrhages are associated with significant morbidity and mortality. While the ENRICH trial supports the efficacy of surgical evacuation for lobar hemorrhages, the impact of antithrombotic therapies on minimally invasive surgery outcomes remains unexplored. This study evaluates the effects of chronic anticoagulants and antiplatelets on the technical and longterm outcomes of minimally invasive intracerebral hemorrhage evacuation. MATERIALS AND METHODS A prospectively collected registry of patients undergoing minimally invasive surgery for intracerebral hemorrhage from a single institution was analyzed (December 2015-September 2022). Data included key demographics, comorbidities, antithrombotic/reversal status, presenting clinical/radiographic characteristics, procedural metrics, and clinical outcomes. Patients were divided into control (neither therapy), antiplatelet-only, and anticoagulant-only groups, with antiplatelet/anticoagulant reversals conducted per current American Heart Association/American Stroke Association guidelines. Variables significant in univariate analyses (p<0.05) were advanced to multivariable regression models. RESULTS Among 226 intracerebral hemorrhage patients treated with minimally invasive surgery, 41% (N=93) had antithrombotic medication history; 28% (N=64) received antiplatelets, and 9% (N=21) received anticoagulants. Patients on both therapies (N=6) were excluded. The antiplatelet group presented more frequently with lobar hemorrhages (56% vs. 37%; p=0.022), while patients on anticoagulants showed increased rates of intraventricular hemorrhage co-presentation (62% vs. 46%; p=0.011) compared to controls. Despite univariate analyses showing a higher postoperative hematoma volume (3.9 vs. 2.9 milliliters; p=0.020) and lower evacuation percentage (88% vs. 92%; p=0.019) for the antiplatelet group, and longer procedures for patients on anticoagulants (2.3 vs. 1.7 hours; p=0.042) compared to control, multivariable analyses indicated that antiplatelets and anticoagulants had no significant impact on these technical outcomes. Longitudinally, antithrombotics were not associated with increased rebleeding, less frequent discharge to home, lower 30-day mortality, or worse, 6-month Modified Rankin Scale scores. CONCLUSIONS Patients on chronic antiplatelets and anticoagulants exhibited characteristic intracerebral hemorrhage phenotypes without worse technical or long-term outcomes after minimally invasive intracerebral hemorrhage evacuation, suggesting the procedure's safety for these patients.
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Affiliation(s)
- Bahie Ezzat
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Christina P Rossitto
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Roshini Kalagara
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Muhammad Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Devarshi Vasa
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Mehek Dedhia
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Zerubabbel Asfaw
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Arushi Arora
- Center for Biostatistics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Braxton Schuldt
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Colton Smith
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Javin Bose
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Christopher P Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
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Micu A, Micu MC, Bodozs G, Duțu AG. To stop or not to stop novel oral anticoagulants prior to performing joint interventional maneuvers? Evidence from a prospective study that the therapy can be maintained. Clin Rheumatol 2024; 43:2983-2992. [PMID: 39008221 DOI: 10.1007/s10067-024-07048-6] [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: 05/01/2024] [Revised: 06/09/2024] [Accepted: 06/26/2024] [Indexed: 07/16/2024]
Abstract
Anticoagulation is common in patients undergoing routine musculoskeletal interventional maneuvers. Previous retrospective studies have established the safety of continuing anticoagulation with novel oral anticoagulants (NOACs) when performing this kind of interventions. Indeed, ultrasound (US)-guided interventional maneuvers have shown a superior safety profile compared to blind anatomical maneuvers. To evaluate prospectively the periprocedural bleeding events in NOAC-anticoagulated patients undergoing interventional articular or periarticular procedures. Consecutive patients diagnosed with inflammatory or degenerative rheumatologic pathology requiring interventional maneuvers were prospectively recruited. Group 1 was treated with NOACs, group 2 was treated with vitamin K antagonists, and group 3 was not anticoagulated. Prior to the international maneuver, NOAC therapy was continuously administered, in regimens dictated by the underlying anticoagulation indication. Demographics, comorbidities, laboratory parameters, locally administered medication (corticosteroids or viscosupplementation), interventional maneuver location, needle size, and local bleeding events were recorded. Post-procedural control was performed at 30 min, 48 h, and 7 days. No articular/periarticular bleeding event occurred in patients treated with NOACs, regardless of their type and dosage, locally administered medication, needle size, location, and number of interventions per individual. Several patients in all groups developed small superficial ecchymoses at the injection site. Our results suggest that NOACs are safe to be used in a continuous regimen prior to US-guided injections, even as dual antithrombotic therapy (in combination with aspirin). The use of lower gauge needles, chosen for viscosupplementation therapy, was not burdened with adverse effects on the procedural outcome. Key Points • Currently, no prospective studies have been performed to establish the safety of continuous NOAC anticoagulation when performing routine intra- or periarticular interventional maneuvers. • The study offers an extensive view on a wide spectrum of intra- and periarticular interventional maneuvers including anatomic targets and needle sizes that were not previously assessed. • The study offers a perspective into performing repetitive maneuvers in the same patient, both over a short time and at longer intervals. • The zero periprocedural bleeding risk observed in our study may reassure practitioners and suggest that US-guided interventional therapeutic interventions are safe in patients treated with a continuous regimen of different NOACs.
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Affiliation(s)
- A Micu
- "Iuliu Hațieganu" University of Medicine and Pharmacy Cluj-Napoca, Cluj-Napoca, Romania
| | - M C Micu
- Rheumatology Division, Rehabilitation Clinical Hospital Cluj-Napoca, Viilor str. No 46-50, 400347, Cluj-Napoca, Romania.
| | - G Bodozs
- Laboratory Unit, Rehabilitation Clinical Hospital Cluj-Napoca, Cluj-Napoca, Romania
| | - A G Duțu
- Department of Medical Biochemistry, "Iuliu Hațieganu" University of Medicine and Pharmacy Cluj-Napoca, Cluj-Napoca, Romania
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Cai Y, Zhang J, Chen F. The impact of anti-thrombotic therapy on bleeding outcomes and thrombosis following laparoscopic cholecystectomy: a meta-analysis. Updates Surg 2024; 76:1669-1683. [PMID: 39095636 DOI: 10.1007/s13304-024-01955-8] [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: 05/22/2024] [Accepted: 07/24/2024] [Indexed: 08/04/2024]
Abstract
Acute cholecyctitis is a common condition which requires immediate or elective surgical interventions and this condition is one among the common causes for emergency hospitalization among the elderly population. However, controversies have been observed with the use of anti-thrombotic agents in patients undergoing laparoscopic cholecyctectomy. Few studies have reported increased risk of bleeding in patients with anticoagulants whereas other studies have reported no significant bleeding outcomes. Nevertheless, the lack of evidence-based guidelines further complicates decision-making. In this analysis we aimed to systematically assess the impact of anti-thrombotic therapy on bleeding outcomes and thrombosis following laparoscopic cholecystectomy. MEDLINE, EMBASE, Cochrane database, Google scholar, Web of Science and http://www.ClinicalTrials.gov were searched for relevant publications based on anti-thrombotic therapy among patients who underwent laparoscopic cholecystectomy. The endpoints in this analysis included: intra-operative bleeding, post-operative bleeding, blood loss, patients requiring blood transfusion and thrombotic complications. The Revman 5.4 software was used to analyze data in this analysis. Risk ratio (RR) with 95% confidence intervals (CIs) were used to represent the data following analysis. A total number of 4008 participants (enrollment period 2002-2019) were included in this analysis whereby 756 participants were assigned to an anti-thrombotic therapy and 3592 participants were in the control group. Our results showed that antithrombotic therapy was associated with significantly higher risk of intra-operative bleeding (RR: 2.23, 95% CI: 1.77-2.79; P = 0.00001), post-operative bleeding (RR: 4.77, 95% CI: 1.13-20.10; P = 0.03), and blood loss (RR: 3.01, 95% CI: 1.13-8.06; P = 0.03). Patients requiring blood transfusion (RR: 4.80, 95% CI: 1.90-12.13; P = 0.0009) were also significantly higher in the anti-thrombotic group. However, thrombotic complications (RR: 2.17, 95% CI: 0.50-9.42; P = 0.30) were not significantly higher. Through this analysis, we concluded that anti-thrombotic therapy was associated with significantly increased risks of intra-operative and post-operative bleeding events following laparoscopic cholecystectomy. Patients requiring blood transfusion were also significantly higher. Therefore, stopping anti-thrombotic agents prior to laparoscopic cholecystectomy could significantly minimize bleeding risks.
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Affiliation(s)
- Ying Cai
- Department of Surgery, Huanggang Central Hospital of Yangtze University, 438000, Huanggang, Hubei, People's Republic of China
| | - Jing Zhang
- The Outpatient Department, Huanggang Central Hospital of Yangtze University, 438000, Huanggang, Hubei, People's Republic of China
| | - Feng Chen
- Department of Hepatobiliary Surgery, Huanggang Central Hospital of Yangtze University, 438000, Huanggang, Hubei, People's Republic of China.
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Plender A, Graumans SE, Gielisse E, Bresser-de Ruyter C, Sissing S, Ruiter-Jakobs MC, Wals A, Faber LM. A Tool Integrated into the Electronic Health Record to Guide Proper Decision-Making Regarding Peri-Endoscopic Anticoagulant Management: A Retrospective Cohort Study. J Clin Med 2024; 13:5194. [PMID: 39274407 PMCID: PMC11396596 DOI: 10.3390/jcm13175194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 08/09/2024] [Accepted: 08/26/2024] [Indexed: 09/16/2024] Open
Abstract
Background-Anticoagulants, such as vitamin-K antagonists (VKA) and direct oral anticoagulants (DOAC), are widely used among patients who undergo endoscopic procedures. To balance between bleeding and thromboembolic risks, careful decisions must be made about whether and for how long anticoagulants have to be stopped peri-endoscopically and if bridging is necessary. We created a tool in the electronic health records system (EHR) HIX (Microsoft) for invasive procedures to aid this decision-making. By selecting the anticoagulant indication or thrombo-embolic risk and the bleeding risk of the procedure, the tool automatically generates advice for periprocedural anticoagulant management. Objectives-This study assesses whether the tool is used properly peri-endoscopically. Secondly, it examines how many bleeding and thromboembolic events have occurred since the implementation of the tool. Methods-This retrospective study included all orders placed for endoscopies for patients using VKA or DOAC between 2018 and 2021. Results-In total, 986 endoscopies were included for analysis. In 89%, the tool was used correctly; the main error was selecting the wrong bleeding risk (7.5%). The cumulative incidence for moderate or severe bleeding events for DOAC and VKA was 2 (0.5%) and 0, respectively. The cumulative incidence of thromboembolic events for DOAC and VKA was 1 (0.2%) for each. Conclusions-This study evaluates the use of an EHR-integrated decision-making tool to aid peri-endoscopic anticoagulant management. By analysing the usage of the tool, we formulated several suggestions to improve the tool. Although this study is not a comparative one, we can conclude that the thromboembolic and major bleeding risks were low.
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Affiliation(s)
- Anja Plender
- Department of Internal Medicine, Red Cross Hospital, Vondellaan 13, 1942 LE Beverwijk, The Netherlands
| | - Suzanne E Graumans
- Department of Internal Medicine, Red Cross Hospital, Vondellaan 13, 1942 LE Beverwijk, The Netherlands
| | - Eric Gielisse
- Department of Gastro-Enterology, Red Cross Hospital, Vondellaan 13, 1942 LE Beverwijk, The Netherlands
| | - Carlinda Bresser-de Ruyter
- Department of Research Internal Medicine, Red Cross Hospital, Vondellaan 13, 1942 LE Beverwijk, The Netherlands
| | - Simone Sissing
- Department of Research Internal Medicine, Red Cross Hospital, Vondellaan 13, 1942 LE Beverwijk, The Netherlands
| | - Marjan C Ruiter-Jakobs
- Department of Quality & Patient Safety, Red Cross Hospital, Vondellaan 13, 1942 LE Beverwijk, The Netherlands
| | - Arian Wals
- Department of ICT Application Management, Red Cross Hospital, Vondellaan 13, 1942 LE Beverwijk, The Netherlands
| | - Laura M Faber
- Department of Hematology, Red Cross Hospital, Vondellaan 13, 1942 LE Beverwijk, The Netherlands
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Olsen M, Adie SK, Divens A, Popova K, Brancaccio A. Low-Intensity Heparin Infusion Compared With High-Intensity Heparin Infusion Dosing in Patients With Mechanical Mitral Valves: A Retrospective Cohort Study. J Cardiovasc Pharmacol 2024; 84:383-388. [PMID: 39027972 DOI: 10.1097/fjc.0000000000001608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 06/15/2024] [Indexed: 07/20/2024]
Abstract
ABSTRACT Patients with a mechanical mitral valve have an increased risk of thrombosis, and guidelines recommend a higher international normalized ratio goal for vitamin K antagonists-based anticoagulation. Guidelines provide recommendations for bridging with unfractionated heparin; however, there is no clear guidance on the heparin infusion intensity that should be used. This study was a retrospective, single-center, cohort study of patients aged ≥18 years or older with a mechanical mitral valve admitted from June 2019 to September 2022 who were maintained on a singular heparin infusion intensity nomogram for at least 48 hours. The patients were stratified into either a low- or a high-intensity heparin infusion nomogram. The exclusion criteria included non-nomogram heparin infusions and patients within 30 days of valve implantation. The primary outcome of this study was a composite of all bleeding events (major, clinically significant nonmajor, and minor bleeding). The secondary outcomes included bleeding events, analyzed individually, and thrombotic events. Seven total bleeding events were observed between the 2 groups, with 1 minor bleeding event in the low-intensity group and 6 bleeding events in the high-intensity group. One thrombotic event occurred in the high-intensity group. No statistically significant differences were found between the primary and secondary outcomes. Future studies are necessary to guide heparin infusion intensity selection in patients with mechanical mitral valves.
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Affiliation(s)
- Megumi Olsen
- University of Michigan Health, Renown Regional Medical Center, Ann Arbor, MI; and
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12
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Leon S, Rouhi AD, Perez JE, Alberstadt AN, Tewksbury CM, Gershuni VM, Altieri MS, Williams NN, Dumon KR. Bariatric surgery in patients with preoperative therapeutic anticoagulation: a 2015-2021 MBSAQIP database study. Surg Obes Relat Dis 2024:S1550-7289(24)00719-6. [PMID: 39232872 DOI: 10.1016/j.soard.2024.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 07/01/2024] [Accepted: 07/18/2024] [Indexed: 09/06/2024]
Abstract
BACKGROUND The link between obesity and adverse cardiovascular events is well-established. With the rising prevalence of metabolic and bariatric surgery (MBS), a greater number of patients undergoing sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) may present with preoperative therapeutic anticoagulation (AC). OBJECTIVES This study evaluated perioperative outcomes of SG and RYGB in patients on preoperative AC. SETTING Patients reported to the 2015-2021 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. METHODS Adults undergoing primary SG or RYGB with and without preoperative anticoagulation (SG-AC or RYGB-AC and non-SG-AC or non-RYGB-AC, respectively) were analyzed from the 2015-2021 MBSAQIP database. Differences in baseline characteristics by AC status for each MBS were adjusted using entropy-balanced weights. Multivariable logistic and linear regressions were developed to analyze the independent association between AC and outcomes of interest. RESULTS Of 1,178,090 patients included, 72.0% (n = 850,682) had SG and 28.0% (n = 327,408) had RYGB, of which 1.8% (n = 15,021) and 1.9% (n = 6201) had AC, respectively. Compared to non-SG-AC and non-RYGB-AC, both SG-AC and RYGB-AC encountered higher absolute 30-day rates of anastomotic leak, deep vein thrombosis and gastrointestinal bleeding. Following multivariable adjustment, SG-AC was associated with significantly greater odds of adverse cardiovascular events, anastomotic leak, gastrointestinal bleeding, and greater operative length and length of stay. RYGB-AC was associated with higher odds of readmission, unplanned ICU admission, and ED visit. CONCLUSIONS While preoperative AC may confer distinct outcomes between SG and RYGB, this 7-year study of MBSAQIP demonstrated an overall association with greater postoperative morbidity. Management of MBS patients with preoperative AC requires consideration of thrombohemorrhagic risks.
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Affiliation(s)
- Sebastian Leon
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Armaun D Rouhi
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Juan E Perez
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Angelika N Alberstadt
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Colleen M Tewksbury
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Victoria M Gershuni
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maria S Altieri
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Noel N Williams
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kristoffel R Dumon
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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13
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Raza S, Pinkerton P, Hirsh J, Callum J, Selby R. The historical origins of modern international normalized ratio targets. J Thromb Haemost 2024; 22:2184-2194. [PMID: 38795872 DOI: 10.1016/j.jtha.2024.05.013] [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: 02/09/2024] [Revised: 05/07/2024] [Accepted: 05/15/2024] [Indexed: 05/28/2024]
Abstract
Prothrombin time (PT) and its derivative international normalized ratio (INR) are frequently ordered to assess the coagulation system. Plasma transfusion to treat incidentally abnormal PT/INR is a common practice with low biological plausibility and without credible evidence, yet INR targets appear in major clinical guidelines and account for the majority of plasma use at many institutions. In this article, we review the historical origins of INR targets. We recount historical milestones in the development of the PT, discovery of vitamin K antagonists (VKAs), motivation for INR standardization, and justification for INR targets in patients receiving VKA therapy. Next, we summarize evidence for INR testing to assess bleeding risk in patients not on VKA therapy and plasma transfusion for treating mildly abnormal INR to prevent bleeding in these patients. We conclude with a discussion of the parallels in misunderstanding of historic PT and present-day INR testing with lessons from the past that might help rationalize plasma transfusion in the future.
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Affiliation(s)
- Sheharyar Raza
- Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada; Canadian Blood Services, Medical Affairs and Innovation, Toronto, Ontario, Canada.
| | - Peter Pinkerton
- Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada; Department of Laboratory Medicine & Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jack Hirsh
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queen's University, Kingston, Kingston, Ontario, Canada
| | - Rita Selby
- Department of Laboratory Medicine & Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Laboratory Medicine Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
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14
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Ullmann M, Guzman R, Mariani L, Soleman J. The effect of anti-thrombotics on the postoperative bleeding rate in patients undergoing craniotomy for brain tumor. Br J Neurosurg 2024; 38:798-804. [PMID: 34423703 DOI: 10.1080/02688697.2021.1968340] [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: 02/28/2021] [Revised: 06/15/2021] [Accepted: 08/09/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The peak prevalence of many brain tumors is in elderly patients. These patients are often treated with platelet inhibitors (PIs) or anticoagulants (ACs), creating a challenge for neurosurgeons concerning the perioperative management. The aim of this study is to analyze the effect of PI/AC treatment on the postoperative bleeding rates in patients undergoing craniotomy due to a brain tumor. METHODS Retrospective analysis of 415 consecutive patients undergoing craniotomy/craniectomy due to a brain tumor. Ninety-nine patients with PI/AC treatment (PI/AC group consisting of 64 PI, 29 AC, and six multiple) and 316 patients without PI/AC (control group) were primarily compared for hemorrhage rate. Secondary outcome measures were clinical outcome and mortality. The association between short preoperative discontinuation (≤5 days), early postoperative resumption time (≤5 days), as well as short total discontinuation time (≤5 days) of PI/AC and postoperative bleeding rates was analyzed. RESULTS Postoperative bleeding rates were comparable between the groups (12.2% and 13.5% in the PI/AC and control group, respectively; p=.74). The majority of bleeds were asymptomatic (85.2%). No significant difference in the postoperative mortality rate was observed (1.0% and 1.6% in the PI/AC and the control group, respectively; p=.67). Shorter discontinuation time of PI/AC was not significantly associated with higher postoperative bleeding rates (preoperative: 12.1% vs. 12.3%; p=.94, postoperative: 11.1% vs. 12.5%, respectively; p=.87, total: 16.7% vs. 12%, respectively; p=.73). CONCLUSIONS Patients treated with PI/AC undergoing craniotomy for the resection of brain tumor do not seem to have increased rates of postoperative bleeding or mortality. We did not find a significant correlation between short discontinuation time of PI/AC in the perioperative period and postoperative bleeding.
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Affiliation(s)
- Muriel Ullmann
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Raphael Guzman
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Department of Neurosurgery, University Hospital Basel, Basel, Switzerland
| | - Luigi Mariani
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Department of Neurosurgery, University Hospital Basel, Basel, Switzerland
| | - Jehuda Soleman
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Department of Neurosurgery, University Hospital Basel, Basel, Switzerland
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15
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Swan D, Turner R, Douketis J, Thachil J. How to undertake procedures while on antiplatelet agents: a hematologist's view. Res Pract Thromb Haemost 2024; 8:102539. [PMID: 39318772 PMCID: PMC11419924 DOI: 10.1016/j.rpth.2024.102539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/28/2024] [Accepted: 06/27/2024] [Indexed: 09/26/2024] Open
Abstract
Cardiovascular diseases (CVDs) are the leading cause of mortality globally while also contributing to excess health system costs. Significant advancements have been made in the understanding and prevention of deaths from CVD. In addition to risk factor modifications, one of the key developments in this area is the appropriate prescribing of antiplatelet medications for secondary prevention of CVD. With the advent of vascular devices, there has been an increased use of potent antiplatelet agents to mitigate thrombosis risk. A well-recognized, albeit rare complication of antiplatelet drugs is the heightened risk of bleeding. This adverse effect is particularly relevant when a patient receiving these medications may require an urgent surgery. In addition, for elective surgeries, although these drugs can be withheld, there may be some situations when interruption of antiplatelet agents, even for short duration, may lead to thrombotic events. There are no robust guidelines on how to manage these clinical scenarios, although there have been some important studies published recently in this area. In this review, we provide our approach to patients on antiplatelet drugs who may require urgent surgeries or surgical interventions.
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Affiliation(s)
- Dawn Swan
- Department of Haematology, Austin Health, Melbourne, Victoria, Australia
| | - Robert Turner
- Department of Intensive Care, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - James Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton and McMaster University, Hamilton, Ontario, Canada
| | - Jecko Thachil
- Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
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16
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Wang R, Wang H, Liu S, Yang L, Ma L, Liu F, Li Y, Li P, Shi Y, Sun M, Song Y, Hou W, Mi W, Ma Y. Coronary heart disease increases the risk of perioperative ischemic stroke after noncardiac surgery: A retrospective cohort study. CNS Neurosci Ther 2024; 30:e14912. [PMID: 39185787 PMCID: PMC11345749 DOI: 10.1111/cns.14912] [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: 03/22/2024] [Revised: 06/18/2024] [Accepted: 06/25/2024] [Indexed: 08/27/2024] Open
Abstract
OBJECTIVE To investigate the association between coronary heart disease (CHD) and the risk of perioperative ischemic stroke in patients undergoing noncardiac surgery. METHODS This retrospective study evaluated the incidence of ischemic stroke within 30 days after a noncardiac surgery. A cohort of 221,541 patients who underwent noncardiac surgery between January 2008 and August 2019 was segregated according to whether they were diagnosed with CHD. Primary, sensitivity, and subgroup logistic regression analyses were conducted to confirm that CHD is an independent risk factor for perioperative ischemic stroke. Propensity score matching analysis was used to account for the potential residual confounding effect of covariates. RESULTS Among the 221,541 included patients undergoing noncardiac surgery, 484 patients (0.22%) experienced perioperative ischemic stroke. The risk of perioperative ischemic stroke was higher in patients with CHD (0.7%) compared to patients without CHD (0.2%), and multivariate logistic regression analysis showed that CHD was associated with a significantly increased risk of perioperative ischemic stroke (odds ratio (OR), 3.7943; 95% confidence interval (CI) 2.865-4.934; p < 0.001). In a subset of patients selected by propensity score matching (PSM) in which all covariates between the two groups were well balanced, the association between CHD and increased risk of perioperative ischemic stroke remained significantly significant (OR 1.8150; 95% CI, 1.254-2.619; p = 0.001). In the subgroup analysis stratified by age, preoperative β-blockers, and fibrinogen-to-albumin ratio (FAR), the association between CHD and perioperative ischemic stroke was stable (p for interaction >0.05). Subgroup analyses also showed that CHD was significantly increased the risk of perioperative ischemic stroke in the preoperative mean arterial pressure (MAP) ≥94.2 mmHg subgroups (p for interaction <0.001). CONCLUSION CHD is significantly associated with an increased risk of perioperative ischemic stroke and is an independent risk factor for perioperative ischemic stroke after noncardiac surgery. Strict control of preoperative blood pressure may reduce the risk of perioperative ischemic stroke for patients with CHD undergoing noncardiac surgery.
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Affiliation(s)
- Rui Wang
- Department of AnesthesiologyThe First Medical Center of Chinese PLA General HospitalBeijingChina
- Nation Clinical Research Center for Geriatric DiseasesChinese PLA General HospitalBeijingChina
| | - Han Wang
- Department of OrthopedicsAir Force Medical CenterBeijingChina
| | - Siyuan Liu
- Department of AnesthesiologyAffiliated Hospital of Nantong UniversityNantongChina
| | - Lujia Yang
- Department of AnesthesiologyThe First Medical Center of Chinese PLA General HospitalBeijingChina
| | - Libin Ma
- Department of AnesthesiologyThe First Medical Center of Chinese PLA General HospitalBeijingChina
| | - Fengjin Liu
- Department of EmergencyYantai Yuhuangding HospitalYantaiChina
| | - Yingfu Li
- Department of AnesthesiologyThe First Medical Center of Chinese PLA General HospitalBeijingChina
| | - Peng Li
- Department of AnesthesiologyThe Sixth Medical Center of Chinese PLA General HospitalBeijingChina
| | - Yizheng Shi
- Department of AnesthesiologyThe First Medical Center of Chinese PLA General HospitalBeijingChina
| | - Miao Sun
- Department of AnesthesiologyThe First Medical Center of Chinese PLA General HospitalBeijingChina
| | - Yuxiang Song
- Department of AnesthesiologyThe First Medical Center of Chinese PLA General HospitalBeijingChina
| | - Wugang Hou
- Department of Anesthesiology and Perioperative MedicineXijing Hospital, Air Force Military Medical UniversityXi’anChina
| | - Weidong Mi
- Department of AnesthesiologyThe First Medical Center of Chinese PLA General HospitalBeijingChina
- Nation Clinical Research Center for Geriatric DiseasesChinese PLA General HospitalBeijingChina
| | - Yulong Ma
- Department of AnesthesiologyThe First Medical Center of Chinese PLA General HospitalBeijingChina
- Nation Clinical Research Center for Geriatric DiseasesChinese PLA General HospitalBeijingChina
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17
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Lo HC, Hsu SC, Soong RS, Huang SK. Unraveling Postoperative Bleeding Dynamics in Laparoscopic Roux-en-Y Gastric Bypass: Insights from a Single-Center Tranexamic Acid Study. Obes Surg 2024:10.1007/s11695-024-07411-1. [PMID: 39037676 DOI: 10.1007/s11695-024-07411-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 07/17/2024] [Accepted: 07/17/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND The efficacy of postoperative tranexamic acid (TXA) administration in mitigating bleeding after primary laparoscopic Roux-en-Y gastric bypass (RYGB), a prevalent complication associated with significant morbidities and mortality, and the use of sequential laboratory parameter changes in bleeding screening and TXA impact tracking were investigated. METHODS This retrospective analysis included RYGB patients (aged 18-65 years, with a body mass index of 35-50 kg/m2) over 5 years who were categorized into three groups by evolving treatment regimens: Group A (n = 42) received standard pre- and postoperative enoxaparin (30 mg) every 12 h; Group B (n = 160) received enoxaparin and postoperative TXA (250 mg every 6 h); and Group C (n = 73) received TXA alone. Postoperative bleeding-related adverse events, vital signs, and laboratory changes were compared. RESULTS Postoperative hemorrhage occurred in 3.6% (10/275) of patients, with no significant intergroup differences. Patients who experienced bleeding had greater decreases in hemoglobin (∆Hb) (2.1 vs. 1.4; p = 0.003), greater ∆Hb > 2 (50% vs. 15%; p = 0.013), and greater use of staples than did those who did not experience bleeding (8 vs. 7; p = 0.001). The ∆Hb values were lower in Groups B (1.4) and C (1.3) than in Group A (1.7, p = 0.011). No significant difference was noted between Groups C and B. CONCLUSION This study emphasizes the potential of TXA to mitigate postoperative bleeding after RYGB, with no added benefit from excluding enoxaparin. Monitoring patients with a ∆Hb > 2 mg/dl and increased stapler usage is crucial. Further research is needed to validate routine TXA use across different procedures.
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Affiliation(s)
- Hung-Chieh Lo
- Division of Trauma and Emergency Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
- TMU Research Center for Digestive Medicine, Taipei Medical University, Taipei, Taiwan.
| | - Shih-Chang Hsu
- Department of Emergency, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Emergency Department, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ruey-Shyang Soong
- Division of General Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, No.111 Sec.3, Xinglong Rd., Wenshan Dist., Taipei City, 116, Taiwan
- College of Medicine, Taipei Medical University, 250 Wu-Hsing Street, Taipei City, 110, Taiwan
- Division of Transplantation Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- TMU Research Center for Organ Transplantation, Taipei Medical University, College of Medicine, Medical University, Taipei, Taiwan
- Taipei Cancer Center, Taipei Medical University, Taipei, Taiwan
| | - Shau-Ku Huang
- National Institute of Environmental Health Sciences, National Health Research Institutes, Miaoli County, Taiwan
- Johns Hopkins Asthma and Allergy Center, Johns Hopkins University School of Medicine, Baltimore, USA
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18
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Fujikawa T, Hasegawa S, Takahashi R, Naito S, Kaihara S, Uryuhara K, Hirata K, Tamura T, Terajima H, Kawai T, Okabe H, Machimoto T, Tanaka H, Honma S, Furumoto K, Honda G, Uemura S, Nishitai R, Hida K, Aoyama R, Wada S, Hirose T, Obama K. Management of Patients Receiving Antiplatelet Therapy During Gastroenterological Surgery: A Multicenter Prospective Cohort Study (GSATT). Ann Surg 2024; 280:82-90. [PMID: 37870247 DOI: 10.1097/sla.0000000000006136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
OBJECTIVE This study aimed to evaluate the effect of continuing preoperative aspirin monotherapy on surgical outcomes in patients receiving antiplatelet therapy (APT). BACKGROUND The effectiveness of continuing preoperative aspirin monotherapy in patients undergoing APT in preventing thromboembolic consequences is mostly unknown. METHODS This prospective multicenter cohort study on the Safety and Feasibility of Gastroenterological Surgery in Patients Undergoing Antithrombotic Therapy (GSATT study) conducted at 14 clinical centers enrolled and screened patients between October 2019 and December 2021. The participants (n=1170) were assigned to the continued-APT group, discontinued-APT group, or non-APT group, and the surgical outcomes of each group were compared. Propensity score matching was performed between the continued and discontinued-APT groups to investigate the effect of continuing preoperative aspirin therapy on thromboembolic complications. RESULTS The rate of thromboembolic complications in the continued-APT group was substantially lower than that in the non-APT or discontinued-APT groups (0.5% vs 2.6% vs. 2.9%; P =0.027). Multivariate investigation of the entire cohort revealed that discontinuation of APT ( P <0.001) and chronic anticoagulant use ( P <0.001) were independent risk factors for postoperative thromboembolism. The post-matching evaluation demonstrated that the rates of thromboembolic complications were significantly different between the continued and discontinued-APT groups (0.6% vs 3.3%; P =0.012). CONCLUSIONS APT discontinuation after elective gastroenterological surgery increases the risk of thromboembolic consequences, whereas continuing preoperative aspirin greatly reduces this risk. The continuation of preoperative aspirin therapy in APT-received patients is considered one of the best alternatives for preventing thromboembolism during elective gastroenterological surgery.
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Affiliation(s)
| | - Suguru Hasegawa
- Department of Gastroenterological Surgery, Fukuoka University, Fukuoka, Japan
| | - Ryo Takahashi
- Department of Surgery, Kokura Memorial Hospital, Kitakyushu, Japan
- Department of Surgery, Kyoto Katsura Hospital, Kyoto, Japan
| | - Shigetoshi Naito
- Department of Surgery, Kokura Memorial Hospital, Kitakyushu, Japan
- Department of Gastroenterological Surgery, Fukuoka University, Fukuoka, Japan
| | - Satoshi Kaihara
- Department of Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Kenji Uryuhara
- Department of Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Keiji Hirata
- Department of Surgery 1, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Toshihisa Tamura
- Department of Surgery 1, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Hiroaki Terajima
- Department of Gastroenterological Surgery and Oncology, Kitano Hospital Medical Research Institute, Osaka, Japan
| | - Takayuki Kawai
- Department of Gastroenterological Surgery and Oncology, Kitano Hospital Medical Research Institute, Osaka, Japan
| | - Hiroshi Okabe
- Department of Gastroenterological Surgery, New Tokyo Hospital, Matsudo, Japan
| | | | - Hirokazu Tanaka
- Department of Gastrointestinal Surgery, Tenri Hospital, Tenri, Japan
| | - Shusaku Honma
- Department of Surgery, Kobe City Medical Center West Hospital, Kobe, Japan
| | | | - Goro Honda
- Department of Surgery, Institute of Gastroenterology, Tokyo Woman's Medical University, Tokyo, Japan
| | - Shuichiro Uemura
- Department of Surgery, Institute of Gastroenterology, Tokyo Woman's Medical University, Tokyo, Japan
| | - Ryuta Nishitai
- Department of Surgery, Kyoto Katsura Hospital, Kyoto, Japan
| | - Koya Hida
- Department of Gastrointestinal Surgery, Kyoto University, Kyoto, Japan
| | - Ryuhei Aoyama
- Department of Gastrointestinal Surgery, Kyoto University, Kyoto, Japan
| | - Seidai Wada
- Department of Surgery, Toyooka Hospital, Toyooka, Japan
| | - Tetsuro Hirose
- Department of Surgery, Japanese Red Cross Otsu Hospital, Otsu, Japan
| | - Kazutaka Obama
- Department of Gastrointestinal Surgery, Kyoto University, Kyoto, Japan
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Johnston MG, Porter MA, Eppich KE, Gray CG, Scott DF. Evaluation of the Safety of Uninterrupted Warfarin Anticoagulation With Tranexamic Acid in Total Joint Arthroplasty. Orthopedics 2024; 47:211-216. [PMID: 38466825 DOI: 10.3928/01477447-20240304-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
BACKGROUND The continuation of long-term warfarin therapy is gaining acceptance in minor surgeries but maintaining therapeutic international normalized ratio (INR) values among patients during major orthopedic procedures raises concern. While bridging therapy with low-molecular-weight heparin is currently recommended for patients receiving anticoagulation, few studies have evaluated the safety of continuing warfarin during total joint arthroplasty. This study evaluated the safety and efficacy of continuous warfarin anticoagulation through total joint arthroplasty with and without prophylactic tranexamic acid (TXA). MATERIALS AND METHODS We conducted a retrospective, matched-pair analysis of two experimental groups of patients who underwent primary total hip arthroplasty or total knee arthroplasty performed by a single surgeon. Our first experimental group, warfarin plus TXA (warfarin+TXA), consisted of 21 patients who underwent arthroplasty while receiving therapeutic anticoagulation with warfarin (INR, 2.0-3.0) and who received prophylactic TXA. Our second experimental group, warfarin without TXA (warfarin-TXA), consisted of 40 patients who underwent arthroplasty while receiving therapeutic anticoagulation with warfarin (INR, 2.0-3.0) without prophylactic TXA. RESULTS The percent change in hemoglobin value after surgery, red blood cells transfused, surgical site infections, bleeding complications, and thrombotic complications were similar between both experimental and control groups. When comparing the historical group with the warfarin+TXA group, the addition of TXA resulted in a statistical decrease in mean red blood cells transfused and estimated blood loss, with no statistically significant increase in complications. CONCLUSION Many factors must be considered when choosing perioperative thromboembolic prophylaxis for arthroplasty candidates with medical comorbidities requiring long-term anticoagulation. This study presents data indicating that it could be safe and effective to continue therapeutic warfarin while using prophylactic TXA. [Orthopedics. 2024;47(4):211-216.].
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20
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Franchini M, Focosi D, Mannucci PM. Tranexamic Acid: An Evergreen Hemostatic Agent. Semin Thromb Hemost 2024; 50:733-738. [PMID: 38335995 DOI: 10.1055/s-0044-1779632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
Abstract
Tranexamic acid (TXA) is an important antifibrinolytic agent, which inhibits plasminogen activation and fibrinolysis. Several controlled randomized trials have investigated the role of TXA in preventing or decreasing blood loss across different surgical interventions or medical conditions characterized by excessive bleeding, consistently documenting its effectiveness and safety. Although the first clinical use of TXA dates back to more than 60 years ago, TXA remains the focus of intense research. This narrative review summarizes the more recent results and indications on the clinical use of TXA.
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Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantua, Italy
| | - Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Italy
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico and University of Milan, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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21
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Boyi T, Richmond RL, Kayastha D, Manes RP, Rimmer R. Restarting Antithrombotic Therapies After Endoscopic Sinus Surgery: A Systematic Review. Ann Otol Rhinol Laryngol 2024; 133:633-638. [PMID: 38557289 DOI: 10.1177/00034894241245840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
OBJECTIVES Antithrombotic therapies, comprised of both anticoagulant and antiplatelet agents, are routinely paused prior to endoscopic sinus surgery (ESS) to reduce the risk of perioperative hemorrhage. At present, no clear guidelines exist to guide otolaryngologists on when to resume these agents after ESS. Our goal was to systematically review the existing literature related to this topic. METHODS Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we systematically queried the PubMed, Embase, Ovid, Web of Science, Cochrane, and CINAHL databases to identify publications reporting on antithrombotic and antiplatelet therapy in the context of ESS. The primary outcomes we sought were recommendations on the timing of antithrombotic therapy resumption after ESS. RESULTS Of the 104 unique articles identified, all were screened for relevance by 2 independent reviewers based on title and abstract, 20 underwent full-text review, and 6 met inclusion criteria for analysis. Of these, 3 were literature reviews, 2 were case-control studies, and 1 was a cohort study. All publications discussed when to pause antithrombotic therapy prior to surgery while only 3 articles discussed resumption of these agents. Recommendations were mixed. CONCLUSION A paucity of literature exists on the resumption of antithrombotic therapies after ESS. As a major determining factor in patient morbidity, guideline-based resumption of these therapies is needed.
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Affiliation(s)
- Trinithas Boyi
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Rhys L Richmond
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Darpan Kayastha
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Yale School of Medicine, New Haven, CT, USA
| | - R Peter Manes
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Ryan Rimmer
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Yale School of Medicine, New Haven, CT, USA
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22
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Jain H, Odat RM, Ahmed M, Jain J, Goyal A, Idrees M, Passey S, Jha J, Shah J, Gole S. Safety and Outcomes with Direct Oral Anticoagulants Versus Vitamin-K Antagonists in Chronic Thromboembolic Pulmonary Hypertension: A Systematic Review, Meta-Analysis, and Meta-Regression. Cardiol Rev 2024:00045415-990000000-00285. [PMID: 38833432 DOI: 10.1097/crd.0000000000000735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a subtype of pulmonary hypertension characterized by organized thrombi inside the pulmonary vasculature, leading to an increase in pulmonary artery pressure. CTEPH is seen in about 3-4% of patients with acute pulmonary embolism and is associated with poor outcomes. Apart from surgical intervention, lifelong anticoagulation is the mainstay of CTEPH management. Traditionally, CTEPH is managed with vitamin-K antagonists (VKA); however, direct oral anticoagulants (DOACs) are recently gaining popularity. However, the current literature comparing DOACs versus VKAs in CTEPH has inconsistent results. An electronic search of the major bibliographic databases was performed to retrieve studies comparing DOACs versus VKAs in CTEPH patients. For dichotomous outcomes, the odds ratio (ORs) with 95% confidence intervals (CI) were pooled using the DerSimonian and Laird random-effects model to generate forest plots. Statistical significance was considered at P < 0.05. Ten studies were included with 3936 patients (1269 in the DOAC group and 2667 in the VKA group). Treatment with DOAC was associated with no statistically significant difference in the risk of all-cause mortality (OR, 0.78; 95% CI, 0.35-1.71; P < 0.53), venous thromboembolism (OR, 1.19; 95% CI, 0.59-2.40; P = 0.63), major bleeding (OR, 0.68; 95% CI, 0.38-1.22; P = 0.20), and clinically relevant nonmajor bleeding (OR, 1.22; 95% CI, 0.80-1.86; P = 0.37). Our analysis demonstrates that DOACs are noninferior to VKAs in terms of their safety and outcomes profile in CTEPH. Further trials are needed to evaluate more robust evidence and to compare additional outcomes.
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Affiliation(s)
- Hritvik Jain
- From the Department of Internal Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur, India
| | - Ramez M Odat
- Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Mushood Ahmed
- Department of Internal Medicine, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Jyoti Jain
- From the Department of Internal Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur, India
| | - Aman Goyal
- Department of Internal Medicine, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Muhammad Idrees
- Department of Internal Medicine, Lahore General Hospital, Lahore, Pakistan
| | - Siddhant Passey
- Department of Internal Medicine, University of Connecticut Health Center, CT
| | - Jagriti Jha
- Department of Pediatrics, University of Connecticut Health Center, CT
| | - Janhvi Shah
- Department of Internal Medicine, St Luke's Hospital, Chesterfield, MO
| | - Shrey Gole
- Department of Immunology and Rheumatology, Stanford University, CA
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23
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Nakamura J, Nakatsuka K, Uchida K, Akisue T, Maeda M, Murata F, Fukuda H, Ono R. Analysis of post-extraction bleeding in patients taking antithrombotic therapy using data from the longevity improvement and fair evidence study. Gerodontology 2024; 41:269-275. [PMID: 37469221 DOI: 10.1111/ger.12703] [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] [Accepted: 06/21/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Several studies have investigated post-extraction bleeding in patients on antithrombotic therapy, but most included a small sample size. OBJECTIVE This study aimed to analyse post-extraction bleeding in patients on antithrombotic therapy using data from a large database. MATERIALS AND METHODS Claims data of National Health Insurance and Late-Stage Elderly Healthcare System enrollees who underwent tooth extraction between October 2014 and March 2019 (n = 107 767) in a large multiregional cohort study (Longevity Improvement and Fair Evidence study) were included. Antithrombotic therapy was determined based on the drug codes used at the time of tooth extraction (classified into six groups: no antithrombotic, single antiplatelet, dual antiplatelet, Direct Oral Anticoagulant, warfarin and combined antiplatelet and anticoagulant therapies). The outcome was defined as the presence of "post-extraction bleeding" as a receipt disease name in the same month as tooth extraction. To examine the association between antithrombotic therapy and post-extraction bleeding in detail, multiple logistic regression analysis was performed with post-extraction bleeding as the objective variable; each antithrombotic therapy as the explanatory variable; and age, sex and comorbidities as adjustment variables. RESULTS Antithrombotic therapy was administered in 14 343 patients (13.3%), and post-extraction bleeding was observed in 419 patients (0.4%). The rate of post-extraction bleeding was significantly lower in the no antithrombotic therapy and single antiplatelet groups than that in the other groups (odds ratio: 2.00-9.02). CONCLUSION The frequency of post-extraction bleeding is high in patients on anticoagulation or dual antithrombotic therapy. Therefore, careful preparation before extraction is necessary in these patients.
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Affiliation(s)
- Junya Nakamura
- Department of Dentistry and Oral Surgery, National Center for Geriatrics and Gerontology, Aichi, Japan
- Department of Rehabilitation Sciences, Kobe University Graduate School of Health Sciences, Hyogo, Japan
| | - Kiyomasa Nakatsuka
- Department of Rehabilitation Sciences, Kobe University Graduate School of Health Sciences, Hyogo, Japan
| | - Kazuaki Uchida
- Department of Rehabilitation Sciences, Kobe University Graduate School of Health Sciences, Hyogo, Japan
- Department of Prevention and Care Science, Research Institute, National Center for Geriatrics and Gerontology, Aichi, Japan
| | - Toshihiro Akisue
- Department of Rehabilitation Sciences, Kobe University Graduate School of Health Sciences, Hyogo, Japan
| | - Megumi Maeda
- Department of Health Care Administration and Management, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Fumiko Murata
- Department of Health Care Administration and Management, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Haruhisa Fukuda
- Department of Health Care Administration and Management, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Rei Ono
- Department of Physical Activity Research, National Institute of Health and Nutrition, National Institutes of Biomedical Innovation, Health and Nutrition, Tokyo, Japan
- Department of Public Health, Kobe University Graduate School of Health Sciences, Hyogo, Japan
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24
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Lucà F, Oliva F, Giubilato S, Abrignani MG, Rao CM, Cornara S, Caretta G, Di Fusco SA, Ceravolo R, Parrini I, Murrone A, Geraci G, Riccio C, Gelsomino S, Colivicchi F, Grimaldi M, Gulizia MM. Exploring the Perioperative Use of DOACs, off the Beaten Track. J Clin Med 2024; 13:3076. [PMID: 38892787 PMCID: PMC11172442 DOI: 10.3390/jcm13113076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 05/19/2024] [Accepted: 05/21/2024] [Indexed: 06/21/2024] Open
Abstract
A notable increase in direct oral anticoagulant (DOAC) use has been observed in the last decade. This trend has surpassed the prescription of vitamin K antagonists (VKAs) due to the absence of the need for regular laboratory monitoring and the more favorable characteristics in terms of efficacy and safety. However, it is very common that patients on DOACs need an interventional or surgical procedure, requiring a careful evaluation and a challenging approach. Therefore, perioperative anticoagulation management of patients on DOACs represents a growing concern for clinicians. Indeed, while several surgical interventions require temporary discontinuation of DOACs, other procedures that involve a lower risk of bleeding can be conducted, maintaining a minimal or uninterrupted DOAC strategy. Therefore, a comprehensive evaluation of patient characteristics, including age, susceptibility to stroke, previous bleeding complications, concurrent medications, renal and hepatic function, and other factors, in addition to surgical considerations, is mandatory to establish the optimal discontinuation and resumption timing of DOACs. A multidisciplinary approach is required for managing perioperative anticoagulation in order to establish how to face these circumstances. This narrative review aims to provide physicians with a practical guide for DOAC perioperative management, addressing the most controversial issues.
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Affiliation(s)
- Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano, GOM, AO Bianchi Melacrino Morelli, 89124 Reggio Calabria, Italy;
| | - Fabrizio Oliva
- Cardiology Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy;
| | - Simona Giubilato
- Cardiology Department, Cannizzaro Hospital, 95126 Catania, Italy;
| | | | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano, GOM, AO Bianchi Melacrino Morelli, 89124 Reggio Calabria, Italy;
| | - Stefano Cornara
- Arrhytmia Unit, Division of Cardiology, Ospedale San Paolo, Azienda Sanitaria Locale 2, 17100 Savona, Italy
| | - Giorgio Caretta
- Sant’Andrea Hospital, ASL 5 Regione Liguria, 19124 La Spezia, Italy
| | | | - Roberto Ceravolo
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy;
| | - Iris Parrini
- Cardiology Department, Mauriziano Hospital, 10128 Torino, Italy;
| | - Adriano Murrone
- Cardiology Unit, Città di Castello Hospital, 06012 Città di Castello, Italy;
| | - Giovanna Geraci
- Cardiology Department, Sant’Antonio Abate Hospital, ASP Trapani, 91100 Erice, Italy;
| | - Carmine Riccio
- Cardiovascular Department, Sant’Anna e San Sebastiano Hospital, 95122 Caserta, Italy;
| | - Sandro Gelsomino
- Cardiovascular Research Institute, Maastricht University, 6211 LK Maastricht, The Netherlands;
| | - Furio Colivicchi
- Cardiology Unit, Giovanni Paolo II Hospital, 97100 Lamezia, Italy; (S.A.D.F.); (F.C.)
| | - Massimo Grimaldi
- Cardiology Department, F. Miulli Hospital, Acquaviva delle Fonti, 70021 Bari, Italy;
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25
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Wang B, Su Y, Ma C, Xu L, Mao Q, Cheng W, Lu Q, Zhang Y, Wang R, Lu Y, He J, Chen S, Chen L, Li T, Gao L. Impact of perioperative low-molecular-weight heparin therapy on clinical events of elderly patients with prior coronary stents implanted > 12 months undergoing non-cardiac surgery: a randomized, placebo-controlled trial. BMC Med 2024; 22:171. [PMID: 38649992 PMCID: PMC11036782 DOI: 10.1186/s12916-024-03391-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 04/15/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Little is known about the safety and efficacy of discontinuing antiplatelet therapy via LMWH bridging therapy in elderly patients with coronary stents implanted for > 12 months undergoing non-cardiac surgery. This randomized trial was designed to compare the clinical benefits and risks of antiplatelet drug discontinuation via LMWH bridging therapy. METHODS Patients were randomized 1:1 to receive subcutaneous injections of either dalteparin sodium or placebo. The primary efficacy endpoint was cardiac or cerebrovascular events. The primary safety endpoint was major bleeding. RESULTS Among 2476 randomized patients, the variables (sex, age, body mass index, comorbidities, medications, and procedural characteristics) and percutaneous coronary intervention information were not significantly different between the bridging and non-bridging groups. During the follow-up period, the rate of the combined endpoint in the bridging group was significantly lower than in the non-bridging group (5.79% vs. 8.42%, p = 0.012). The incidence of myocardial injury in the bridging group was significantly lower than in the non-bridging group (3.14% vs. 5.19%, p = 0.011). Deep vein thrombosis occurred more frequently in the non-bridging group (1.21% vs. 0.4%, p = 0.024), and there was a trend toward a higher rate of pulmonary embolism (0.32% vs. 0.08%, p = 0.177). There was no significant difference between the groups in the rates of acute myocardial infarction (0.81% vs. 1.38%), cardiac death (0.24% vs. 0.41%), stroke (0.16% vs. 0.24%), or major bleeding (1.22% vs. 1.45%). Multivariable analysis showed that LMWH bridging, creatinine clearance < 30 mL/min, preoperative hemoglobin < 10 g/dL, and diabetes mellitus were independent predictors of ischemic events. LMWH bridging and a preoperative platelet count of < 70 × 109/L were independent predictors of minor bleeding events. CONCLUSIONS This study showed the safety and efficacy of perioperative LMWH bridging therapy in elderly patients with coronary stents implanted > 12 months undergoing non-cardiac surgery. An alternative approach might be the use of bridging therapy with half-dose LMWH. TRIAL REGISTRATION ISRCTN65203415.
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Affiliation(s)
- Bin Wang
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Yanhui Su
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Cong Ma
- Health Management Institute, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Lining Xu
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Qunxia Mao
- National Research Institute for Family Planning, Beijing, China
| | - Wenjia Cheng
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Qingming Lu
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Ying Zhang
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Rong Wang
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Yan Lu
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Jing He
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Shihao Chen
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Lei Chen
- Department of Thoracic Surgery of The First Medical Center, General Hospital of Chinese People's Liberation Army, Beijing, 100853, China.
| | - Tianzhi Li
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China.
| | - Linggen Gao
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China.
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26
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Alfano G, Morisi N, Giovanella S, Frisina M, Amurri A, Tei L, Ferri M, Ligabue G, Donati G. Risk of infections related to endovascular catheters and cardiac implantable devices in hemodialysis patients. J Vasc Access 2024:11297298241240502. [PMID: 38506890 DOI: 10.1177/11297298241240502] [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: 03/21/2024] Open
Abstract
Patients requiring dialysis are extremely vulnerable to infectious diseases. The high burden of comorbidities and weakened immune system due to uremia and previous immunosuppressive therapy expose the patient on dialysis to more infectious events than the general population. The infectious risk is further increased by the presence of endovascular catheters and implantable cardiologic devices. The former is generally placed as urgent vascular access for dialysis and in subjects requiring hemodialysis treatments without autogenous arteriovenous fistula. The high frequency of cardiovascular events also increases the likelihood of implanting indwelling implantable cardiac devices (CIED) such as pacemakers (PMs) and defibrillators (ICDs). The simultaneous presence of CVC and CIED yields an increased risk of developing severe prosthetic device-associated bloodstream infections often progressing to septicemia. Although, antibiotic therapy is the mainstay of prosthetic device-related infections, antibiotic resistance of biofilm-residing bacteria reduces the choice of infection eradication. In these cases, the resolution of the infection process relies on the removal of the prosthetic device. Compared to CVC removal, the extraction of leads is a more complex procedure and poses an increased risk of vessel tearing. As a result, the prevention of prosthetic device-related infection is of utmost importance in hemodialysis (HD) patients and relies principally on avoiding CVC as vascular access for HD and placement of a new class of wireless implantable medical devices. When the combination of CVC and CIED is inevitable, prevention of infection, mainly due translocation of skin bacteria, should be a mandatory priority for healthcare workers.
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Affiliation(s)
- Gaetano Alfano
- Nephrology, Dialysis and Kidney Transplant Unit, Azienda Ospedaliero-Universitaria di Modena, Modena, Emilia-Romagna, Italy
| | - Niccolò Morisi
- Nephrology, Dialysis and Kidney Transplant Unit, Azienda Ospedaliero-Universitaria di Modena, Modena, Emilia-Romagna, Italy
- Surgical, Medical, Dental and Morphological Sciences Department (CHIMOMO), University of Modena and Reggio Emilia, Modena, Emilia-Romagna, Italy
| | - Silvia Giovanella
- Surgical, Medical, Dental and Morphological Sciences Department (CHIMOMO), University of Modena and Reggio Emilia, Modena, Emilia-Romagna, Italy
| | - Monica Frisina
- Nephrology, Dialysis and Kidney Transplant Unit, Azienda Ospedaliero-Universitaria di Modena, Modena, Emilia-Romagna, Italy
- Surgical, Medical, Dental and Morphological Sciences Department (CHIMOMO), University of Modena and Reggio Emilia, Modena, Emilia-Romagna, Italy
| | - Alessio Amurri
- Nephrology, Dialysis and Kidney Transplant Unit, Azienda Ospedaliero-Universitaria di Modena, Modena, Emilia-Romagna, Italy
- Surgical, Medical, Dental and Morphological Sciences Department (CHIMOMO), University of Modena and Reggio Emilia, Modena, Emilia-Romagna, Italy
| | - Lorenzo Tei
- Surgical, Medical, Dental and Morphological Sciences Department (CHIMOMO), University of Modena and Reggio Emilia, Modena, Emilia-Romagna, Italy
- Nephrology and Dialysis Unit, Azienda USL di Modena, Modena, Emilia-Romagna, Italy
| | - Maria Ferri
- Nephrology, Dialysis and Kidney Transplant Unit, Azienda Ospedaliero-Universitaria di Modena, Modena, Emilia-Romagna, Italy
- Surgical, Medical, Dental and Morphological Sciences Department (CHIMOMO), University of Modena and Reggio Emilia, Modena, Emilia-Romagna, Italy
| | - Giulia Ligabue
- Surgical, Medical, Dental and Morphological Sciences Department (CHIMOMO), University of Modena and Reggio Emilia, Modena, Emilia-Romagna, Italy
| | - Gabriele Donati
- Nephrology, Dialysis and Kidney Transplant Unit, Azienda Ospedaliero-Universitaria di Modena, Modena, Emilia-Romagna, Italy
- Surgical, Medical, Dental and Morphological Sciences Department (CHIMOMO), University of Modena and Reggio Emilia, Modena, Emilia-Romagna, Italy
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27
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Kubota M, Kawakita M, Yoshida S, Kimura H, Sumiyoshi T, Yamasaki T, Okumura K, Yoshimura K, Matsui Y, Sugiyama K, Okuno H, Segawa T, Shimizu Y, Ito N, Onishi H, Ishitoya S, Soda T, Yoshida T, Uemura Y, Iwamura H, Okubo K, Suzuki R, Fukuzawa S, Akao T, Kurahashi R, Shimatani K, Sekine Y, Negoro H, Akamatsu S, Kamoto T, Ogawa O, Kawakami K, Kobayashi T, Goto T. Effects of thienopyridine class antiplatelets on bleeding outcomes following robot-assisted radical prostatectomy. Sci Rep 2024; 14:5847. [PMID: 38462660 PMCID: PMC10925592 DOI: 10.1038/s41598-024-56570-9] [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: 11/09/2023] [Accepted: 03/08/2024] [Indexed: 03/12/2024] Open
Abstract
This study aimed to assess the effects of thienopyridine-class antiplatelet agents (including ticlopidine, clopidogrel, and prasugrel) on bleeding complications in patients who underwent robot-assisted radical prostatectomy. This cohort study used a database for robot-assisted radical prostatectomy at 23 tertiary centers nationwide between 2011 and 2022. Patients who received thienopyridines (thienopyridine group) were compared with those who received aspirin monotherapy (aspirin group). The primary outcome was the incidence of bleeding complications. High-grade complications were defined as Clavien-Dindo grade III or higher. The risks of these outcomes were evaluated using inverse probability of treatment weighted regression models. The study results demonstrated that thienopyridine therapy was associated with a higher risk of overall bleeding complications (OR: 3.62, 95%CI 1.54-8.49). The increased risks of the thienopyridine group were detected for low-grade bleeding complications (OR: 3.20, 95%CI 1.23-8.30) but not for high-grade bleeding complications (OR: 5.23, 95%CI 0.78-34.9). The increased risk of bleeding complications was not observed when thienopyridine was discontinued (OR: 2.52, 95%CI 0.83-7.70); however, it became apparent when it was continued perioperatively (OR: 4.35, 95%CI 1.14-16.61). In conclusion, thienopyridine increased the incidence of bleeding complications, particularly low-grade bleeding complications, following robot-assisted radical prostatectomy. These bleeding effects emerged when thienopyridine was continued perioperatively.
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Affiliation(s)
- Masashi Kubota
- Department of Urology, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Urology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Mutsushi Kawakita
- Department of Urology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Satomi Yoshida
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Hiroko Kimura
- Department of Urology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takayuki Sumiyoshi
- Department of Urology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Toshinari Yamasaki
- Department of Urology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | | | - Koji Yoshimura
- Department of Urology, Shizuoka General Hospital, Shizuoka, Japan
| | - Yoshiyuki Matsui
- Department of Urology, National Cancer Center Hospital, Tokyo, Japan
| | - Kyohei Sugiyama
- Department of Urology, Kurashiki Central Hospital, Okayama, Japan
| | - Hiroshi Okuno
- Department of Urology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | | | - Yosuke Shimizu
- Department of Urology, Kobe City Nishi-Kobe Medical Center, Kobe, Hyogo, Japan
| | - Noriyuki Ito
- Department of Urology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Hiroyuki Onishi
- Department of Urology, Japanese Red Cross Osaka Hospital, Osaka, Japan
| | - Satoshi Ishitoya
- Department of Urology, Japanese Red Cross Otsu Hospital, Otsu, Shiga, Japan
| | - Takeshi Soda
- Department of Urology, Kitano Hospital, Osaka, Japan
| | - Toru Yoshida
- Department of Urology, Shiga General Hospital, Moriyama, Shiga, Japan
| | - Yuichi Uemura
- Department of Urology, Toyooka Hospital, Toyooka, Hyogo, Japan
| | - Hiroshi Iwamura
- Department of Urology, Himeji Medical Center, Himeji, Hyogo, Japan
| | | | - Ryosuke Suzuki
- Department of Urology, Numazu City Hospital, Shizuoka, Japan
| | - Shigeki Fukuzawa
- Department of Urology, Shimada General Medical Center, Shizuoka, Japan
| | - Toshiya Akao
- Department of Urology, Rakuwakai Otowa Hospital, Kyoto, Japan
| | - Ryoma Kurahashi
- Department of Urology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Kimihiro Shimatani
- Department of Urology, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Yuya Sekine
- Department of Urology, Akita University Graduate School of Medicine, Akita, Japan
| | - Hiromitsu Negoro
- Department of Urology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | | | | | - Osamu Ogawa
- Department of Urology, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Urology, Japanese Red Cross Otsu Hospital, Otsu, Shiga, Japan
| | - Koji Kawakami
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Takashi Kobayashi
- Department of Urology, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Takayuki Goto
- Department of Urology, Kyoto University Graduate School of Medicine, Kyoto, Japan
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28
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Balaji N, Olukayode O, Faiz F, Dixit P, Bhavsar V. Periprocedural Bridging Therapy in Patients With Mechanical Heart Valves. Cureus 2024; 16:e56465. [PMID: 38638777 PMCID: PMC11024885 DOI: 10.7759/cureus.56465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2024] [Indexed: 04/20/2024] Open
Abstract
Mechanical heart valves (MHVs) are thrombogenic and require lifelong anticoagulation with vitamin K antagonists (VKAs) such as warfarin. Periprocedural bridging with unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) aims to reduce the risk of thromboembolic events in patients. Currently, there are no definitive class I recommendations for anticoagulation management in patients with MHVs. In this report, we present the case of a 77-year-old female who was perioperatively bridged with enoxaparin and subsequently developed an acute thrombus.
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Affiliation(s)
- Nivedha Balaji
- Internal Medicine, Northeast Georgia Medical Center Gainesville, Gainesville, USA
| | - Oluwafemi Olukayode
- Internal Medicine, Northeast Georgia Medical Center Gainesville, Gainesville, USA
| | - Fardeen Faiz
- Cardiology, Northeast Georgia Medical Center Gainesville, Gainesville, USA
| | | | - Vedang Bhavsar
- Cardiology, Northeast Georgia Medical Center Gainesville, Gainesville, USA
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Allyn S, Bentov N, Dillon J. Perioperative Optimization and Management of the Oral and Maxillofacial Surgical Patient: A Narrative Review on Updates in Anticoagulation, Hypertension and Diabetes Medications. J Oral Maxillofac Surg 2024; 82:364-375. [PMID: 38103577 DOI: 10.1016/j.joms.2023.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 11/16/2023] [Accepted: 11/18/2023] [Indexed: 12/19/2023]
Abstract
PURPOSE The preoperative management guidelines of surgical patients are constantly evolving as newer evidence-based research is published. Oral and maxillofacial surgeons need to be current with the increasingly more complex new drug therapies and updated national association(s) guidelines. This narrative review provides a synopsis with important reference tables for updated preoperative optimization guidelines for anticoagulation, antiplatelet therapy, antihypertensive management, and glycemic control in the preoperative period for the oral and maxillofacial surgery patient. It also includes the most current anesthesia guidelines on glucagon-like peptide receptor agonists. METHODS The search strategy utilized pubmed.gov to identify the most recent national society guidelines and review articles pertinent to perioperative anticoagulation, antiplatelet therapy, antihypertensive management, and glycemic control. RESULTS The search identified 75 articles from the American College of Surgeons, American Heart Association, American Society of Anesthesiologists, American College of Cardiologists, in addition to recent reviews discussing the standard of care for optimization of patients in the perioperative period. CONCLUSION Medical optimization prior to surgery is important for safe and efficient surgical practice and has been shown to improve overall mortality. This narrative review provides a summary of the current data with recommendations focusing on four key points.
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Affiliation(s)
- Stuart Allyn
- Resident, Department of Oral & Maxillofacial Surgery, University of Washington, Seattle, WA
| | - Nathalie Bentov
- Pre-anesthesia Clinic Medical Director, Harborview Medical Center, Department of Family Medicine, University of Washington, Seattle, WA
| | - Jasjit Dillon
- Professor & Program Director, Department of Oral & Maxillofacial Surgery, University of Washington, Chief of Service, Harborview Medical Center, Seattle, WA.
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Romano LGR, Schütte LM, van Hest RM, Meijer K, Laros-van Gorkom BAP, Nieuwenhuizen L, Eikenboom J, Heubel-Moenen FCJI, Uitslager N, Coppens M, Fijnvandraat K, Driessens MHE, Polinder S, Cnossen MH, Leebeek FWG, Mathôt RAA, Kruip MJHA. Peri-operative desmopressin combined with pharmacokinetic-guided factor VIII concentrate in non-severe haemophilia A patients. Haemophilia 2024; 30:355-366. [PMID: 38343113 DOI: 10.1111/hae.14946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 12/10/2023] [Accepted: 01/13/2024] [Indexed: 03/14/2024]
Abstract
INTRODUCTION Non-severe haemophilia A patient can be treated with desmopressin or factor VIII (FVIII) concentrate. Combining both may reduce factor consumption, but its feasibility and safety has never been investigated. AIM We assessed the feasibility and safety of combination treatment in nonsevere haemophilia A patients. METHODS Non-severe, desmopressin responsive, haemophilia A patients were included in one of two studies investigating peri-operative combination treatment. In the single-arm DAVID study intravenous desmopressin (0.3 μg/kg) once-a-day was, after sampling, immediately followed by PK-guided FVIII concentrate, for maximally three consecutive days. The Little DAVID study was a randomized trial in patients undergoing a minor medical procedure, whom received either PK-guided combination treatment (intervention arm) or PK-guided FVIII concentrate only (standard arm) up to 2 days. Dose predictions were considered accurate if the absolute difference between predicted and measured FVIII:C was ≤0.2 IU/mL. RESULTS In total 32 patients (33 procedures) were included. In the DAVID study (n = 21), of the FVIII:C trough levels 73.7% (14/19) were predicted accurately on day 1 (D1), 76.5% (13/17) on D2. On D0, 61.9% (13/21) of peak FVIII:C levels predictions were accurate. In the Little DAVID study (n = 12), on D0 83.3% (5/6) FVIII:C peak levels for both study arms were predicted accurately. Combination treatment reduced preoperative FVIII concentrate use by 47% versus FVIII monotherapy. Desmopressin side effects were mild and transient. Two bleeds occurred, both despite FVIII:C > 1.00 IU/mL. CONCLUSION Peri-operative combination treatment with desmopressin and PK-guided FVIII concentrate dosing in nonsevere haemophilia A is feasible, safe and reduces FVIII consumption.
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Affiliation(s)
- Lorenzo G R Romano
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Lisette M Schütte
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Reinier M van Hest
- Department of Hospital Pharmacy and Clinical Pharmacology, Amsterdam University Medical Centers-University of Amsterdam, Amsterdam, The Netherlands
| | - Karina Meijer
- Department of Hematology, University Medical Center Groningen, Groningen, The Netherlands
| | | | | | - Jeroen Eikenboom
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Nanda Uitslager
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Michiel Coppens
- Department of Hematology, Amsterdam University Medical Centers-University of Amsterdam, Amsterdam, The Netherlands
- Pulmonary Hypertension & Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Karin Fijnvandraat
- Department of Pediatric Hematology, Amsterdam University Medical Centers-University of Amsterdam, Emma Children's Hospital, Amsterdam, The Netherlands
- Department of Plasma Proteins, Sanquin Research, Amsterdam, The Netherlands
| | | | - Suzanne Polinder
- Department of Public Health, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marjon H Cnossen
- Department of Pediatric Hematology and Oncology, Erasmus MC, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Frank W G Leebeek
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ron A A Mathôt
- Department of Hospital Pharmacy and Clinical Pharmacology, Amsterdam University Medical Centers-University of Amsterdam, Amsterdam, The Netherlands
| | - Marieke J H A Kruip
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
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Ntalouka MP, Brotis A, Karagianni MD, Arvaniti C, Mermiri M, Solou M, Stamoulis K, Bareka M, Fountas KN, Arnaoutoglou EM. Perioperative management of antithrombotics in elective intracranial procedures: systematic review, critical appraisal. Acta Neurochir (Wien) 2024; 166:97. [PMID: 38383680 DOI: 10.1007/s00701-024-05990-7] [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: 12/07/2023] [Accepted: 12/29/2023] [Indexed: 02/23/2024]
Abstract
PURPOSE Perioperative management of patients medicated with antithrombotics requiring elective intracranial procedures is challenging. We ought to (1) identify the clinical practice guidelines (CPGs) and recommendations (CPRs) on perioperative management of antithrombotic agents in elective intracranial surgery and (2) assess their methodological quality and reporting clarity. METHODS The study was conducted following the 2020 PRISMA guidelines for a systematic review and has been registered (PROSPERO, CRD42023415710). An electronic search was conducted using PubMed, Scopus, and Google Scholar. The search terms used were "adults," "antiplatelets," "anticoagulants," "guidelines," "recommendations," "english language," "cranial surgery," "brain surgery," "risk of bleeding," "risk of coagulation," and "perioperative management" in all possible combinations. The search period extended from 1964 to April 2023 and was limited to literature published in the English language. The eligible studies were evaluated by three blinded raters, by employing the Appraisal of Guidelines for Research & Evaluation II (AGREE-II) analysis tool. RESULTS A total of 14 sets of guidelines were evaluated. Two guidelines from the European Society of Anaesthesiology and one from the American College of Chest Physicians found to have the highest methodological quality and reporting clarity according to the AGREE-II tool. The interrater agreement was good with a mean Cohens Kappa of 0.70 (range, 46.5-94.4%) in the current analysis. CONCLUSION The perioperative management of antithrombotics in intracranial procedures may be challenging, complex, and demanding. Due to the lack of high quality data, uncertainty remains regarding the optimal practices to balance the risk of thromboembolism against that of bleeding.
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Affiliation(s)
- Maria P Ntalouka
- Department of Anaesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece.
| | - Alexandros Brotis
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Maria D Karagianni
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Christina Arvaniti
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Maria Mermiri
- Department of Anaesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Maria Solou
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Konstantinos Stamoulis
- Department of Anaesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Metaxia Bareka
- Department of Anaesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Konstantinos N Fountas
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Eleni M Arnaoutoglou
- Department of Anaesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
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Maytal A, Naidorf Rosenblatt H, Rotem R, Segev F. Effect of direct oral anticoagulants on bleeding during and after cataract surgery. Int Ophthalmol 2024; 44:100. [PMID: 38376717 PMCID: PMC10879357 DOI: 10.1007/s10792-024-02944-x] [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: 04/27/2023] [Accepted: 12/07/2023] [Indexed: 02/21/2024]
Abstract
PURPOSE To assess the risk for intraoperative and postoperative ocular bleeding associated with direct oral anticoagulant treatment in patients undergoing phacoemulsification surgery. METHODS Consecutive patients had phacoemulsification and intraocular lens implantation while taking uninterrupted direct oral anticoagulants (dabigatran, rivaroxaban, or apixaban). Gender and age-matched patients without antithrombotic therapy were used as the control group. Patients were examined one week postoperatively. Intraoperative and postoperative hemorrhagic and non-hemorrhagic complications were assessed. RESULTS Forty patients (56 eyes) on direct oral anticoagulants and 120 patients (172 eyes) without anticoagulation, at a mean age of 77 years, had phacoemulsification. There was no significant difference between the groups in the rate of intraoperative and postoperative bleeding. One eye (1.8%) in the treatment group and 3 eyes (1.7%) in the control group had hyphema (p = 0.72). No patient had thromboembolic event during or after surgery. CONCLUSIONS Cataract surgery was safely performed while continuing direct oral anticoagulation.
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Affiliation(s)
- Anat Maytal
- Department of Ophthalmology, Meir Medical Center, Meir Hospital, 59 Tchernichovsky St, 4428164, Kfar Saba, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | | | - Reut Rotem
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Fani Segev
- Department of Ophthalmology, Assuta-Samson Medical Center, Ashdod, Israel
- Joyce and Irwing Goldman Medical School, Ben-Gurion University, Beer-Sheva, Israel
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Iaccarino C, Carretta A, Demetriades AK, Di Minno G, Giussani C, Marcucci R, Marklund N, Mastrojanni G, Pompucci A, Stefini R, Zona G, Cividini A, Petrella G, Coluccio V, Marietta M. Management of Antithrombotic Drugs in Patients with Isolated Traumatic Brain Injury: An Intersociety Consensus Document. Neurocrit Care 2024; 40:314-327. [PMID: 37029314 DOI: 10.1007/s12028-023-01715-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/07/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND All available recommendations about the management of antithrombotic therapies (ATs) in patients who experienced traumatic brain injury (TBI) are mainly based on expert opinion because of the lack of strength in the available evidence-based medicine. Currently, the withdrawal and the resumption of AT in these patients is empirical, widely variable, and based on the individual assessment of the attending physician. The main difficulty is to balance the thrombotic and hemorrhagic risks to improve patient outcome. METHODS Under the endorsement of the Neurotraumatology Section of Italian Society of Neurosurgery, the Italian Society for the Study about Haemostasis and Thrombosis, the Italian Society of Anaesthesia, Analgesia, Resuscitation, and Intensive Care, and the European Association of Neurosurgical Societies, a working group (WG) of clinicians completed two rounds of questionnaires, using the Delphi method, in a multidisciplinary setting. A table for thrombotic and bleeding risk, with a dichotomization in high risk and low risk, was established before questionnaire administration. In this table, the risk is calculated by matching different isolated TBI (iTBI) scenarios such as acute and chronic subdural hematomas, extradural hematoma, brain contusion (intracerebral hemorrhage), and traumatic subarachnoid hemorrhage with patients under active AT treatment. The registered indication could include AT primary prevention, cardiac valve prosthesis, vascular stents, venous thromboembolism, and atrial fibrillation. RESULTS The WG proposed a total of 28 statements encompassing the most common clinical scenarios about the withdrawal of antiplatelets, vitamin K antagonists, and direct oral anticoagulants in patients who experienced blunt iTBI. The WG voted on the grade of appropriateness of seven recommended interventions. Overall, the panel reached an agreement for 20 of 28 (71%) questions, deeming 11 of 28 (39%) as appropriate and 9 of 28 (32%) as inappropriate interventions. The appropriateness of intervention was rated as uncertain for 8 of 28 (28%) questions. CONCLUSIONS The initial establishment of a thrombotic and/or bleeding risk scoring system can provide a vital theoretical basis for the evaluation of effective management in individuals under AT who sustained an iTBI. The listed recommendations can be implemented into local protocols for a more homogeneous strategy. Validation using large cohorts of patients needs to be developed. This is the first part of a project to update the management of AT in patients with iTBI.
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Affiliation(s)
- Corrado Iaccarino
- Department of Biomedical, Metabolic and Neural Sciences, School of Neurosurgery, University of Modena and Reggio Emilia, Modena, Italy
- Neurosurgery Division, "Nocsae" Hospital of Baggiovara, University Hospital of Modena, Modena, Italy
- Emergency Neurosurgery Unit, AUSL RE IRCCS, "ASMN" Hospital of Reggio Emilia, Reggio Emilia, Italy
| | - Alessandro Carretta
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy.
| | | | - Giovanni Di Minno
- Regional Reference Center for Coagulation Disorders, Federico II University Hospital, Naples, Italy
- Department of Clinical and Surgical Medicine, Federico II University of Naples, Naples, Italy
| | - Carlo Giussani
- Department of Neurosurgery, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Rossella Marcucci
- Center for Atherothrombotic Disease, Department of Experimental and Clinical Medicine, Careggi University Hospital, University of Florence, Florence, Italy
| | - Niklas Marklund
- Department of Neuroscience, Neurosurgery, Uppsala University, Uppsala, Sweden
- Department of Clinical Sciences, Department of Neurosurgery, Skåne University Hospital, Lund University, Lund, Sweden
| | | | - Angelo Pompucci
- Neurosurgery Division, ASL Latina Ospedale Santa Maria Goretti, Latina, Italy
| | - Roberto Stefini
- Neurosurgery Division, Department of Neurosciences, Head, Neck and Neurosurgery, Ospedale Civile di Legnano, Legnano, Italy
| | - Gianluigi Zona
- Neurosurgery Division, Department of Neurosciences (DINOGMI), IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Andrea Cividini
- Neurosurgery Division, Department of Neurosciences, Head, Neck and Neurosurgery, Ospedale Civile di Legnano, Legnano, Italy
| | - Gianpaolo Petrella
- Neurosurgery Division, ASL Latina Ospedale Santa Maria Goretti, Latina, Italy
| | - Valeria Coluccio
- Department of Hematology and Oncology, Hemostasis and Thrombosis Unit, University Hospital of Modena, Modena, Italy
| | - Marco Marietta
- Department of Hematology and Oncology, Hemostasis and Thrombosis Unit, University Hospital of Modena, Modena, Italy
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Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bellmunt Montoya S, Berard X, Boyle JR, D'Oria M, Prendes CF, Karkos CD, Kazimierczak A, Koelemay MJW, Kölbel T, Mani K, Melissano G, Powell JT, Trimarchi S, Tsilimparis N, Antoniou GA, Björck M, Coscas R, Dias NV, Kolh P, Lepidi S, Mees BME, Resch TA, Ricco JB, Tulamo R, Twine CP, Branzan D, Cheng SWK, Dalman RL, Dick F, Golledge J, Haulon S, van Herwaarden JA, Ilic NS, Jawien A, Mastracci TM, Oderich GS, Verzini F, Yeung KK. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2024; 67:192-331. [PMID: 38307694 DOI: 10.1016/j.ejvs.2023.11.002] [Citation(s) in RCA: 119] [Impact Index Per Article: 119.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.
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Baldini E, Lori E, Morini C, Palla L, Coletta D, De Luca GM, Giraudo G, Intini SG, Perotti B, Sorge A, Sozio G, Arganini M, Beltrami E, Pironi D, Ranalli M, Saviano C, Patriti A, Usai S, Vernaccini N, Vittore F, D’Andrea V, Nardi P, Sorrenti S, Palumbo P. Sutureless Repair for Open Treatment of Inguinal Hernia: Three Techniques in Comparison. J Clin Med 2024; 13:589. [PMID: 38276095 PMCID: PMC10816828 DOI: 10.3390/jcm13020589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/17/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024] Open
Abstract
Currently, groin hernia repair is mostly performed with application of mesh prostheses fixed with or without suture. However, views on safety and efficacy of different surgical approaches are still partly discordant. In this multicentre retrospective study, three sutureless procedures, i.e., mesh fixation with glue, application of self-gripping mesh, and Trabucco's technique, were compared in 1034 patients with primary unilateral non-complicated inguinal hernia subjected to open anterior surgery. Patient-related features, comorbidities, and drugs potentially affecting the intervention outcomes were also examined. The incidence of postoperative complications, acute and chronic pain, and time until discharge were assessed. A multivariate logistic regression was used to compare the odds ratio of the surgical techniques adjusting for other risk factors. The application of standard/heavy mesh, performed in the Trabucco's technique, was found to significantly increase the odds ratio of hematomas (p = 0.014) and, most notably, of acute postoperative pain (p < 0.001). Among the clinical parameters, antithrombotic therapy and large hernia size were independent risk factors for hematomas and longer hospital stay, whilst small hernias were an independent predictor of pain. Overall, our findings suggest that the Trabucco's technique should not be preferred in patients with a large hernia and on antithrombotic therapy.
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Affiliation(s)
- Enke Baldini
- Department of Surgery, “Sapienza” University of Rome, 00161 Rome, Italy; (E.B.); (E.L.); (C.M.); (D.P.); (S.U.); (V.D.); (P.N.); (S.S.)
| | - Eleonora Lori
- Department of Surgery, “Sapienza” University of Rome, 00161 Rome, Italy; (E.B.); (E.L.); (C.M.); (D.P.); (S.U.); (V.D.); (P.N.); (S.S.)
| | - Carola Morini
- Department of Surgery, “Sapienza” University of Rome, 00161 Rome, Italy; (E.B.); (E.L.); (C.M.); (D.P.); (S.U.); (V.D.); (P.N.); (S.S.)
| | - Luigi Palla
- Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, 00161 Rome, Italy;
| | - Diego Coletta
- United Hospitals of Northern Marche (AOORMN)—Pesaro, 61121 Pesaro, Italy; (D.C.); (A.P.)
| | - Giuseppe M. De Luca
- Unit of Academic General Surgery “V. Bonomo”, University of Bari, 70124 Bari, Italy; (G.M.D.L.); (F.V.)
| | - Giorgio Giraudo
- Department of Surgery, Santa Croce e Carle Hospital (ASO) of Cuneo, 12100 Cuneo, Italy; (G.G.); (E.B.)
| | - Sergio G. Intini
- Department of Surgery, S. Maria Della Misericordia Hospital, ASUFC of Udine, 33100 Udine, Italy; (S.G.I.); (N.V.)
| | - Bruno Perotti
- Department of Surgery, Versilia Hospital of Viareggio, 55049 Camaiore, Italy; (B.P.); (M.A.)
| | - Angelo Sorge
- Day Surgery P.O.S. Giovanni Bosco, 80144 Naples, Italy; (A.S.); (C.S.)
| | - Giampaolo Sozio
- Department of Surgery, Alta Val D’Elsa Hospital of Poggibonsi—Siena, 53036 Poggibonsi, Italy; (G.S.); (M.R.)
| | - Marco Arganini
- Department of Surgery, Versilia Hospital of Viareggio, 55049 Camaiore, Italy; (B.P.); (M.A.)
| | - Elsa Beltrami
- Department of Surgery, Santa Croce e Carle Hospital (ASO) of Cuneo, 12100 Cuneo, Italy; (G.G.); (E.B.)
| | - Daniele Pironi
- Department of Surgery, “Sapienza” University of Rome, 00161 Rome, Italy; (E.B.); (E.L.); (C.M.); (D.P.); (S.U.); (V.D.); (P.N.); (S.S.)
| | - Massimo Ranalli
- Department of Surgery, Alta Val D’Elsa Hospital of Poggibonsi—Siena, 53036 Poggibonsi, Italy; (G.S.); (M.R.)
| | - Cecilia Saviano
- Day Surgery P.O.S. Giovanni Bosco, 80144 Naples, Italy; (A.S.); (C.S.)
| | - Alberto Patriti
- United Hospitals of Northern Marche (AOORMN)—Pesaro, 61121 Pesaro, Italy; (D.C.); (A.P.)
| | - Sofia Usai
- Department of Surgery, “Sapienza” University of Rome, 00161 Rome, Italy; (E.B.); (E.L.); (C.M.); (D.P.); (S.U.); (V.D.); (P.N.); (S.S.)
| | - Nicola Vernaccini
- Department of Surgery, S. Maria Della Misericordia Hospital, ASUFC of Udine, 33100 Udine, Italy; (S.G.I.); (N.V.)
| | - Francesco Vittore
- Unit of Academic General Surgery “V. Bonomo”, University of Bari, 70124 Bari, Italy; (G.M.D.L.); (F.V.)
| | - Vito D’Andrea
- Department of Surgery, “Sapienza” University of Rome, 00161 Rome, Italy; (E.B.); (E.L.); (C.M.); (D.P.); (S.U.); (V.D.); (P.N.); (S.S.)
| | - Priscilla Nardi
- Department of Surgery, “Sapienza” University of Rome, 00161 Rome, Italy; (E.B.); (E.L.); (C.M.); (D.P.); (S.U.); (V.D.); (P.N.); (S.S.)
| | - Salvatore Sorrenti
- Department of Surgery, “Sapienza” University of Rome, 00161 Rome, Italy; (E.B.); (E.L.); (C.M.); (D.P.); (S.U.); (V.D.); (P.N.); (S.S.)
| | - Piergaspare Palumbo
- Department of Surgery, “Sapienza” University of Rome, 00161 Rome, Italy; (E.B.); (E.L.); (C.M.); (D.P.); (S.U.); (V.D.); (P.N.); (S.S.)
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Chan MH, Sun F, Malakan J. Controversies in Stoppage of Antiplatelet and Anticoagulant Medications Prior to Oral Surgery. Dent Clin North Am 2024; 68:21-45. [PMID: 37951634 DOI: 10.1016/j.cden.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Dental procedures can pose a risk of bleeding, and it is not uncommon for dentists to consult prescribing physicians regarding a mutual patient's antiplatelet and anticoagulant medication to prevent excessive bleeding during or after an upcoming procedure. However, there has been a growing controversy in the dental community surrounding the stoppage of these medications prior to dental procedures. Some believe that stopping these medications prior to dental procedures is necessary to reduce the risk of bleeding complications, while others argue that stopping them can increase the risk of stroke or other thromboembolic events. The debate has left many dentists and specialists unsure about the best course of action when it comes to managing bleeding risk during dental procedures.In this article, we will review the antithrombotic medications, indications, mechanism of action, and its effects on the coagulation pathway, laboratory testing and reversal agents. Also, we will explore the controversy surrounding the stoppage of novel anitplatelets (eg,: prasurgrel and ticagrelor), dual-antiplatelets, triple-antiplatelet, vitamin K antagonists (eg,: wafarin, coumadin), and direct oral anticoagulants (eg,: dabigatran, rivaroxaban, xarelto and endoxaban) in dentistry and examine the current evidence and guidelines for managing dental patients undergoing oral surgery.
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Affiliation(s)
- Michael H Chan
- Oral & Maxillofacial Surgery, Department of Veterans Affairs, New York Harbor Healthcare System (Brooklyn Campus), 800 Poly Place (Bk-160), Brooklyn, NY 11209, USA; Oral & Maxillofacial Surgery, Department of Oral and Maxillofacial Surgery, The Brooklyn Hospital Center, 121 DeKalb Avenue (Box-187), Brooklyn, NY 11201, USA.
| | - Feiyi Sun
- Oral & Maxillofacial Surgery, Department of Oral and Maxillofacial Surgery, The Brooklyn Hospital Center, 121 DeKalb Avenue, Brooklyn, NY 11201, USA
| | - Jonathan Malakan
- Oral & Maxillofacial Surgery, Department of Oral and Maxillofacial Surgery, The Brooklyn Hospital Center, 121 DeKalb Avenue, Brooklyn, NY 11201, USA
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Iijima Y, Ishikawa M, Motono N, Uramoto H. Bilateral adrenal infarction and insufficiency associated with antiphospholipid syndrome and surgery: a case report. Int J Emerg Med 2023; 16:93. [PMID: 38129772 PMCID: PMC10734168 DOI: 10.1186/s12245-023-00575-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 12/14/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Antiphospholipid syndrome causes systemic arterial and venous thromboses due to the presence of antiphospholipid antibodies. Adrenal insufficiency is a rare complication of antiphospholipid syndrome that may result in fatal outcomes if left untreated. Therefore, we report adrenal insufficiency as a rare complication of bilateral adrenal infarction associated with antiphospholipid syndrome and trauma surgery. CASE PRESENTATION A 64-year-old male patient underwent surgery for a left traumatic hemothorax. He concurrently had antiphospholipid syndrome and was receiving warfarin. Postoperatively, the patient complained of severe lumbar back pain despite resuming anticoagulation therapy, and he experienced paralytic ileus and shock. Abdominal contrast-enhanced computed tomography revealed adrenal swelling and increased surrounding retroperitoneal adipose tissue density. Diffusion-weighted abdominal magnetic resonance imaging showed high-intensity areas in the bilateral adrenal glands. Cortisol and adrenocorticotropic hormone levels were 3.30 μg/dL and 185.1 pg/dL, respectively. Subsequently, the patient was diagnosed with bilateral adrenal infarction and acute adrenal insufficiency, and hydrocortisone was immediately administered. Adrenal insufficiency improved gradually, and the patient was discharged after initiating steroid replacement therapy. CONCLUSIONS The timing of postoperative anticoagulant therapy initiation remains controversial. Therefore, adrenal insufficiency due to adrenal infarction should be monitored while anticoagulant therapy is discontinued in patients with antiphospholipid syndrome.
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Affiliation(s)
- Yoshihito Iijima
- Department of Thoracic Surgery, Kanazawa Medical University, 1-1 Daigaku, Uchinada-Machi, Kahoku-Gun, Ishikawa, 920-0293, Japan.
| | - Masahito Ishikawa
- Department of Thoracic Surgery, Kanazawa Medical University, 1-1 Daigaku, Uchinada-Machi, Kahoku-Gun, Ishikawa, 920-0293, Japan
| | - Nozomu Motono
- Department of Thoracic Surgery, Kanazawa Medical University, 1-1 Daigaku, Uchinada-Machi, Kahoku-Gun, Ishikawa, 920-0293, Japan
| | - Hidetaka Uramoto
- Department of Thoracic Surgery, Kanazawa Medical University, 1-1 Daigaku, Uchinada-Machi, Kahoku-Gun, Ishikawa, 920-0293, Japan
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Ballif M, Vazquez SR, Saunders J, Witt DM. Prevalence of antiphospholipid antibody syndrome misclassification in an academic health system. Thromb Res 2023; 232:163-167. [PMID: 36446659 DOI: 10.1016/j.thromres.2022.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 10/12/2022] [Accepted: 11/11/2022] [Indexed: 11/18/2022]
Abstract
PURPOSE Antiphospholipid Antibody Syndrome (APS) is a complex autoimmune disorder that includes a combination of laboratory criteria and clinical events (thrombosis, pregnancy complications). Accurate classification is essential, as APS patients may have limited oral anticoagulant options and requires indefinite anticoagulation. The prevalence of inaccurate APS misclassification is unknown. This study sought to determine the proportion of patients in an academic health-system who formally met APS criteria. METHODS This retrospective cohort study included any patient within the University of Utah Health system who had an International Classification of Diseases-10 code for APS, between January 1, 2016 and June 30, 2020. Manual chart review was performed to assess the appropriateness of the APS classification by laboratory and clinical criteria. RESULTS Of the 184 patients identified, 59 (32.1 %) formally met APS criteria, while 69 (37.5 %) did not meet criteria. The remaining 56 (30.4 %) patients lacked enough information in their medical records to decide on appropriateness of APS classification. The most prevalent reason for inappropriate APS classification in the 69 patients identified was incorrect interpretation of lab values as positive (62; 89.9 %), followed by lack of repeat confirmation testing (32; 46.4 %). CONCLUSION The results of this single-center study indicate that only one-third of patients with presumed APS met classification criteria. This was predominantly due to incorrect collection or interpretation of APS laboratory data. One-third had insufficient medical record data to determine APS classification, which impairs clinical decision-making. This suggests more education or implementation of anticoagulation stewardship is needed to ensure accurate APS classification and proper management of anticoagulation therapy.
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Affiliation(s)
- Madison Ballif
- University of Utah College of Pharmacy, Department of Pharmacotherapy, University of Utah, 30 South 2000 East, Salt Lake City, UT 84112, United States of America
| | - Sara R Vazquez
- University of Utah College of Pharmacy, Department of Pharmacotherapy, University of Utah, 30 South 2000 East, Salt Lake City, UT 84112, United States of America; University of Utah Health Thrombosis Service, 6056 Fashion Square Drive Suite 1200, Murray, UT 84107, United States of America.
| | - John Saunders
- University of Utah College of Pharmacy, Department of Pharmacotherapy, University of Utah, 30 South 2000 East, Salt Lake City, UT 84112, United States of America
| | - Daniel M Witt
- University of Utah College of Pharmacy, Department of Pharmacotherapy, University of Utah, 30 South 2000 East, Salt Lake City, UT 84112, United States of America; University of Utah Health Thrombosis Service, 6056 Fashion Square Drive Suite 1200, Murray, UT 84107, United States of America
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Paciaroni M, Caso V, Romoli M, Becattini C, Salerno A, Rapillo C, Simonnet F, Strambo D, Canavero I, Zedde M, Pascarella R, Sohn SI, Sacco S, Ornello R, Barlinn K, Schoene D, Rahmig J, Mosconi MG, Leone De Magistris I, Alberti A, Venti M, Silvestrelli G, Ciccone A, Padroni M, Laudisi M, Zini A, Gentile L, Kargiotis O, Tsivgoulis G, Tassi R, Guideri F, Acampa M, Masotti L, Grifoni E, Rocco A, Diomedi M, Karapanayiotides T, Engelter ST, Polymeris AA, Zietz A, Bandini F, Caliandro P, Reale G, Moci M, Zauli A, Cappellari M, Emiliani A, Gasparro A, Terruso V, Mannino M, Giorli E, Toni D, Andrighetti M, Falcou A, Palaiodimou L, Ntaios G, Sagris D, Karagkiozi E, Adamou A, Halvatsiotis P, Flomin Y, Scoditti U, Genovese A, Popovic N, Pantoni L, Mele F, Molitierno N, Lochner P, Pezzini A, Del Sette M, Sassos D, Giannopoulos S, Kosmidou M, Ntais E, Lotti EM, Mastrangelo V, Chiti A, Naldi A, Vanacker P, Ferrante M, Volodina V, Mancuso M, Giannini N, Baldini M, Vadikolias K, Kitmeridou S, Saggese CE, Tassinari T, Saia V, Michel P. Anticoagulation in acute ischemic stroke patients with mechanical heart valves: To bridge or not with heparin. The ESTREM study. Eur Stroke J 2023; 8:1030-1040. [PMID: 37452632 PMCID: PMC10683741 DOI: 10.1177/23969873231186863] [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: 05/19/2023] [Accepted: 06/21/2023] [Indexed: 07/18/2023] Open
Abstract
INTRODUCTION The best therapeutic strategy for patients with mechanical heart valves (MHVs) having acute ischemic stroke during treatment with vitamin K antagonists (VKAs) remain unclear. Being so, we compared the outcomes for: (i) full dose heparin along with VKA (bridging therapy group) and (ii) restarting VKA without heparin (nonbridging group). PATIENTS AND METHODS For this multicenter observational cohort study, data on consecutive acute ischemic stroke patients with MHV was retrospectively collected from prospective registries. Propensity score matching (PSM) was adopted to adjust for any treatment allocation confounders. The primary outcome was the composite of stroke, systemic embolism, symptomatic cerebral bleeding, and major extracerebral bleeding at 90 days. RESULTS Overall, 255 out of 603 patients (41.3%) received bridging therapy: 36 (14.1%) had combined outcome, compared with 28 (8.0%) in the nonbridging group (adjusted OR 1.83; 95% CI 1.05-3.18; p = 0.03). Within the bridging group, 13 patients (5.1%) compared to 12 (3.4%) in the nonbridging group had an ischemic outcome (adjusted OR 1.71; 95% CI 0.84-3.47; p = 0.2); major bleedings were recorded in 23 (9.0%) in the bridging group and 16 (4.6%) in the nonbridging group (adjusted OR 1.88; 95% CI 0.95-3.73; p = 0.07). After PSM, 36 (14.2%) of the 254 bridging patients had combined outcome, compared with 23 (9.1%) of 254 patients in the nonbridging group (OR 1.66; 95% CI 0.95-2.85; p = 0.07). CONCLUSION Acute ischemic stroke patients with MHV undergoing bridging therapy had a marginally higher risk of ischemic or hemorrhagic events, compared to nonbridging patients.
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Affiliation(s)
- Maurizio Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Valeria Caso
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy
| | - Cecilia Becattini
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Alexander Salerno
- Stroke Center, Neurology Service,Department of Clinical Neuroscience, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Costanza Rapillo
- Stroke Center, Neurology Service,Department of Clinical Neuroscience, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Stroke Unit, Careggi University Hospital, Florence, Italy
| | - Fanny Simonnet
- Stroke Center, Neurology Service,Department of Clinical Neuroscience, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Davide Strambo
- Stroke Center, Neurology Service,Department of Clinical Neuroscience, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Isabella Canavero
- Emergency Neurology, IRCCS Casimiro Mondino Foundation, Pavia, Italy
- Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico “Carlo Besta,” Milano, Italy
| | - Marialuisa Zedde
- Neurology Unit, AUSL - IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | | | - Sung-Il Sohn
- Department of Neurology, Keimyung University School of Medicine, Daegu, South Korea
| | - Simona Sacco
- Neuroscience Section, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Raffaele Ornello
- Neuroscience Section, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Kristian Barlinn
- Department of Neurology, Dresden University Stroke Center, Dresden, Germany
| | - Daniela Schoene
- Department of Neurology, Dresden University Stroke Center, Dresden, Germany
| | - Jan Rahmig
- Department of Neurology, Dresden University Stroke Center, Dresden, Germany
| | - Maria Giulia Mosconi
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | | | - Andrea Alberti
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Michele Venti
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | | | - Alfonso Ciccone
- S.C. di Neurologia e S.S. di Stroke Unit, ASST di Mantova, Mantova, Italy
| | - Marina Padroni
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
| | - Michele Laudisi
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Luana Gentile
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | | | - Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” Hospital, National & Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | | | | | | | - Luca Masotti
- Internal Medicine, San Giuseppe Hospital, Empoli, Italy
| | - Elisa Grifoni
- Internal Medicine, San Giuseppe Hospital, Empoli, Italy
| | - Alessandro Rocco
- Stroke Unit, Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - Marina Diomedi
- Stroke Unit, Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | | | - Stefan T Engelter
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Alexandros A Polymeris
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Annaelle Zietz
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Fabio Bandini
- Department of Neurology, ASL 3 Genovese, Genova, Italy
| | - Pietro Caliandro
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giuseppe Reale
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Marco Moci
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Aurelia Zauli
- Department of Geriatrics, Neurosciences and Orthopedics, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Manuel Cappellari
- Stroke Unit, DAI di Neuroscienze, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Andrea Emiliani
- Stroke Unit, DAI di Neuroscienze, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | | | | | - Elisa Giorli
- Stroke Unit, Department of Neurology, Sant’Andrea Hospital, La Spezia, Italy
| | - Danilo Toni
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Marco Andrighetti
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Anne Falcou
- Stroke Unit – Emergency Department, Policlinico Umberto I, Rome, Italy
| | - Lina Palaiodimou
- Second Department of Neurology, “Attikon” Hospital, National & Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Dimitrios Sagris
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Efstathia Karagkiozi
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Anastasia Adamou
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Panagiotis Halvatsiotis
- Second Department of Internal Medicine-Propaedeutic and Diabetes Center, Medical School, University General Hospital “Attikon,” National and Kapodistrian University of Athens, Greece
| | - Yuriy Flomin
- Stroke and Neurorehabilitation Unit MC ‘Universal Clinic “Oberig” Kyiv, Kyiv, Ukraine
| | - Umberto Scoditti
- Stroke Unit, Emergency Department, University of Parma, Parma, Italy
| | - Antonio Genovese
- Stroke Unit, Emergency Department, University of Parma, Parma, Italy
| | - Nemanja Popovic
- Clinic of Neurology, University Clinical Center of Vòsvodina, University of Novi Sad, Novi Sad, Serbia
| | - Leonardo Pantoni
- Department of Biomedical and Clinical Sciences, University of Milano, Milano, Italy
| | - Francesco Mele
- Department of Biomedical and Clinical Sciences, University of Milano, Milano, Italy
| | - Nicola Molitierno
- Department of Biomedical and Clinical Sciences, University of Milano, Milano, Italy
| | - Piergiorgio Lochner
- Department of Neurology, Saarland University, Medical Center, Homburg, Germany
| | - Alessandro Pezzini
- Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Brescia, Italy
| | | | - Davide Sassos
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Sotirios Giannopoulos
- Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Maria Kosmidou
- Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Evangelos Ntais
- Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
| | | | | | | | - Andrea Naldi
- Neurology Unit, San Giovanni Bosco Hospital, Turin, Italy
| | - Peter Vanacker
- NeuroVascular Center and Stroke Unit Antwerp, Department of Neurology, Antwerp University Hospital, Antwerp, Belgium
- Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Groeninge Hospital, Kortrijk, Belgium
| | - Mario Ferrante
- Operative Research Unit of Neurology, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Vera Volodina
- Municipal Budgetary Healthcare Institution of Novosibirsk, City Clinical Hospital # 1, Novosibirsk (Russia) at the Novosibirsk State Medical University, Novosibirsk, Russia
| | - Michelangelo Mancuso
- Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Pisa, Italy
| | - Nicola Giannini
- Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Pisa, Italy
| | - Marco Baldini
- Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Pisa, Italy
| | - Kostantinos Vadikolias
- Department of Neurology, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Sofia Kitmeridou
- Department of Neurology, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | | | - Tiziana Tassinari
- Department of Neurology and Stroke Unit, Santa Corona Hospital, Pietra Ligure (Savona), Italy
| | - Valentina Saia
- Department of Neurology and Stroke Unit, Santa Corona Hospital, Pietra Ligure (Savona), Italy
| | - Patrik Michel
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy
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Wessels EM, Masclee GMC, Bredenoord AJ. An overview of the efficacy, safety, and predictors of achalasia treatments. Expert Rev Gastroenterol Hepatol 2023; 17:1241-1254. [PMID: 37978889 DOI: 10.1080/17474124.2023.2286279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 11/17/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Achalasia is a rare esophageal motility disorder characterized by abnormal esophageal peristalsis and the inability of the lower esophageal sphincter to relax, resulting in poor esophageal emptying. This can be relieved by endoscopic and surgical treatments; each comes with certain advantages and disadvantages. AREAS COVERED This review aims to guide the clinician in clinical decision making on the different treatment options for achalasia regarding the efficacy, safety, and important predictors. EXPERT OPINION Botulinum toxin injection is only recommended for a selective group of achalasia patients because of the short term effect. Pneumatic dilation improves achalasia symptoms, but this effect diminishes over time and requiring repeated dilations to maintain clinical effect. Heller myotomy combined with fundoplication and peroral endoscopic myotomy are highly effective on the long term but are more invasive than dilations. Gastro-esophageal reflux complaints are more often encountered after peroral endoscopic myotomy. Patient factors such as age, comorbidities, and type of achalasia must be taken into account when choosing a treatment. The preference of the patient is also of great importance and therefore shared decision making has to play a fundamental role in deciding about treatment.
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Affiliation(s)
- Elise M Wessels
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, Netherlands
| | - Gwen M C Masclee
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, Netherlands
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Patient Assessment. J Oral Maxillofac Surg 2023; 81:E13-E34. [PMID: 37833021 DOI: 10.1016/j.joms.2023.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
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Dean KR, Pavuluri H, Fox S, Tan X, Watson B, Wallenborn JG, Blestel GA. The Impact of Antithrombotic Medications on Postoperative Bleeding Events Following Hemorrhoidectomy. Am Surg 2023; 89:4610-4615. [PMID: 36048039 DOI: 10.1177/00031348221124332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Bleeding complications are a risk associated with hemorrhoid procedures. Despite the prevalence of anticoagulant and antiplatelet therapies, including newer direct oral anticoagulants (DOACs) in the aging patient population there is a paucity of data regarding the impact of the use of antithrombotic therapy (AT) especially DOACs, on bleeding complications of hemorrhoid procedures. METHODS We retrospectively reviewed charts of patients who had undergone a total of 1152 procedures, including hemorrhoid excision and ligation, at a single institution in the years 2016-2018. We noted whether they were prescribed AT, the indication for therapy, perioperative medication management, whether a PBE occurred, and how the PBE was managed. RESULTS PBE's were noted in 5.92% of patients on ATs, as opposed to 2.66% of patients not on ATs (P = .014.) The odds ratio of having a PBE when on ATs vs not on ATs is 2.3 (95% CI 1.21 to 4.38, P = .011). Seven out of 40 (17.5%) total PBE's required hospital admission or repeat procedure, and this was not associated with AT use. Surprisingly, although males represented most of the patients on ATs, females were statistically more likely to have a PBE following a hemorrhoidectomy if on ATs. DISCUSSION Patients on AT have an elevated risk of PBE compared to patients not on AT. No significant difference was found between the two groups when considering only those PBE's severe enough to require hospital admission or repeat procedure. Further research is required to establish clear guidelines regarding the perioperative management of AT for hemorrhoid procedures.
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Affiliation(s)
| | - Haritha Pavuluri
- University of South Carolina School of Medicine-Greenville, Greenville, SC, USA
| | - Sarah Fox
- New Hanover Regional Medical Center/Colon and Rectal Surgery, Wilmington, NC, USA
| | - Xiyan Tan
- School of Mathematical and Statistical Sciences, Clemson University, Clemson, SC, USA
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Chhaya VY, Kibbe MR. What Surgeons Need to Know About the Recent Updates to the CHEST Guidelines on Antithrombotic Therapy for Venous Thromboembolic Disease and Perioperative Management of Antithrombotic Therapy. Ann Surg 2023; 278:e695-e697. [PMID: 37249189 DOI: 10.1097/sla.0000000000005931] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Vina Y Chhaya
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Melina R Kibbe
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA, USA
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Wei Q, Wei ZQ, Jing CQ, Li YX, Zhou DB, Lin MB, He XL, Li F, Liu Q, Zheng JY, Wang GY, Tu SL, Wang ZJ, Li A, Xiao G, Zhuang J, Bai L, Huang H, Li Y, Song W, Liang ZL, Shen ZL, Liu FL, Dai Y, Zhou XJ, Dong M, Wang H, Qiu J, Zhou L, Li XX, Wang ZQ, Zhang H, Wang Q, Pang MH, Wei HB, Hu ZQ, Yan YD, Che Y, Gu ZC, Yao HW, Zhang ZT. Incidence, prevention, risk factors, and prediction of venous thromboembolism in Chinese patients after colorectal cancer surgery: a prospective, multicenter cohort study. Int J Surg 2023; 109:3003-3012. [PMID: 37338597 PMCID: PMC10583908 DOI: 10.1097/js9.0000000000000553] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 06/02/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a common and serious complication after colorectal cancer (CRC) surgery. Few large-sample studies have reported VTE incidence and management status after CRC surgery in China. This study aimed to investigate the incidence and prevention of VTE in Chinese patients after CRC surgery, identify risk factors for developing VTE, and construct a new scoring system for clinical decision-making and care planning. METHODS Participants were recruited from 46 centers in 17 provinces in China. Patients were followed up for 1 month postoperatively. The study period was from May 2021 to May 2022. The Caprini score risk stratification and VTE prevention and incidence were recorded. The predictors of the occurrence of VTE after surgery were identified by multivariate logistic regression analysis, and a prediction model (CRC-VTE score) was developed. RESULTS A total of 1836 patients were analyzed. The postoperative Caprini scores ranged from 1 to 16 points, with a median of 6 points. Of these, 10.1% were classified as low risk (0-2 points), 7.4% as moderate risk (3-4 points), and 82.5% as high risk (≥5 points). Among these patients, 1210 (65.9%) received pharmacological prophylaxis, and 1061 (57.8%) received mechanical prophylaxis. The incidence of short-term VTE events after CRC surgery was 11.2% (95% CI 9.8-12.7), including deep venous thrombosis (DVT) (11.0%, 95% CI 9.6-12.5) and pulmonary embolism (PE) (0.2%, 95% CI 0-0.5). Multifactorial analysis showed that age (≥70 years), history of varicose veins in the lower extremities, cardiac insufficiency, female sex, preoperative bowel obstruction, preoperative bloody/tarry stool, and anesthesia time at least 180 min were independent risk factors for postoperative VTE. The CRC-VTE model was developed from these seven factors and had good VTE predictive performance ( C -statistic 0.72, 95% CI 0.68-0.76). CONCLUSIONS This study provided a national perspective on the incidence and prevention of VTE after CRC surgery in China. The study offers guidance for VTE prevention in patients after CRC surgery. A practical CRC-VTE risk predictive model was proposed.
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Affiliation(s)
- Qi Wei
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center of Digestive Diseases, Beijing
| | - Zheng-Qiang Wei
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Chang-Qing Jing
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province
| | - Yong-Xiang Li
- Department of General Surgery, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province
| | - Dong-Bing Zhou
- Department of Gastrointestinal Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan Province
| | - Mou-Bin Lin
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai
| | - Xian-Li He
- Department of General Surgery, Tangdu Hospital, The Air Force Medical University, Xi’an, Shannxi Province
| | - Fan Li
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing
| | - Qian Liu
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
| | - Jian-Yong Zheng
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Air Force Military Medical University, Xi’an, Shaanxi Province
| | - Gui-Ying Wang
- Department of General Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province
| | - Shi-Liang Tu
- General Surgery, Cancer Center, Department of Colorectal Surgery, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang Province
| | - Zhen-Jun Wang
- Department of General Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing
| | - Ang Li
- Department of General Surgery, Xuanwu Hospital Capital Medical University, Beijing
| | - Gang Xiao
- Department of Gastrointestinal Surgery, Beijing Hospital, National Center of Gerontology, Beijing
| | - Jing Zhuang
- Department of General Surgery, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, Henan Province
| | - Lian Bai
- Department of Gastrointestinal Surgery, Yongchuan Hospital of Chongqing Medical University, Chongqing
| | - He Huang
- Department of Gastrointestinal Surgery, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi Province
| | - Yong Li
- Department of Gastrointestinal Surgery, Department of General Surgery, Guangdong Provincial People’s Hospital, Guangzhou, Guangdong Province
| | - Wu Song
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province
| | - Zhong-Lin Liang
- Department of Colorectal and Anal Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Zhan-Long Shen
- Department of Gastroenterological Surgery, Peking University People’s Hospital, Beijing
| | - Fan-Long Liu
- First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province
| | - Yong Dai
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, Shandong Province
| | - Xiao-Jun Zhou
- Department of General Surgery, First Affiliated Hospital of Soochow University, Soochow, Jiangsu Province
| | - Ming Dong
- Department of Gastrointestinal Surgery, The First Hospital of China Medical University, Shenyang, Liaoning Province
| | - Hui Wang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province
| | - Jian Qiu
- Department of General Surgery, Shaanxi Provincial People’s Hospital, Xi’an, Shaanxi Province
| | - Lei Zhou
- Department of General Surgery, China-Japan Friendship Hospital, Beijing
| | - Xin-Xiang Li
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai
| | - Zi-Qiang Wang
- Colorectal Cancer Center, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province
| | - Hong Zhang
- Department of Colorectal Oncology, Fourth General Surgery Department, Shengjing Hospital, China Medical University, Shenyang, Liaoning Province
| | - Quan Wang
- Department of Gastric and Colorectal Surgery, General Surgery Center, The First Hospital of Jilin University, Changchun, Jilin Province
| | - Ming-Hui Pang
- Department of Geriatric Surgery; Department of Gastrointestinal Surgery, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, Sichuan Province
| | - Hong-Bo Wei
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province
| | - Zhi-Qian Hu
- Department of Gastrointestinal Surgery, Tongji Hospital, Medical College of Tongji University, Shanghai
| | - Yi-Dan Yan
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Yan Che
- NHC Key Lab of Reproduction Regulation, Shanghai Institute for Biomedical and Pharmaceutical Technologies, Shanghai, People’s Republic of China
| | - Zhi-Chun Gu
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Hong-Wei Yao
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center of Digestive Diseases, Beijing
| | - Zhong-Tao Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center of Digestive Diseases, Beijing
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Lin L, Li Z, Jin Y, Yin SC. Treatment strategies for periodontitis patients with systemic disease. HUA XI KOU QIANG YI XUE ZA ZHI = HUAXI KOUQIANG YIXUE ZAZHI = WEST CHINA JOURNAL OF STOMATOLOGY 2023; 41:502-511. [PMID: 37805674 PMCID: PMC10580230 DOI: 10.7518/hxkq.2023.2023181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/06/2023] [Indexed: 10/09/2023]
Abstract
Periodontitis is a chronic inflammatory disease that destroys the integrity of tooth-supporting tissue. Periodontitis is listed as a major oral disease by the World Health Organization and is a public-health problem affecting global oral and systemic health. The fourth national oral health epidemiological survey has revealed that periodontitis is one of the most common oral problems in China. With the development of science and medicine, increased attention is being paid to the importance of oral health and its influence on general health. Accordingly, stomatologists are required to master more relevant information on clinical diagnosis and treatment, as well as to pay more attention to the diagnosis and treatment methods of patients with different systemic diseases. This article expounds the diagnosis and treatment strategy of patients with systemic disease periodontitis. We aimed to help stomatologists make more reasonable diagnosis and treatment decisions.
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Affiliation(s)
- Li Lin
- Dept. of Periodontics, School and Hospital of Stomatology, China Medical University, Shenyang 110002, China
| | - Zhaorong Li
- Dept. of Periodontics, School and Hospital of Stomatology, China Medical University, Shenyang 110002, China
| | - Yining Jin
- Dept. of Periodontics, School and Hospital of Stomatology, China Medical University, Shenyang 110002, China
| | - Shou-Cheng Yin
- Dept. of Periodontics, School and Hospital of Stomatology, China Medical University, Shenyang 110002, China
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Hiraoka E, Tanabe K, Izuta S, Kubota T, Kohsaka S, Kozuki A, Satomi K, Shiomi H, Shinke T, Nagai T, Manabe S, Mochizuki Y, Inohara T, Ota M, Kawaji T, Kondo Y, Shimada Y, Sotomi Y, Takaya T, Tada A, Taniguchi T, Nagao K, Nakazono K, Nakano Y, Nakayama K, Matsuo Y, Miyamoto T, Yazaki Y, Yahagi K, Yoshida T, Wakabayashi K, Ishii H, Ono M, Kishida A, Kimura T, Sakai T, Morino Y. JCS 2022 Guideline on Perioperative Cardiovascular Assessment and Management for Non-Cardiac Surgery. Circ J 2023; 87:1253-1337. [PMID: 37558469 DOI: 10.1253/circj.cj-22-0609] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Affiliation(s)
- Eiji Hiraoka
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital
| | | | - Tadao Kubota
- Department of General Surgery, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Amane Kozuki
- Division of Cardiology, Osaka Saiseikai Nakatsu Hospital
| | | | | | - Toshiro Shinke
- Division of Cardiology, Showa University School of Medicine
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Susumu Manabe
- Department of Cardiovascular Surgery, International University of Health and Welfare Narita Hospital
| | - Yasuhide Mochizuki
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Taku Inohara
- Department of Cardiovascular Medicine, Keio University Graduate School of Medicine
| | - Mitsuhiko Ota
- Department of Cardiovascular Center, Toranomon Hospital
| | | | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital
| | - Yumiko Shimada
- JADECOM Academy NP·NDC Training Center, Japan Association for Development of Community Medicine
| | - Yohei Sotomi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Tomofumi Takaya
- Department of Cardiovascular Medicine, Hyogo Prefectural Himeji Cardiovascular Center
| | - Atsushi Tada
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Tomohiko Taniguchi
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Kazuya Nagao
- Department of Cardiology, Osaka Red Cross Hospital
| | - Kenichi Nakazono
- Department of Pharmacy, St. Marianna University Yokohama Seibu Hospital
| | | | | | - Yuichiro Matsuo
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center
| | | | | | | | | | | | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine
| | - Yoshihiro Morino
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
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Iwamoto T, Suda T, Inoue T, Nozaki Y, Mizumoto R, Arimoto Y, Ohta T, Yamaguchi S, Ito Y, Hagiwara H. Postoperative bleeding after percutaneous transhepatic gallbladder drainage and aspiration in patients receiving antithrombotic therapy. PLoS One 2023; 18:e0288463. [PMID: 37594942 PMCID: PMC10437875 DOI: 10.1371/journal.pone.0288463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 06/27/2023] [Indexed: 08/20/2023] Open
Abstract
This study aimed to investigate the bleeding risk associated with percutaneous transhepatic gallbladder interventions in patients with acute cholecystitis receiving antithrombotic therapy. In this retrospective study, 194 consecutive patients who underwent percutaneous transhepatic gallbladder interventions for acute cholecystitis between April 2011 and April 2021 were enrolled. Patients were sorted into four groups: no prior antithrombotic therapy, discontinued antithrombotic drugs, single antithrombotic drug continued perioperatively, and multiple antithrombotic drugs continued perioperatively. The risk of postoperative bleeding after percutaneous transhepatic gallbladder interventions was evaluated via multivariate logistic regression analysis. Of the 116 (59.8%) patients receiving antithrombotic therapy, 32 (16.5%) discontinued antithrombotic drugs before their respective procedure, 50 (25.8%) continued a single antithrombotic drug, and 34 (17.5%) continued multiple antithrombotic drugs during the perioperative period. The rates of significant and severe bleeding were 10.3% (20/194) and 3.1% (6/194), respectively. The rate of significant bleeding was significantly higher in patients who continued multiple antithrombotic drugs than in patients who received no prior antithrombotic therapy (P = 0.006). In the multivariate logistic regression analysis, the continuation of multiple antithrombotic drugs during the perioperative period was a risk factor for significant bleeding after percutaneous transhepatic gallbladder interventions. In conclusion, the perioperative continuation of multiple antithrombotic drugs is a risk factor for postoperative bleeding after percutaneous transhepatic gallbladder interventions.
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Affiliation(s)
- Takayuki Iwamoto
- Department of Gastroenterology and Hepatology, Kansai Rosai Hospital, Hyogo, Japan
| | - Takahiro Suda
- Department of Gastroenterology and Hepatology, Kansai Rosai Hospital, Hyogo, Japan
| | - Takanori Inoue
- Department of Gastroenterology and Hepatology, Kansai Rosai Hospital, Hyogo, Japan
| | - Yasutoshi Nozaki
- Department of Gastroenterology and Hepatology, Kansai Rosai Hospital, Hyogo, Japan
| | - Rui Mizumoto
- Department of Gastroenterology and Hepatology, Kansai Rosai Hospital, Hyogo, Japan
| | - Yuki Arimoto
- Department of Gastroenterology and Hepatology, Kansai Rosai Hospital, Hyogo, Japan
| | - Takashi Ohta
- Department of Gastroenterology and Hepatology, Kansai Rosai Hospital, Hyogo, Japan
| | - Shinjiro Yamaguchi
- Department of Gastroenterology and Hepatology, Kansai Rosai Hospital, Hyogo, Japan
| | - Yoshiki Ito
- Department of Gastroenterology and Hepatology, Kansai Rosai Hospital, Hyogo, Japan
| | - Hideki Hagiwara
- Department of Gastroenterology and Hepatology, Kansai Rosai Hospital, Hyogo, Japan
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48
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Lee K, Chang M. Intraoperative use of fibrin glue in blepharoplasty: a possible solution to reduce postoperative complication. Sci Rep 2023; 13:12982. [PMID: 37563229 PMCID: PMC10415304 DOI: 10.1038/s41598-023-40183-9] [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: 09/29/2022] [Accepted: 08/06/2023] [Indexed: 08/12/2023] Open
Abstract
The purpose of this study was to investigate the effects of intraoperative fibrin glue use on surgery for blepharoptosis. This retrospective study included patients with acquired blepharoptosis who underwent surgical correction and were followed for at least one month. Patients were classified into two groups depending on whether treated with antithrombotic agents or otherwise. All patients taking antithrombotic agents discontinued with the treatment one week prior to surgery in accordance with our clinical guidelines. Preoperative and postoperative marginal reflex distance 1(MRD1) and ecchymosis grade were evaluated and compared. The subjects were 56 patients (111 eyes) who discontinued antithrombotic agents before surgery and 59 patients (117 eyes) who had never taken antithrombotic agents. Fibrin glue was used in 13 patients (26 eyes, 23.4%) in the antithrombotic group, and 11 patients (21 eyes, 17.9%) in the non-antithrombotic group. The rate of severe ecchymosis was significantly lower in patients who used fibrin glue in the antithrombotic group at 1 week (11.5 vs 40.0%, p = 0.008). However, in non-antithrombotic group, there was no difference in the rate of severe ecchymosis according to the use of fibrin glue at 1 week (14.3 vs 30.2%, p = 0.181). In patients with a history of taking antithrombotic agents, the intraoperative use of fibrin glue is thought to be helpful as it could significantly reduce significant ecchymosis.
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Affiliation(s)
- Kangmin Lee
- Department of Ophthalmology, Dongguk University Ilsan Hospital, 27, Dongguk-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, Republic of Korea
- Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, Republic of Korea
| | - Minwook Chang
- Department of Ophthalmology, Dongguk University Ilsan Hospital, 27, Dongguk-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, Republic of Korea.
- Shiley Eye Clinic, Hwa Sung, Republic of Korea.
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Hamulyák EN, Westenberg D, Bresser C, Sissing S, Ruiter M, Scheres LJJ, Wals A, Faber LM. Implementation of a clinical decision-making tool for perioperative management of vitamin K antagonists in patients with atrial fibrillation. Thromb Res 2023; 228:200-202. [PMID: 37348321 DOI: 10.1016/j.thromres.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/01/2023] [Accepted: 06/12/2023] [Indexed: 06/24/2023]
Affiliation(s)
- Eva N Hamulyák
- Department of Hematology, Red Cross Hospital, Beverwijk, Noord-Holland, the Netherlands; Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Dirk Westenberg
- Department of Hematology, Red Cross Hospital, Beverwijk, Noord-Holland, the Netherlands; Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Carlinda Bresser
- Department of Hematology, Red Cross Hospital, Beverwijk, Noord-Holland, the Netherlands
| | - Simone Sissing
- Department of Hematology, Red Cross Hospital, Beverwijk, Noord-Holland, the Netherlands
| | - Marjan Ruiter
- Department of Hematology, Red Cross Hospital, Beverwijk, Noord-Holland, the Netherlands
| | - Luuk J J Scheres
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands; Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Arian Wals
- Department of Hematology, Red Cross Hospital, Beverwijk, Noord-Holland, the Netherlands
| | - Laura M Faber
- Department of Hematology, Red Cross Hospital, Beverwijk, Noord-Holland, the Netherlands.
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50
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Soler-Espejo E, Esteve-Pastor MA, Rivera-Caravaca JM, Roldan V, Marín F. Reducing bleeding risk in patients on oral anticoagulation therapy. Expert Rev Cardiovasc Ther 2023; 21:923-936. [PMID: 37905915 DOI: 10.1080/14779072.2023.2275662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/23/2023] [Indexed: 11/02/2023]
Abstract
INTRODUCTION Oral anticoagulation (OAC) significantly mitigates thromboembolism risks in atrial fibrillation (AF) and venous thromboembolism (VTE) patients yet concern about major bleeding events persist. In fact, clinically relevant hemorrhages can be life-threatening. Bleeding risk is dynamic and influenced by factors such as age, new comorbidities, and drug therapies, and should not be assessed solely based on static baseline factors. AREAS COVERED We comprehensively review the bleeding risk associated with OAC therapy. Emphasizing the importance of assessing both thromboembolic and bleeding risks, we present clinical tools for estimating stroke and systemic embolism (SSE) and bleeding risk in AF and VTE patients. We also address overlapping risk factors and the dynamic nature of bleeding risk. EXPERT OPINION The OAC management is undergoing constant transformation, motivated by the primary objective of mitigating thromboembolism and bleeding hazards, thereby amplifying patient safety throughout the course of treatment. The future of OAC embraces personalized approaches and innovative therapies, driven by advanced pathophysiological insights and technological progress. This holds promise for improving patient outcomes and revolutionizing anticoagulation practices.
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Affiliation(s)
- Eva Soler-Espejo
- Department of Hematology and Hemotherapy, Hospital General Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), Murcia, Spain
| | - María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), CIBERCV, Murcia, Spain
| | - José Miguel Rivera-Caravaca
- Faculty of Nursing, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), CIBERCV, Murcia, Spain
| | - Vanessa Roldan
- Department of Hematology and Hemotherapy, Hospital General Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), Murcia, Spain
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), CIBERCV, Murcia, Spain
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