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Kozieł M, Ding WY, Kalarus Z, Lip GYH. Considerations when restarting anticoagulants in patients with atrial fibrillation after bleeding. Expert Rev Hematol 2019; 12:845-855. [PMID: 31334670 DOI: 10.1080/17474086.2019.1647779] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Introduction: Oral anticoagulants (OACs) are established treatments to reduce thromboembolic risk in patients with atrial fibrillation (AF). Due to their mechanisms of action, they are associated with increased bleeding risk. Evaluation with bleeding risk scores may be useful to identify patients at high risk. However, the approach in patients who have suffered a recent bleeding event while on OACs is a contentious issue. If a decision is made to re-initiate OACs, the optimal timing for this remains controversial. Areas covered: Bleeding risk scores were designed to evaluate risk in patients with AF and indications for OACs. Some practical schemes were created to manage bleeding in this population. The types of bleeding were classified as minor, major non-life-threatening and major life-threatening bleeding. In AF patients suffering from severe acute bleeding, it is recommended to withhold OACs until the underlying cause is identified and treated. Each case will require an individualized decision to restarting OAC therapy after consideration of the risks, benefits, alternatives and patient's choice in the matter. Expert opinion: Management of major bleeding and restarting OACs in patients with a recent major bleeding poses a special challenge due to high bleeding and thrombotic risk. This will be discussed in this review.
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Affiliation(s)
- Monika Kozieł
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital , Liverpool , UK.,Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases , Zabrze , Poland
| | - Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital , Liverpool , UK
| | - Zbigniew Kalarus
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases , Zabrze , Poland
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital , Liverpool , UK.,Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases , Zabrze , Poland.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University , Aalborg , Denmark
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2
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Steiner T, Köhrmann M, Schellinger PD, Tsivgoulis G. Non-Vitamin K Oral Anticoagulants Associated Bleeding and Its Antidotes. J Stroke 2018; 20:292-301. [PMID: 30309225 PMCID: PMC6186922 DOI: 10.5853/jos.2018.02250] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 09/12/2018] [Indexed: 01/12/2023] Open
Abstract
Oral anticoagulant-associated intracerebral hemorrhage (OAC-ICH) accounts for nearly 20% of all ICH. The number of patients with an indication for oral anticoagulant therapy (OAT) increases with increasing age. OAT became less complicate with the introduction of non-vitamin K oral anticoagulants (NOAC) OAT because of easier handling, favorable risk-benefit profile, reduced rates of ICH compared to vitamin K antagonists and no need for routine coagulation testing. Consequently, despite a better safety profile of NOAC the number of patients with OAC-ICH will increase. The mortality and complication rates of OAC-ICH are high and therefore they are the most feared complication of OAT. Immediate normalization of coagulation is the main goal and therefore knowledge of pharmacodynamics and coagulation status is essential. Laboratory measurements of anticoagulant activity in NOAC patients is challenging as specific tests are not widely available. More accessible tests such as the prothrombin time and activated partial thromboplastin time have important limitations. In dabigatran-associated ICH 5 g Idarucizumab should be administered. In rivaroxaban and apixaban-associated ICHs administration of andexanet alpha should be considered. Prothrombin complex concentrate may be considered if andexanet alpha is not available or in case of an ICH associated with edoxaban.
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Affiliation(s)
- Thorsten Steiner
- Department of Neurology, Frankfurt Hoechst Hospital, Frankfurt, Germany.,Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Köhrmann
- Department of Neurology, Essen University Hospital, Essen, Germany
| | - Peter D Schellinger
- Department of Neurology, Essen University Hospital, Essen, Germany.,Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, University Clinic RUB, Minden, Germany
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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3
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Touzé E, Gruel Y, Gouin-Thibault I, De Maistre E, Susen S, Sie P, Derex L. Intravenous thrombolysis for acute ischaemic stroke in patients on direct oral anticoagulants. Eur J Neurol 2018; 25:747-e52. [PMID: 29360254 DOI: 10.1111/ene.13582] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 01/11/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Whereas intravenous thrombolysis (IVT) is allowed for acute ischaemic stroke in patients on vitamin K antagonists with international normalized ratio ≤1.7, there are no similar recommendations for patients on direct oral anticoagulants (DOACs), notably due to the lack of coagulation tests to assess the therapeutic effects. Although the literature is scarce, consisting of small case series and retrospective studies, considering the frequency of this situation the French Vascular Neurology Society and the French Study Group on Haemostasis and Thrombosis have worked on a joint position paper to provide a practical position regarding the emergency management of ischaemic stroke in patients on DOACs. METHOD Based on a review of the literature, the authors wrote a first text that was submitted to a broad panel of members from the two societies. The text was then amended by the authors to address experts' comments and to reach a consensus. RESULTS In patients with normal renal function and who stopped the DOAC for at least 48 h, the management should not differ from that in patients without oral anticoagulant. In patients who are still on DOACs, mechanical thrombectomy is encouraged preferentially when applicable in first line. Otherwise, when specific tests are available, values <50 ng/ml indicate that IVT is allowed. In the absence of specific tests, standard tests (thrombin time, prothrombin time and activated partial thromboplastin time) can be used for dabigatran and rivaroxaban, although interpretation of these tests may be less reliable. In some patients on dabigatran, idarucizumab may be used before IVT. CONCLUSIONS In this expert opinion paper, it is suggested that IVT can be performed in patients selected according to the time elapsed since the drug was last taken, renal function, type of hospital where the patient is admitted and plasma concentration of DOAC.
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Affiliation(s)
- E Touzé
- Normandie Université, UNICAEN, Unité Neurovasculaire, CHU Caen, Caen, France
| | - Y Gruel
- Service d'Hématologie-Hémostase, Centre Régional de Traitement de l'Hémophilie, UMR CNRS 7292, Hôpital Trousseau, CHRU de Tours et Université François Rabelais, Tours, France
| | - I Gouin-Thibault
- Laboratoire d'Hématologie, Hôpital Cochin, UMR_S1140, Université Paris Descartes, Paris, France
| | - E De Maistre
- Laboratoire d'Hématologie-Hémostase, CHU Dijon Bourgogne, Université de Bourgogne, Dijon Cedex, France
| | - S Susen
- Département d'Hématologie et Transfusion, CHRU, Lille, France
| | - P Sie
- Laboratoire d'Hématologie, Hôpital Rangueil, CHU de Toulouse, Université Toulouse 3, Paul Sabatier, Toulouse, France
| | - L Derex
- Unité Neurovasculaire, Hôpital Neurologique, Hospices Civils, Lyon, France
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4
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Bluecher A, Meyer Dos Santos S, Ferreirós N, Labocha S, Meyer Dos Santos IMR, Picard-Willems B, Harder S, Singer OC. Microfluidic coagulation assay for monitoring anticoagulant therapy in acute stroke patients. Thromb Haemost 2017; 117:519-528. [PMID: 28124061 DOI: 10.1160/th16-08-0619] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 12/10/2016] [Indexed: 11/05/2022]
Abstract
Reliable detection of anticoagulation status in patients treated with non-vitamin K antagonist oral anticoagulants (NOACs) is challenging but of importance especially in the emergency setting. This study evaluated the potential of a whole-blood clotting time assay based on Surface Acoustic Waves (SAW-CT) in stroke-patients. The SAW-technology was used for quick and homogenous recalcification of whole blood inducing a surface-activated clotting reaction quantified and visualised by real-time fluorescence microscopy with automatic imaging processing. In 20 stroke or transient ischaemic attack (TIA)-patients taking NOACs kinetics of SAW-CT were assessed and correlated to other coagulation parameters (PT, aPTT) and NOAC-plasma concentration measured by tandem mass spectrometry (LC-MS/MS). In 225 emergency patients with suspicion of acute stroke or TIA, SAW-CT values were assessed. Mean (± SD) SAW-CT in non-anticoagulated stroke patients (n=180) was 124 s (± 21). In patients on dabigatran or rivaroxaban, SAW-CT values were significantly higher 2 and 8 hours (h) after intake rising up to 267 seconds (s) (dabigatran, 2 h after intake) and 250 s (rivaroxaban, 8 h after intake). In patients on apixaban, SAW-CT values were only moderately increased 2 h after intake (SAW-CT 153 s). In emergency patients, SAW-CT values were significantly higher in NOAC and vitamin K antagonist (VKA)-treated as compared to non-anticoagulated patients. In conclusion, the SAW-CT assay is capable to monitor anticoagulant level and effect in patients receiving dabigatran, rivaroxaban and the VKA phenprocoumon. It has a limited sensitivity for apixaban-detection. If specific SAW-CT results were used as cut-offs, SAW-CT yields high diagnostic accuracy to exclude relevant rivaroxaban and dabigatran concentrations in stroke-patients.
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Affiliation(s)
| | | | | | | | | | | | | | - Oliver C Singer
- Oliver C. Singer, MD, Department of Neurology, HELIOS HSK Kliniken, Ludwig-Erhard-Str. 100, 65199 Wiesbaden, Germany, Tel.: +49 611 432376, Fax: +49 611 432732, E-mail:
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5
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Abstract
OPINION STATEMENT Direct oral anticoagulants (DOAC) are an attractive therapeutic option for anticoagulant treatment in the setting of venous thromboembolism or non-valvular atrial fibrillation. These drugs overall appear to have a lower risk of life-threatening hemorrhage than the vitamin K antagonists. In addition, they demonstrate more predictable and stable pharmacokinetics. Measurement of the degree of anticoagulation is desirable in patients with DOAC-associated hemorrhage, but commonly available coagulation assays show poor sensitivity for degree of DOAC effect. DOAC-specific tests are time consuming and not widely available. All coagulation tests should be interpreted considering the timing of last intake and renal function. When life-threatening bleeding occurs, hemostasis should be restored as rapidly as possible. Non-specific prohemostatic drugs may have a role in DOAC reversal, and specific antidotes are at different stages of development. In this review, we provide a summary of DOAC characteristics and an overview of the different therapeutic options available for DOAC reversal.
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6
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Specific antidotes against direct oral anticoagulants: A comprehensive review of clinical trials data. Int J Cardiol 2016; 214:292-8. [DOI: 10.1016/j.ijcard.2016.03.056] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 03/13/2016] [Accepted: 03/15/2016] [Indexed: 11/23/2022]
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7
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Sato N, Ichikawa J, Wako M, Ohba T, Saito M, Sato H, Koyama K, Hagino T, Schoenecker JG, Ando T, Haro H. Thrombin induced by the extrinsic pathway and PAR-1 regulated inflammation at the site of fracture repair. Bone 2016; 83:23-34. [PMID: 26475502 DOI: 10.1016/j.bone.2015.10.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 09/30/2015] [Accepted: 10/11/2015] [Indexed: 02/07/2023]
Abstract
Thrombin (coagulation factor IIa) is a serine protease encoded by the F2 gene. Pro-thrombin (coagulation factor II) is cut to generate thrombin in the coagulation cascade that results in a reduction of blood loss. Procoagulant states that lead to activation of thrombin are common in bone fracture sites. However, its physiological roles and relationship with osteoblasts in bone fractures are largely unknown. We herein report various effects of thrombin on mouse osteoblastic MC3T3-E1 cells. MC3T3-E1 cells expressed proteinase-activated receptor 1 (PAR1), also known as the coagulation factor II receptor. They also produced monocyte chemoattractant protein (MCP-1), tissue factor (TF), MCSF and IL-6 upon thrombin stimulation through the PI3K-Akt and MEK-Erk1/2 pathways. Furthermore, MCP-1 obtained from thrombin-stimulated MC3T3-E1 cells induced migration by macrophage RAW264 cells. All these effects of thrombin on MC3T3-E1 cells were abolished by the selective non-peptide thrombin receptor inhibitor SCH79797. We also found that thrombin, PAR-1, MCP-1, TF as well as phosphorylated AKT and p42/44 were significantly expressed at the fracture site of mouse femoral bone. Collectively, thrombin/PAR-1 interaction regulated MCP-1, TF, MCSF and IL-6 production by MC3T3-E1 cells. Furthermore, MCP-1 induced RAW264 cell migration. Thrombin may thus be a novel cytokine that regulates several aspects of osteoblast function and fracture healing.
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Affiliation(s)
- Nobutaka Sato
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokatou, Chuo, Yamanashi 409-3898, Japan
| | - Jiro Ichikawa
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokatou, Chuo, Yamanashi 409-3898, Japan
| | - Masanori Wako
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokatou, Chuo, Yamanashi 409-3898, Japan
| | - Tetsuro Ohba
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokatou, Chuo, Yamanashi 409-3898, Japan
| | - Masanori Saito
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokatou, Chuo, Yamanashi 409-3898, Japan
| | - Hironao Sato
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokatou, Chuo, Yamanashi 409-3898, Japan
| | - Kensuke Koyama
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokatou, Chuo, Yamanashi 409-3898, Japan
| | - Tetsuo Hagino
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokatou, Chuo, Yamanashi 409-3898, Japan; The Sports Medicine and Knee Center, Kofu National Hospital, 11-35 Tenjincho, Kofu, Yamanashi 400-8533, Japan
| | - Jonathan G Schoenecker
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN 37232-9565, United States; Department of Orthopaedics, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN 37232-9565, United States; Department of Center for Bone Biology, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN 37232-9565, United States; Department of Pharmacology, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN 37232-9565, United States; Department of Pediatrics, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN 37232-9565, United States
| | - Takashi Ando
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokatou, Chuo, Yamanashi 409-3898, Japan.
| | - Hirotaka Haro
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokatou, Chuo, Yamanashi 409-3898, Japan
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Müller P, Windpessl M. Ischemic stroke in patients on dabigatran: a role for rescue thrombectomy? Intern Med 2015; 54:1001. [PMID: 25876595 DOI: 10.2169/internalmedicine.54.3799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Petra Müller
- Department of Neurology, Landesnervenklinik Linz, Austria
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