1
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King RC, Mathew T, Whang S, Premyodhin N, Patel P. Left atrial Thrombus formation after discontinuation of anticoagulation in patient with severe bioprosthetic mitral stenosis. BMC Cardiovasc Disord 2023; 23:616. [PMID: 38097932 PMCID: PMC10720059 DOI: 10.1186/s12872-023-03644-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 11/29/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Mitral valve stenosis can be a highly symptomatic condition with significant complications if left untreated. In such cases, mitral valve replacement with a bioprosthetic or mechanical valve may be a viable solution to prevent progressive disease. Current guidelines do not recommend continued anticoagulation beyond 6 months for patients who have undergone bioprosthetic valve replacement without a separate indication for anticoagulation. With this case discussion we aim to 1) Review the current indications for anticoagulation for bioprosthetic mitral valves in patients without atrial fibrillation and 2) Discuss the constellation of comorbidities that may affect the decision to begin anticoagulation therapy. CASE PRESENTATION We present a case describing a 55-year-old male with end-stage renal disease, coronary artery disease with coronary artery bypass graft surgery, and bioprosthetic mitral valve replacement 2 years prior with rapid degeneration of the replaced valve and on warfarin without a clear indication for anticoagulation. The patient was admitted for symptomatic, severe mitral stenosis and consideration of transcatheter mitral valve-in-valve replacement. During hospital admission, warfarin was discontinued and replaced with prophylactic anticoagulation. However, 8 days after warfarin cessation an intraoperative transesophageal echocardiography revealed a newly developed large left atrial thrombus leading to cancellation of the planned operation. CONCLUSIONS This patient developed a left atrial thrombus after discontinuing warfarin in the setting of rapidly deteriorating bioprosthetic valve stenosis and vascular comorbidities. The decision to discontinue warfarin was made in concordance with current guidelines, which do not indicate systemic anticoagulation post 3-6 months after bioprosthetic valve replacement without separate indication for anticoagulation. This case identifies the need to investigate rebound hypercoagulability and further risk stratify comorbidities which may independently increase the risk of clot formation in the setting of severe mitral valve stenosis.
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Affiliation(s)
- Ryan C King
- Department of Medicine, Division of Cardiology, University of California, Irvine Medical Center, 101 The City Drive, S, Orange, CA, 92868, USA.
| | - Tobin Mathew
- Department of Medicine, Division of Cardiology, University of California, Irvine Medical Center, 101 The City Drive, S, Orange, CA, 92868, USA
| | - Stella Whang
- Department of Medicine, Division of Cardiology, University of California, Irvine Medical Center, 101 The City Drive, S, Orange, CA, 92868, USA
| | - Ned Premyodhin
- Department of Medicine, Division of Cardiology, University of California, Irvine Medical Center, 101 The City Drive, S, Orange, CA, 92868, USA
| | - Pranav Patel
- Department of Medicine, Division of Cardiology, University of California, Irvine Medical Center, 101 The City Drive, S, Orange, CA, 92868, USA
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2
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Parks AL, Fang MC. Periprocedural Anticoagulation. Ann Intern Med 2023; 176:ITC49-ITC64. [PMID: 37037035 DOI: 10.7326/aitc202304180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2023] Open
Abstract
Management of patients taking anticoagulants around the time of a procedure is a common and complex clinical scenario. Providing evidence-based care requires estimation of risk for thrombosis and bleeding, knowledge of commonly used medications, multidisciplinary communication and collaboration, and patient engagement and education. This review provides a standardized, evidence-based approach to periprocedural management of anticoagulation, based on current evidence and expert clinical guidelines.
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Affiliation(s)
- Anna L Parks
- University of Utah School of Medicine, Salt Lake City, Utah (A.L.P.)
| | - Margaret C Fang
- University of California, San Francisco, San Francisco, California (M.C.F.)
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3
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Nakazawa T, Yamazaki S, Uchida M, Suzuki T, Nakamura T, Ohtsuka M, Ishii I. Relationship between elevated bilirubin levels and enhanced warfarin effects during biliary obstruction. Eur J Clin Pharmacol 2023; 79:437-443. [PMID: 36723758 DOI: 10.1007/s00228-023-03459-7] [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: 10/26/2022] [Accepted: 01/18/2023] [Indexed: 02/02/2023]
Abstract
OBJECTIVES A marked prolongation of the prothrombin time-international normalized ratio (PT-INR) is frequently observed during biliary obstruction in patients using warfarin. The objective of this study was to identify factors associated with PT-INR prolongation during biliary obstruction in patients using warfarin. METHODS Among 44 patients using warfarin who had biliary obstruction, we retrospectively investigated warfarin doses and laboratory data before and during biliary obstruction. The primary outcome was the association between changes in PT-INR (ΔPT-INR) and changes in laboratory data before and during biliary obstruction. RESULTS Median PT-INR was 1.59 (IQR 1.38-1.95) before biliary obstruction and 2.27 (IQR 1.60-3.49) during biliary obstruction, indicating significant prolongation during the obstruction (P < 0.001). ΔPT-INR showed strong positive correlations with change in total bilirubin (ΔT-Bil; ρ = 0.692, P < 0.001) and change in conjugated bilirubin (ΔC-Bil; ρ = 0.731, P < 0.001). ΔPT-INR showed a weak negative correlation with the change in albumin (ΔAlb; ρ = -0.371, P < 0.05). When ΔPT-INR was used as the dependent variable in multiple linear regression analysis, ΔT-Bil, ΔC-Bil, and ΔAlb were significantly associated with ΔPT-INR. CONCLUSIONS PT-INR was prolonged during biliary obstruction in patients using warfarin, and changes in bilirubin levels were associated with ΔPT-INR. If biliary obstruction with markedly elevated bilirubin levels occurs, measuring PT-INR could lead to safer warfarin therapy.
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Affiliation(s)
- Takafumi Nakazawa
- Division of Pharmacy, Chiba University Hospital, 1-8-1 Inohana, Chuo-Ku, Chiba-Shi, Chiba, 260-8677, Japan.,Graduate School of Pharmaceutical Sciences, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba-Shi, Chiba, 260-8675, Japan
| | - Shingo Yamazaki
- Division of Pharmacy, Chiba University Hospital, 1-8-1 Inohana, Chuo-Ku, Chiba-Shi, Chiba, 260-8677, Japan
| | - Masashi Uchida
- Division of Pharmacy, Chiba University Hospital, 1-8-1 Inohana, Chuo-Ku, Chiba-Shi, Chiba, 260-8677, Japan.,Graduate School of Pharmaceutical Sciences, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba-Shi, Chiba, 260-8675, Japan
| | - Takaaki Suzuki
- Division of Pharmacy, Chiba University Hospital, 1-8-1 Inohana, Chuo-Ku, Chiba-Shi, Chiba, 260-8677, Japan. .,Graduate School of Pharmaceutical Sciences, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba-Shi, Chiba, 260-8675, Japan.
| | - Takako Nakamura
- Division of Pharmacy, Chiba University Hospital, 1-8-1 Inohana, Chuo-Ku, Chiba-Shi, Chiba, 260-8677, Japan
| | - Masayuki Ohtsuka
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba-Shi, Chiba, 260-8677, Japan
| | - Itsuko Ishii
- Division of Pharmacy, Chiba University Hospital, 1-8-1 Inohana, Chuo-Ku, Chiba-Shi, Chiba, 260-8677, Japan.,Graduate School of Pharmaceutical Sciences, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba-Shi, Chiba, 260-8675, Japan
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4
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Wenninger FC, Wabbels B. Frequency of Hemorrhagic Side Effects of Botulinum Neurotoxin Treatment in Patients with Blepharospasm and Hemifacial Spasm on Antithrombotic Medication. Toxins (Basel) 2022; 14:toxins14110769. [PMID: 36356019 PMCID: PMC9693354 DOI: 10.3390/toxins14110769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/24/2022] [Accepted: 11/02/2022] [Indexed: 11/09/2022] Open
Abstract
The aim of this study was to investigate the frequency of hemorrhagic side effects of botulinum neurotoxin A injections (BoNT/A) for the treatment of benign essential blepharospasm (BEB) and hemifacial spasm (HFS) in patients taking antithrombotic drugs (ATD). A total of 140 patients were included (female: 65%; BEB: 75%; mean age: 70 ± 12 years). According to their current antithrombotic medication, participants were either assigned to the ATD group (41%), or to the control group (59%). The ATD group was further divided into subgroups depending on the medication administered: acetylsalicylic acid, ADP receptor antagonists, direct oral anticoagulants, vitamin-K antagonists, or dual antiplatelet therapy. The frequency of hemorrhagic side effects was recorded by retrospective analysis of past treatments as documented in the patient's file set in relation to the number of past treatments (hematoma frequency of past treatments, HFretro) as well as by a prospective survey capturing the side effects of one single treatment (hematoma frequency of actual treatment, HFactual). There was no significant difference in hematoma frequency between the ATD group and the control group, neither for past (HFretro: ATD: 2%; 45/2554; control: 4%; 109/2744) nor for the current BoNT/A treatments (HFactual: ATD: 30%; 16/53; control: 31%; 22/72). Even between ATD subgroups, hematoma frequency did not differ significantly. Overall, hemorrhagic side effects of the BoNT/A treatment for BEB and HFS were mild and non-disabling.
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Affiliation(s)
- Fiona Carolin Wenninger
- Department of Ophthalmology, University Hospital of Bonn, Ernst-Abbe-Str. 2, D-53127 Bonn, Germany
- Department of Neurology, University Hospital of Münster, Albert-Schweitzer-Campus 1, D-48149 Münster, Germany
| | - Bettina Wabbels
- Department of Ophthalmology, University Hospital of Bonn, Ernst-Abbe-Str. 2, D-53127 Bonn, Germany
- Correspondence: ; Tel.: +49-(0)228-287-15612; Fax: +49-(0)228-287-14692
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5
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Douketis JD, Spyropoulos AC, Murad MH, Arcelus JI, Dager WE, Dunn AS, Fargo RA, Levy JH, Samama CM, Shah SH, Sherwood MW, Tafur AJ, Tang LV, Moores LK. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest 2022; 162:e207-e243. [PMID: 35964704 DOI: 10.1016/j.chest.2022.07.025] [Citation(s) in RCA: 78] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/10/2022] [Accepted: 07/11/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug. METHODS Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines. RESULTS A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures. CONCLUSIONS Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.
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Affiliation(s)
- James D Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton and McMaster University, Hamilton, ON, Canada.
| | - Alex C Spyropoulos
- Department of Medicine, Northwell Health at Lenox Hill Hospital, New York, NY; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Institute of Health Systems Science at The Feinstein Institutes for Medical Research, Manhasset, NY
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | - Juan I Arcelus
- Department of Surgery, Facultad de Medicina, University of Granada, Granada, Spain
| | - William E Dager
- Department of Pharmacy, University of California-Davis, Sacramento, CA
| | - Andrew S Dunn
- Division of Hospital Medicine, Department of Medicine, Mt. Sinai Health System, New York, NY
| | - Ramiz A Fargo
- Department of Internal Medicine, Loma Linda University Medical Center, Loma Linda, CA; Department of Internal Medicine, Riverside University Health System Medical Center, Moreno Valley, CA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, NC
| | - C Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP, Centre-Université Paris-Cité-Cochin Hospital, Paris, France
| | - Sahrish H Shah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | | | - Alfonso J Tafur
- Department of Medicine, Cardiovascular, NorthShore University HealthSystem, Evanston, IL
| | - Liang V Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong, University of Science and Technology, Wuhan, China
| | - Lisa K Moores
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
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6
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Romano MC, Francis KA, Janes JG, Poppenga RH, Filigenzi MS, Stefanovski D, Gaskill CL. Determining an approximate minimum toxic dosage of diphacinone in horses and corresponding serum, blood, and liver diphacinone concentrations: a pilot study. J Vet Diagn Invest 2022; 34:489-495. [PMID: 35369800 PMCID: PMC9254070 DOI: 10.1177/10406387221086923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Poisoning of nontarget species is a major concern with the use of anticoagulant rodenticides (ARs). At postmortem examination, differentiating toxicosis from incidental exposure is sometimes difficult. Clotting profiles cannot be performed on postmortem samples, and clinically significant serum, blood, and liver AR concentrations are not well-established in most species. We chose diphacinone for our study because, at the time, it was the publicly available AR most commonly detected in samples analyzed at the University of Kentucky Veterinary Diagnostic Laboratory. We determined an approximate minimum toxic dosage (MTD) of oral diphacinone in 3 horses and measured corresponding serum, blood, and liver diphacinone concentrations. Diphacinone was administered orally to healthy horses. Prothrombin time (PT), activated partial thromboplastin time (aPTT), and serum and blood diphacinone concentrations were measured daily. At the study endpoint, the horses were euthanized, and diphacinone concentration was measured in each liver lobe. The horse that received 0.2 mg/kg diphacinone developed prolonged (>1.5× baseline) PT and aPTT; the horse that received 0.1 mg/kg did not. This suggests an approximate oral MTD in horses of 0.2 mg/kg diphacinone. Median liver diphacinone concentration at this dosage was 1,780 (range: 1,590–2,000) ppb wet weight. Marginal (model-adjusted) mean diphacinone concentrations of liver lobes were not significantly different from one another ( p = NS). Diphacinone was present in similar concentrations in both serum and blood at each time after administration, indicating that both matrices are suitable for detection of diphacinone exposure in horses.
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Affiliation(s)
- Megan C. Romano
- Department of Veterinary Science, University of Kentucky, Lexington, KY, USA
| | - Kyle A. Francis
- Department of Veterinary Science, University of Kentucky, Lexington, KY, USA
| | - Jennifer G. Janes
- Department of Veterinary Science, University of Kentucky, Lexington, KY, USA
| | - Robert H. Poppenga
- California Animal Health and Food Safety Laboratory System, School of Veterinary Medicine, University of California–Davis, Davis, CA, USA
| | - Michael S. Filigenzi
- California Animal Health and Food Safety Laboratory System, School of Veterinary Medicine, University of California–Davis, Davis, CA, USA
| | - Darko Stefanovski
- University of Pennsylvania School of Veterinary Medicine, New Bolton Center, Kennett Square, PA, USA
| | - Cynthia L. Gaskill
- Department of Veterinary Science, University of Kentucky, Lexington, KY, USA
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8
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Abstract
PURPOSE OF REVIEW The management of patients with mechanical heart valves who require surgery or invasive procedures is a common clinical scenario in contemporary practice. The risk of thromboembolism versus the risk of bleeding is the foundation of optimal patient care. RECENT FINDINGS Randomized, controlled trials are not available; yet, there is a wealth of experience to guide best practice. Current guidelines represent a compilation of data from trials of atrial fibrillation and expert opinion. Results from the PERI-OP trial of patients with either a mechanical heart valve, atrial fibrillation, or atrial flutter requiring interruption of oral anticoagulant therapy for surgery will inform clinical practice. Patient-specific factors and valve-specific factors are paramount when deciding whether a period of anticoagulant therapy interruption is safe. Similarly, the safety and efficacy of bridging anticoagulant therapy and the optimal time after surgery for restarting oral anticoagulants is vital to optimal patient care.
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Affiliation(s)
- Mahboob Ali
- Division of Cardiovascular Health and Disease, Department of Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML 0542, CVC, Room 4936, Cincinnati, OH, 45267-0542, USA
| | - Richard C Becker
- Division of Cardiovascular Health and Disease, Department of Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML 0542, CVC, Room 4936, Cincinnati, OH, 45267-0542, USA.
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9
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Abstract
Decisions surrounding periprocedural anticoagulation management must balance thromboembolic and procedural bleed risk. The interruption of both warfarin and DOACs requires consideration of anticoagulant pharmacokinetics, procedural bleed risk and patient characteristics. There is a diminishing role for periprocedural bridging LMWH overall and no role for bridging LMWH for the procedural interruption of DOACs. A clinical approach to perioperative DOAC management based on operative bleeding risk and renal function is safe and effective, and at present, is preferred over preprocedural DOAC levels testing. Clear communication of the anticoagulation interruption plan to both the patient and the patient's care team is essential.
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Affiliation(s)
- Joseph R Shaw
- Ottawa Blood Disease Center, Division of Hematology, The Ottawa Hospital, Box 206, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada. https://twitter.com/JRand083
| | - Eric Kaplovitch
- Department of Medicine, University Health Network, The University of Toronto, 585 University Avenue, Norman Urquhart Building, 7th Floor, Room 739, Toronto, Ontario M5G 2N2, Canada. https://twitter.com/kaplovitch
| | - James Douketis
- Department of Medicine, Division of General Internal Medicine, McMaster University, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, Ontario L4N 4A6, Canada; Department of Medicine, Division of Hematology and Thromboembolism, McMaster University, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, Ontario L4N 4A6, Canada.
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10
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Kuo HC, Liu FL, Chen JT, Cherng YG, Tam KW, Tai YH. Thromboembolic and bleeding risk of periprocedural bridging anticoagulation: A systematic review and meta-analysis. Clin Cardiol 2020; 43:441-449. [PMID: 31944351 PMCID: PMC7244304 DOI: 10.1002/clc.23336] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 01/06/2020] [Accepted: 01/08/2020] [Indexed: 12/26/2022] Open
Abstract
The risk and benefit of periprocedural heparin bridging is not completely clarified. We aimed to assess the safety and efficacy of bridging anticoagulation prior to invasive procedures or surgery. Heparin bridging was associated with lower risks of thromboembolism and bleeding compared to non‐bridging. PubMed, Ovid and Elsevier, and Cochrane Library (2000‐2016) were searched for English‐language studies. Studies comparing interrupted anticoagulation with or without bridging and continuous oral anticoagulation in patients at moderate‐to‐high thromboembolic risk before invasive procedures were included. Primary outcomes were thromboembolic events and bleeding events. Mantel‐Haenszel method and random‐effects models were used to analyze the pooled risk ratio (RR) and 95% confidence interval (CI) for thromboembolic and bleeding risks. Eighteen studies (six randomized controlled trials and 12 cohort studies) were included (N = 23 364). There was no difference in thromboembolic risk between bridged and non‐bridged patients (RR: 1.26, 95% CI: 0.61‐2.58; RCTs: RR: 0.71, 95% CI: 0.23‐2.24; cohorts: RR: 1.45, 95% CI: 0.63‐3.37). However, bridging anticoagulation was associated with higher risk of overall bleeding (RR: 2.83, 95% CI: 2.00‐4.01; RCTs: RR: 2.24, 95% CI: 0.99‐5.09; cohorts: RR: 3.09, 95% CI: 2.07‐4.62) and major bleeding (RR: 3.00, 95% CI: 1.78‐5.06; RCTs: RR: 2.48, 95% CI: 1.29‐4.76; cohorts: RR: 3.22, 95% CI: 1.65‐6.32). Bridging anticoagulation was associated with increased bleeding risk compared to non‐bridging. Thromboembolism risk was similar between two strategies. Our results do not support routine use of bridging during anticoagulation interruption.
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Affiliation(s)
- Hsien-Cheng Kuo
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Feng-Lin Liu
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Jui-Tai Chen
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yih-Giun Cherng
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ka-Wai Tam
- Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Division of General Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Center for Evidence-Based Health Care, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Ying-Hsuan Tai
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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11
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Chen AF, He X, Nirwan RS, Sridhar J, Kuriyan AE. Perioperative Management of Anticoagulants in Ocular Surgeries. Int Ophthalmol Clin 2020; 60:3-15. [PMID: 32576719 PMCID: PMC7334869 DOI: 10.1097/iio.0000000000000316] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Use of anticoagulant therapy has increased in patients presenting for ophthalmic surgery over the past decade. The decision of whether or not to discontinue anticoagulant medications prior to ophthalmic surgeries is nuanced and ultimately based on multiple factors including the type of surgery and the patient’s comorbidities and risk profile. In the setting of cataract surgery, no increased risk of bleeding with anticoagulation was observed in a large prospective study, which suggests that anticoagulation should not be interrupted for the average-risk patient on anticoagulation. In other types of ophthalmic surgery, expert opinion and studies are divided on the perioperative management of anticoagulant therapy. Preoperative thromboembolic risk stratification, intraoperative techniques to minimize bleeding, and postoperative management are also reviewed to generate more comprehensive recommendations on ophthalmic perioperative management of anticoagulation.
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Affiliation(s)
- Alexander F. Chen
- Flaum Eye Institute, University of Rochester Medical Center, Rochester, NY
| | - Xu He
- Flaum Eye Institute, University of Rochester Medical Center, Rochester, NY
| | - Rajinder S. Nirwan
- Flaum Eye Institute, University of Rochester Medical Center, Rochester, NY
| | | | - Ajay E. Kuriyan
- Flaum Eye Institute, University of Rochester Medical Center, Rochester, NY
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12
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Kampouraki E, Wynne H, Avery P, Kamali F. Validation of an algorithm to predict decline in INR following warfarin cessation in patients undergoing invasive procedures. J Thromb Thrombolysis 2019; 49:630-635. [PMID: 31848875 PMCID: PMC7182614 DOI: 10.1007/s11239-019-02017-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Patients on warfarin are required to withdraw from treatment for a fixed period (normally 5 days) prior to an invasive procedure. However, the anticoagulant effect of warfarin subsides at different rates among different patients, exposing some to increased risk of either thrombosis or bleeding. In a recent study in patients awaiting surgery, following warfarin cessation the INR declined slower over time in those with two CYP2C9 variant alleles, increasing age, weight and number of comorbidities and that INR decline was faster in those with higher maintenance INR value. Subsequently, we developed an algorithm which predicts INR decline in individual patients after 5 days of warfarin cessation. The current study validated the algorithm. An independent cohort of patients completing a short course of warfarin took part in the study. INR values for subsequent 9 days and CYP2C9 genotype were available. The predicted INR decline (INRday 1–INRday 5) was compared to the observed one (where an INR check on day 5 was unavailable, INR was estimated using a linear approximation model). There was a strong correlation between the decline in INR by day 5 and that predicted from the algorithm for the 117 patients (r = 0.949, p < 0.001). The algorithm was precise, with low degree of bias and variance of the prediction error. The algorithm can accurately predict the INR decline following warfarin cessation in individual adult patients. The use of this easily adoptable algorithm can reduce cancellation or delays of planned surgical procedures.
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Affiliation(s)
- Emmanouela Kampouraki
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Hilary Wynne
- Older People's Medicine, Freeman Hospital, Newcastle upon Tyne, UK
| | - Peter Avery
- School of Mathematics Statistics and Physics, Newcastle University, Newcastle upon Tyne, UK
| | - Farhad Kamali
- Translational and Clinical Research Institute, Newcastle University and Newcastle upon Tyne Hospitals, NHS Foundation Trust, Newcastle upon Tyne, NE1 7RU, UK.
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Abdou MM, El-Saeed RA, Bondock S. Recent advances in 4-hydroxycoumarin chemistry. Part 1: Synthesis and reactions. ARAB J CHEM 2019. [DOI: 10.1016/j.arabjc.2015.06.012] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Mays EM, Dorman DC, McKendry C, Hanel RM. A pilot study documenting increased thrombin generation following abrupt withdrawal of heparin therapy in healthy dogs. J Vet Emerg Crit Care (San Antonio) 2018; 28:518-526. [PMID: 30303616 DOI: 10.1111/vec.12778] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 04/12/2017] [Accepted: 05/24/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To document if a transient hypercoagulable state occurs in healthy dogs following abrupt cessation of unfractionated heparin (UFH) therapy. DESIGN Prospective experimental pilot study. SETTING University research facility. ANIMALS Seven adult random-source male dogs. INTERVENTION Thromboelastography (TEG) and thrombin-antithrombin (TAT) complex formation were used to assess coagulation status in healthy dogs. Seven adult research dogs received 200-300 IU/kg subcutaneous UFH every 8 hours for 4 days. A final IV bolus of 100 IU/kg was given on day 4 and the peak measured heparin concentration 1 hour later is defined as the start of heparin withdrawal (time 0). Citrated whole blood samples were collected at baseline (prior to heparin administration) and 3, 6, 12, 30, and 48 hours after UFH withdrawal. At all time points, a kaolin-activated TEG was performed and citrated plasma for measurement of TAT concentration was collected for batch analysis. Fibrinogen concentration, PCV, total plasma proteins, and platelet count were measured at baseline and 48 hours after heparin withdrawal. MEASUREMENTS AND MAIN RESULTS Compared to baseline, TAT was increased 12 hours after heparin withdrawal and returned to baseline by 30 hours. TEG clot formation time (K) was decreased 30 and 48 hours after heparin withdrawal. CONCLUSION TAT results suggest that a transient increase in thrombin generation developed 12 hours after withdrawal of UFH therapy. Though clot kinetics were rapid compared to baseline beginning 30 hours after heparin withdrawal, a return to baseline was not documented. Future studies are warranted to determine the clinical relevance of these results and to evaluate the effect of UFH withdrawal in critically ill animals.
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Affiliation(s)
- Erin M Mays
- Departments of Clinical Sciences, North Carolina State University College of Veterinary Medicine, Raleigh, NC 27695 (Mays, Daorman, Hanel), and
| | - David C Dorman
- Departments of Clinical Sciences, North Carolina State University College of Veterinary Medicine, Raleigh, NC 27695 (Mays, Daorman, Hanel), and
| | - Colleen McKendry
- Department of Statistics, NCSU Bioinformatics Research Center, NCSU College of Physical and Mathematical Sciences, Raleigh, NC, 27607 (McKendry)
| | - Rita M Hanel
- Departments of Clinical Sciences, North Carolina State University College of Veterinary Medicine, Raleigh, NC 27695 (Mays, Daorman, Hanel), and
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Ing Lorenzini K, Lloret-Linares C, Desmeules J, Samer C. Absorption des médicaments lors de syndrome du grêle court. NUTR CLIN METAB 2018. [DOI: 10.1016/j.nupar.2018.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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16
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Engelen ET, Schutgens REG, Mauser‐Bunschoten EP, van Es RJJ, van Galen KPM. Antifibrinolytic therapy for preventing oral bleeding in people on anticoagulants undergoing minor oral surgery or dental extractions. Cochrane Database Syst Rev 2018; 7:CD012293. [PMID: 29963686 PMCID: PMC6513563 DOI: 10.1002/14651858.cd012293.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Individuals on continuous treatment with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) are at increased risk of bleeding complications during and after oral or dental procedures. Anticoagulant treatment is preferably continued at the same dose, since dose reduction or discontinuation of treatment is associated with an increased risk of thromboembolism. The use of haemostatic measures during or after the procedure (or both) could enable continuation of the oral anticoagulant treatment. OBJECTIVES We aimed to assess the efficacy of antifibrinolytic agents for preventing bleeding complications in people on oral anticoagulants undergoing minor oral surgery or dental extractions. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Coagulopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews. We searched PubMed, Embase and the Cochrane Library. Additional searches were performed using ClinicalTrials.gov, the International Clinical Trials Registry Platform (ICTRP), the CINAHL database of nursing and allied health services, the open access ProQuest dissertation database, papers and reports from the American College of Clinical Pharmacy (ACCP) and abstract books from annual scientific conferences.Date of last search: 04 January 2018. SELECTION CRITERIA Randomised and quasi-randomised controlled trials in people on continuous treatment with VKAs or DOACs undergoing oral or dental procedures using antifibrinolytic agents (tranexamic acid (TXA) or epsilon aminocaproic acid) to prevent perioperative bleeding compared to no intervention or usual care with or without placebo. DATA COLLECTION AND ANALYSIS Two authors independently screened the titles and abstracts of all identified articles. Full texts were obtained from potentially relevant abstracts and two authors independently assessed these for inclusion based of the selection criteria. A third author verified trial eligibility. Two authors independently performed data extraction and risk of bias assessments using standardized forms. The quality of the evidence was assessed using GRADE. MAIN RESULTS No eligible trials in people on continuous treatment with DOACs undergoing oral or dental procedures were identified.Three randomised trials and one quasi-randomised trial (follow-up in all was seven days) in people on continuous treatment with VKAs were included with a total of 253 participants (mean age 60 years). Two trials published in 1989 and 1993 compared the antifibrinolytic agent TXA with placebo in people using VKAs. Two other trials were published in 1999 and 2015 and compared TXA with gelatin sponge and sutures, and dry gauze compression, respectively. In all included trials, those who were treated with VKAs had international normalised ratio (INR) values within the therapeutic range and TXA was applied locally, not systemically.The two trials from 1989 and 1993 comparing TXA with placebo showed a statistically significant beneficial effect regarding the number of major postoperative bleeding episodes requiring intervention, with a pooled risk difference (RD) of -0.25 (95% confidence interval (CI) -0.36 to -0.14) (128 participants) (moderate-quality evidence). For the two trials that compared TXA with either gelatin sponge and sutures or with dry gauze compression, there was no difference between the TXA and the standard care group, RD 0.02 (95% CI -0.07 to 0.11) (125 participants) (moderate-quality evidence). The combined RD of all included trials was -0.13 (95% CI -0.30 to 0.05) (moderate-quality evidence). There were no side effects of antifibrinolytic therapy that required treatment withdrawal (128 participants) (moderate-quality evidence). Despite heterogeneity between trials with respect to the different haemostatic measures used in the control groups, the trials were comparable regarding design and baseline participant characteristics.Overall, we considered the risk of bias to be low in the trials comparing TXA with placebo and moderate in the trials comparing TXA with alternative haemostatic measures. AUTHORS' CONCLUSIONS Based on the results of this Cochrane Review, there seems to be a beneficial effect of locally applied TXA in preventing oral bleeding in people on continuous treatment with VKAs undergoing minor oral surgery or dental extractions. However, the small number of identified randomised controlled trials, the relatively small number of participants included in the trials and the differences in standard therapy and treatment regimens between trials, do not allow us to conclude definite efficacy of antifibrinolytic therapy in this population.We were unable to identify any eligible trials in people on continuous treatment with DOACs undergoing oral or dental procedures. Therefore, a beneficial effect of antifibrinolytic therapy can currently only be assumed based on data from the people using VKAs.
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Affiliation(s)
- Eveline T Engelen
- University Medical Centre UtrechtPoortstraat 95UtrechtNetherlands3572HG
| | - Roger EG Schutgens
- University Medical Centre UtrechtVan Creveldkliniek / Department of HaematologyHeidelberglaan 100UtrechtNetherlands3584CX
| | - Evelien P Mauser‐Bunschoten
- University Medical Centre UtrechtVan Creveldkliniek / Department of HaematologyHeidelberglaan 100UtrechtNetherlands3584CX
| | - Robert JJ van Es
- University Medical Center UtrechtOral and Maxillofacial SurgeryHeidelberglaan 100UtrechtNetherlands3584CX
| | - Karin PM van Galen
- University Medical Centre UtrechtVan Creveldkliniek / Department of HaematologyHeidelberglaan 100UtrechtNetherlands3584CX
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Ranjbar bandforuzi S, Hadjmohammadi MR. Solvent bar microextraction using a reverse micelle containing extraction phase for the determination of warfarin from human plasma by high-performance liquid chromatography. J Chromatogr A 2017; 1496:1-8. [DOI: 10.1016/j.chroma.2017.03.037] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 03/15/2017] [Accepted: 03/17/2017] [Indexed: 11/25/2022]
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Zirlik A, Bode C. Vitamin K antagonists: relative strengths and weaknesses vs. direct oral anticoagulants for stroke prevention in patients with atrial fibrillation. J Thromb Thrombolysis 2017; 43:365-379. [PMID: 27896543 PMCID: PMC5337242 DOI: 10.1007/s11239-016-1446-0] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Vitamin K antagonists (VKAs) have been the mainstay of anticoagulation therapy for more than 50 years. VKAs are mainly used for the prevention of stroke in patients with atrial fibrillation (AF) and the treatment and secondary prevention of venous thromboembolism. In the past 5 years, four new agents-the direct factor Xa inhibitors apixaban, edoxaban and rivaroxaban and the direct thrombin inhibitor dabigatran [collectively known as direct oral anticoagulants (DOACs) or non-VKA oral anticoagulants]-have been approved for these and other indications. Despite these new treatment options, the VKA warfarin currently remains the most frequently prescribed oral anticoagulant. The availability of DOACs provides an alternative management option for patients with AF, especially when the treating physician is hesitant to prescribe a VKA owing to associated limitations, such as food and drug interactions, and concerns about bleeding complications. Currently available real-world evidence shows that DOACs have similar or improved effectiveness and safety outcomes compared with warfarin. Treatment decisions on which DOAC is best suited for which patient to maximize safety and effectiveness should take into account not only clinically relevant patient characteristics but also patient preference. This article reviews and highlights real and perceived implications of VKAs for the prevention of stroke in patients with non-valvular AF, with specific reference to their strengths and weaknesses compared with DOACs.
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Affiliation(s)
- Andreas Zirlik
- Department of Cardiology and Angiology I, University Heart Centre Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany.
| | - Christoph Bode
- Department of Cardiology and Angiology I, University Heart Centre Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
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Zhang MS, Houtman JCD. Human Serum Albumin (HSA) Suppresses the Effects of Glycerol Monolaurate (GML) on Human T Cell Activation and Function. PLoS One 2016; 11:e0165083. [PMID: 27764189 PMCID: PMC5072635 DOI: 10.1371/journal.pone.0165083] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 10/05/2016] [Indexed: 01/30/2023] Open
Abstract
Glycerol monolaurate (GML) is a monoglyceride with well characterized anti-microbial properties. Because of these properties, GML is widely used in food, cosmetics, and personal care products and currently being tested as a therapeutic for menstrual associated toxic shock syndrome, superficial wound infections, and HIV transmission. Recently, we have described that GML potently suppresses select T cell receptor (TCR)-induced signaling events, leading to reduced human T cell effector functions. However, how soluble host factors present in the blood and at sites of infection affect GML-mediated human T cell suppression is unknown. In this study, we have characterized how human serum albumin (HSA) affects GML-induced inhibition of human T cells. We found that HSA and other serum albumins bind to 12 carbon acyl side chain of GML at low micromolar affinities and restores the TCR-induced formation of LAT, PLC-γ1, and AKT microclusters at the plasma membrane. Additionally, HSA reverses GML mediated inhibition of AKT phosphorylation and partially restores cytokine production in GML treated cells. Our data reveal that HSA, one of the most abundant proteins in the human serum and at sites of infections, potently reverses the suppression of human T cells by GML. This suggests that GML-driven human T cell suppression depends upon the local tissue environment, with albumin concentration being a major determinant of GML function.
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Affiliation(s)
- Michael S. Zhang
- Department of Microbiology, Carver College of Medicine, University of Iowa, Iowa City, Iowa 52242, United States of America
| | - Jon C. D. Houtman
- Department of Microbiology, Carver College of Medicine, University of Iowa, Iowa City, Iowa 52242, United States of America
- * E-mail:
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20
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Dunn AS, Wisnivesky J, Ho W, Moore C, McGinn T, Sacks HS. Perioperative Management of Patients on Oral Anticoagulants: A Decision Analysis. Med Decis Making 2016; 25:387-97. [PMID: 16061890 DOI: 10.1177/0272989x05278432] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background . To better inform clinicians on the optimal management of patients on oral anticoagulation who need to undergo surgery or invasive procedures, the authors performed a decision analysis examining whether a perioperative aggressive or minimalist strategy results in greater quality-adjusted survival. Methods . A decision analysis model was created comparing withholding warfarin (minimalist strategy) to withholding warfarin and administering treatment-dose subcutaneous low-molecular-weight heparin (LMWH) or intravenous heparin perioperatively (aggressive strategy). The base-case analysis examined a hypothetical 60-year-old hypertensive individual with mechanical aortic valve replacement undergoing major abdominal surgery. A probabilistic sensitivity analysis was performed using a Monte Carlo simulation with quality-adjusted life expectancy (QALE) as the outcome. Secondary analyses examined patients with a mechanical mitral valve and atrial fibrillation. Sensitivity analyses were performed for each variable. Results . Under the base-case scenario, the minimalist strategy was preferred for 78% of trials in the Monte Carlo simulation, with a mean benefit of 0.003 years (95% confidence interval, -0.005 years to 0.011 years). Sensitivity analyses based on point estimates indicate that the aggressive strategy is preferred when the annual stroke rate is >5.6% or the increase in postoperative major bleeding induced by heparin is <2.0%; however, the benefit is small over the range of plausible values. Conclusions . For most patients with a mechanical aortic valve or atrial fibrillation undergoing major surgery, a minimalist strategy of simply withholding oral anticoagulation provides similar QALE as an aggressive strategy of administering perioperative subcutaneous LMWH or intravenous heparin. The aggressive therapy provides greater QALE for patients at higher risk of stroke (e.g., mechanical mitral valves), although the benefit is small.
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Affiliation(s)
- Andrew S Dunn
- Division of General Medicine, Department of Medicine, Mount Sinai School of Medicine, New York, NY 10029, USA.
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21
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Engelen ET, Schutgens REG, Mauser-Bunschoten EP, van Es RJJ, van Galen KPM. Antifibrinolytic therapy for preventing oral bleeding in people on anticoagulants undergoing oral or dental procedures. Hippokratia 2016. [DOI: 10.1002/14651858.cd012293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Eveline T Engelen
- University Medical Centre Utrecht; Poortstraat 95 Utrecht Netherlands 3572HG
| | - Roger EG Schutgens
- University Medical Centre Utrecht; Van Creveldkliniek / Department of Haematology; Heidelberglaan 100 Utrecht Netherlands 3584CX
| | - Evelien P Mauser-Bunschoten
- University Medical Centre Utrecht; Van Creveldkliniek / Department of Haematology; Heidelberglaan 100 Utrecht Netherlands 3584CX
| | - Robert JJ van Es
- University Medical Center Utrecht; Oral and Maxillofacial Surgery; Heidelberglaan 100 Utrecht Netherlands 3584CX
| | - Karin PM van Galen
- University Medical Centre Utrecht; Van Creveldkliniek / Department of Haematology; Heidelberglaan 100 Utrecht Netherlands 3584CX
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22
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Martinez C, Katholing A, Folkerts K, Cohen AT. Risk of recurrent venous thromboembolism after discontinuation of vitamin K antagonist treatment: a nested case-control study. J Thromb Haemost 2016; 14:1374-83. [PMID: 27079164 DOI: 10.1111/jth.13337] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Indexed: 01/22/2023]
Abstract
UNLABELLED Essentials Vitamin K antagonists (VKA) in venous thromboembolism (VTE) lower the risk of recurrences. 41 841 VKA-treated VTE patients had 1242 recurrent VTEs on therapy or early after cessation. An increased risk of recurrence was found in the first 120 days after VKA cessation. Patient education for the early detection of recurrent VTE after VKA cessation is recommended. SUMMARY Background The standard treatment for venous thromboembolism (VTE) and the prevention of recurrent VTE (rVTE) consists of anticoagulant therapy. The optimal duration of anticoagulation depends on the presence of risk factors for rVTE. Objectives To estimate the risk of rVTE in association with time since discontinuation of vitamin K antagonist (VKA) treatment. Methods From the UK Clinical Practice Research Datalink with linked information on hospitalization and cause of death, a cohort of patients with a first VTE receiving initial VKA treatment between 2001 and 2013 was formed. With a nested case-control approach, patients with incident rVTE (cases) were matched to patients with VTE but without rVTE (controls). Adjusted rate ratios (RRs) of rVTE associated with time since VKA discontinuation relative to current VKA use were estimated from conditional logistic regression. Results The VTE cohort comprised 41 841 patients with 1242 rVTEs and 6205 matched controls. The RR of rVTE was increased within 60 days following VKA discontinuation (RR 2.23, 95% confidence interval [CI] 1.71-2.91) and within 61-120 days following VKA discontinuation (RR 1.49, 95% CI 1.08-2.05) relative to current VKA use. The increased RR corresponded to excess incidence rates of 6.72 (95% CI 3.90-10.06) rVTE cases per 100 person-years within 60 days, and of 2.68 (95% CI 0.42-5.58) rVTE cases per 100 person-years within 61-120 days after VKA discontinuation. Conclusions VKA discontinuation results in a transient increased risk of rVTE, which peaks within 60 days and lasts for up to 120 days after VKA discontinuation. Specific patient education for increased vigilance for signs and symptoms of recurrences is recommended in this period.
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Affiliation(s)
- C Martinez
- Institute for Epidemiology, Statistics and Informatics, Frankfurt, Germany
| | - A Katholing
- Institute for Epidemiology, Statistics and Informatics, Frankfurt, Germany
| | - K Folkerts
- Bayer Pharma AG, Global Market Access GHEOR GM, Wuppertal, Germany
| | - A T Cohen
- Department of Haematological Medicine, Guys and St Thomas' Hospitals, King's College Hospital, London, UK
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Marzo M, Ciccarelli R, Di Iorio P, Giuliani P, Caciagli F, Marzo A. Synergic development of pharmacokinetics and bioanalytical methods as support of pharmaceutical research. Int J Immunopathol Pharmacol 2016; 29:168-79. [PMID: 26684641 PMCID: PMC5806721 DOI: 10.1177/0394632015589531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 05/05/2015] [Indexed: 11/15/2022] Open
Abstract
The development of pharmacokinetics led this science to achieve a relevant role in the investigation of new chemical entities for therapeutic application, and has allowed a series of new useful realizations of out of patent drugs like prolonged release and delayed release formulations, therapeutic delivery system (TDS) for drugs to be active in systemic circulation avoiding the first pass effect, orodispersible and effervescent formulations, intramuscular and subcutaneous depot formulations acting over a long period, oral inhalatory systems, and drug association at fixed dose. The above applications had pharmacokinetics as protagonist and have required the support from bioanalytical methods to assay drug concentrations, even in pg·mL(-1) of plasma, that really have paralleled the synergic development of pharmacokinetics.The complexity of the above realizations required specific guidelines from the regulatory authorities, mainly the US FDA and EU EMA, which have normalized and, in most cases, simplified the above applications admitting some waivers of in vivo bioequivalence.However, this review highlights some critical points, not yet focused on by operating guidelines, which need to be clarified by regulatory authorities. One of the most relevant issues is about the planning and conducting bioavailability and bioequivalence trials with endogenous substances, that possess own homeostatic equilibria with fluctuations, in some cases with specific rhythms, like melatonin and female sex hormones. The baseline subtraction required by guidelines to define the net contribute to the exogenous absorbed drug in most cases is a non-solvable problem.
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Affiliation(s)
- M Marzo
- Department of Medical, Oral e Biotechnological Sciences, "G. d'Annunzio" University of Chieti-Pescara, Via dei Vestini 31, I-66013, Chieti, Italy
| | - R Ciccarelli
- Department of Medical, Oral e Biotechnological Sciences, "G. d'Annunzio" University of Chieti-Pescara, Via dei Vestini 31, I-66013, Chieti, Italy
| | - P Di Iorio
- Department of Medical, Oral e Biotechnological Sciences, "G. d'Annunzio" University of Chieti-Pescara, Via dei Vestini 31, I-66013, Chieti, Italy
| | - P Giuliani
- Department of Medical, Oral e Biotechnological Sciences, "G. d'Annunzio" University of Chieti-Pescara, Via dei Vestini 31, I-66013, Chieti, Italy
| | - F Caciagli
- Department of Medical, Oral e Biotechnological Sciences, "G. d'Annunzio" University of Chieti-Pescara, Via dei Vestini 31, I-66013, Chieti, Italy
| | - A Marzo
- Department of Medical, Oral e Biotechnological Sciences, "G. d'Annunzio" University of Chieti-Pescara, Via dei Vestini 31, I-66013, Chieti, Italy
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Rose AJ, Allen AL, Minichello T. A Call to Reduce the Use of Bridging Anticoagulation. Circ Cardiovasc Qual Outcomes 2016; 9:64-7. [DOI: 10.1161/circoutcomes.115.002430] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 12/07/2015] [Indexed: 01/22/2023]
Affiliation(s)
- Adam J. Rose
- From the Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, MA (A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (A.J.R.); Department of Pharmacy, VA Salt Lake City Healthcare System, UT (A.L.A.); Department of Medicine, San Francisco VA Medical Center, CA (T.M.); and Department of Medicine, University of California San Francisco School of Medicine (T.M.)
| | - Arthur L. Allen
- From the Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, MA (A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (A.J.R.); Department of Pharmacy, VA Salt Lake City Healthcare System, UT (A.L.A.); Department of Medicine, San Francisco VA Medical Center, CA (T.M.); and Department of Medicine, University of California San Francisco School of Medicine (T.M.)
| | - Tracy Minichello
- From the Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, MA (A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (A.J.R.); Department of Pharmacy, VA Salt Lake City Healthcare System, UT (A.L.A.); Department of Medicine, San Francisco VA Medical Center, CA (T.M.); and Department of Medicine, University of California San Francisco School of Medicine (T.M.)
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Shen C, Huang X, Li J, Zhang P, Li L, Zhang W, Hu T, Pappoe F, Huang J, Tang H. Pharmacokinetic and pharmacodynamic interactions of aspirin with warfarin in beagle dogs. Xenobiotica 2015; 46:530-41. [PMID: 26548565 DOI: 10.3109/00498254.2015.1096979] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
1. Warfarin and aspirin are widely used in a wide spectrum of thromboembolic and atherothrombotic diseases. Despite the potential efficacy of warfarin-aspirin therapy, the safety and side effect of combined therapy remains unclear. 2. The aim of this study was to investigate the pharmacokinetic and pharmacodynamic interactions between warfarin and aspirin in beagles after single and multiple doses. 3. Coadministration of aspirin had no significant effects on the area under the plasma concentration time curve (AUC(0-t)) and maximum plasma concentration (Cmax) of R- and S-warfarin after a single dose of warfarin, but significantly increase the AUC(0-t) and Cmax and dramatically decrease the clearance (CL) of R- and S-warfarin after multiple dose of warfarin. Accordingly, there was a slight increase in the AUEC(0-t) and Emax of activated partial thromboplastin time (aPTT), prothrombin time (PT) and international normalized ratio (INR) after multiple dose of warfarin. 4. Coadministration of warfarin had no markedly effects on the AUC(0-t) and Cmax of aspirin and its metabolite salicylic acid after single or multiple dose of aspirin. Meanwhile, the AUEC(0-t) and Emax of inhibition of platelet aggregation (IPA) were not significantly affected by warfarin. 5. Our animal study indicated that coadministration of aspirin with warfarin can cause significant pharmacokinetic and pharmacodynamic drug-drug interactions in beagles. However, more studies are urgently needed to assess related information of warfarin-aspirin drug interactions in healthy volunteers or patients.
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Affiliation(s)
- Chenlin Shen
- a Department of Basic and Clinical Pharmacology , School of Pharmacy, Anhui Medical University , Hefei , Anhui , China .,b Institute for Liver Diseases of Anhui Medical University (AMU), Anhui Key Laboratory of Bioactivity of Natural Products, School of Pharmacy, Anhui Medical University , Hefei , Anhui , China
| | - Xiaohui Huang
- a Department of Basic and Clinical Pharmacology , School of Pharmacy, Anhui Medical University , Hefei , Anhui , China
| | - Jun Li
- b Institute for Liver Diseases of Anhui Medical University (AMU), Anhui Key Laboratory of Bioactivity of Natural Products, School of Pharmacy, Anhui Medical University , Hefei , Anhui , China
| | - Ping Zhang
- a Department of Basic and Clinical Pharmacology , School of Pharmacy, Anhui Medical University , Hefei , Anhui , China
| | - Lin Li
- a Department of Basic and Clinical Pharmacology , School of Pharmacy, Anhui Medical University , Hefei , Anhui , China
| | - Wei Zhang
- a Department of Basic and Clinical Pharmacology , School of Pharmacy, Anhui Medical University , Hefei , Anhui , China
| | - Tingting Hu
- b Institute for Liver Diseases of Anhui Medical University (AMU), Anhui Key Laboratory of Bioactivity of Natural Products, School of Pharmacy, Anhui Medical University , Hefei , Anhui , China
| | - Faustina Pappoe
- c Department of Parasitology , Provincial Laboratory of Microbiology & Parasitology and the Key Laboratory of Zoonoses Anhui, Anhui Medical University , Hefei , Anhui , China
| | - Jihan Huang
- d Center for Drug Clinical Research, Shanghai University of Chinese Medicine , Shanghai , China , and
| | - Haiqin Tang
- e Department of Cardiology , the First Affiliated Hospital of Anhui Medical University , Hefei , Anhui , China
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Ogawa Y, Tominaga T. Sellar and parasellar tumor removal without discontinuing antithrombotic therapy. J Neurosurg 2015; 123:794-8. [DOI: 10.3171/2014.9.jns141088] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECT
Treatment with dual antiplatelet agents associated with coronary stenting procedures and long-term anticoagulant therapy is increasingly common, but the treatment carries risks during surgical procedures. Evidence-based recommendations have proposed discontinuation of antithrombotic treatment or introduction of bridging therapy in some procedures less invasive and with lower risk of bleeding. However, neurosurgical procedures without discontinuation of antithrombotic treatment and perioperative management have received little investigation.
METHODS
Between October 2008 and January 2014, 15 consecutive patients (11 males and 4 females; age range 51–75 years [mean 68.2 years]), with sellar and parasellar tumors were treated through the transsphenoidal approach without discontinuation of antithrombotic therapy. Clinical data were compared with another 15 patients, who underwent transsphenoidal surgeries without preoperative antithrombotic therapy.
RESULTS
Gross-total removal of the tumor or total aspiration of the content of Rathke's cleft cyst was achieved in 13 patients, and subtotal removal was achieved in 1 patient with a small remnant in the cavernous sinus. No difference was found in intraoperative bleeding between the antithrombotic agent group and the control group (mean 255 ml vs 215 ml, Mann-Whitney U-test, p = 0.547), and no patient required transfusion. No difference was found in operation time between the antithrombotic agent group and the control group (167.8 minutes vs 150.0 minutes, Mann-Whitney U-test, p = 0.262). All patients were discharged on postoperative Day 12 without neurological deficits.
CONCLUSIONS
The present study suggests that discontinuation of antithrombotic therapy may be unnecessary before the typical transsphenoidal surgery. Large randomized clinical trials at multiple centers are needed to confirm these findings.
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Affiliation(s)
| | - Teiji Tominaga
- 2Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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Douketis JD, Spyropoulos AC, Kaatz S, Becker RC, Caprini JA, Dunn AS, Garcia DA, Jacobson A, Jaffer AK, Kong DF, Schulman S, Turpie AGG, Hasselblad V, Ortel TL. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med 2015; 373:823-33. [PMID: 26095867 PMCID: PMC4931686 DOI: 10.1056/nejmoa1501035] [Citation(s) in RCA: 706] [Impact Index Per Article: 78.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND It is uncertain whether bridging anticoagulation is necessary for patients with atrial fibrillation who need an interruption in warfarin treatment for an elective operation or other elective invasive procedure. We hypothesized that forgoing bridging anticoagulation would be noninferior to bridging with low-molecular-weight heparin for the prevention of perioperative arterial thromboembolism and would be superior to bridging with respect to major bleeding. METHODS We performed a randomized, double-blind, placebo-controlled trial in which, after perioperative interruption of warfarin therapy, patients were randomly assigned to receive bridging anticoagulation therapy with low-molecular-weight heparin (100 IU of dalteparin per kilogram of body weight) or matching placebo administered subcutaneously twice daily, from 3 days before the procedure until 24 hours before the procedure and then for 5 to 10 days after the procedure. Warfarin treatment was stopped 5 days before the procedure and was resumed within 24 hours after the procedure. Follow-up of patients continued for 30 days after the procedure. The primary outcomes were arterial thromboembolism (stroke, systemic embolism, or transient ischemic attack) and major bleeding. RESULTS In total, 1884 patients were enrolled, with 950 assigned to receive no bridging therapy and 934 assigned to receive bridging therapy. The incidence of arterial thromboembolism was 0.4% in the no-bridging group and 0.3% in the bridging group (risk difference, 0.1 percentage points; 95% confidence interval [CI], -0.6 to 0.8; P=0.01 for noninferiority). The incidence of major bleeding was 1.3% in the no-bridging group and 3.2% in the bridging group (relative risk, 0.41; 95% CI, 0.20 to 0.78; P=0.005 for superiority). CONCLUSIONS In patients with atrial fibrillation who had warfarin treatment interrupted for an elective operation or other elective invasive procedure, forgoing bridging anticoagulation was noninferior to perioperative bridging with low-molecular-weight heparin for the prevention of arterial thromboembolism and decreased the risk of major bleeding. (Funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health; BRIDGE ClinicalTrials.gov number, NCT00786474.).
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Affiliation(s)
- James D Douketis
- From St. Joseph's Healthcare Hamilton (J.D.D.) and the Department of Medicine (J.D.D.) and Hamilton Health Science Center (S.S., A.G.G.T.), McMaster University, Hamilton, ON, Canada; Hofstra North Shore-Long Island Jewish School of Medicine, Manhasset (A.C.S.), and Mount Sinai Medical Center, New York (A.S.D.) - both in New York; Hurley Medical Center, Flint, MI (S.K.); University of Cincinnati College of Medicine, Cincinnati (R.C.B.); NorthShore University HealthSystem, Evanston (J.A.C.), and Rush University Medical Center, Chicago (A.K.J.) - both in Illinois; University of Washington Medical Center, Seattle (D.A.G.); Veterans Affairs Loma Linda Healthcare System, Loma Linda, CA (A.J.); and Duke Clinical Research Institute (D.F.K., V.H.) and Department of Medicine (T.L.O.), Duke University Medical Center, Durham, NC
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Zaca V, Marcucci R, Parodi G, Limbruno U, Notarstefano P, Pieragnoli P, Di Cori A, Bongiorni MG, Casolo G. Management of antithrombotic therapy in patients undergoing electrophysiological device surgery. Europace 2015; 17:840-54. [DOI: 10.1093/europace/euu357] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 11/13/2014] [Indexed: 11/14/2022] Open
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Deitelzweig S. Practical considerations in the use of novel oral anticoagulants for stroke prevention in nonvalvular atrial fibrillation. Cardiovasc Ther 2014; 32:74-81. [PMID: 24119252 DOI: 10.1111/1755-5922.12048] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Atrial fibrillation (AF) is a highly prevalent cardiac arrhythmia associated with an increased risk of stroke. The role of anticoagulation therapy in the prevention of thrombosis and stroke is of critical importance for patients with AF. Limitations with vitamin K antagonists (VKAs), the current standard of care, have led to the development of novel oral anticoagulants (NOACs) that target either thrombin (dabigatran etexilate) or activated factor X (rivaroxaban, apixaban, and edoxaban). In comparison with traditional VKAs such as warfarin, these NOACs offer several pharmacologic advantages, including rapid onset of action, no significant food interactions, low potential for drug-drug interactions, and no requirement for routine coagulation monitoring. Completed phase-III clinical trials have demonstrated the therapeutic potential of dabigatran, rivaroxaban, and apixaban in comparison with warfarin for stroke prevention in patients with nonvalvular AF (NVAF). While the future utility of NOACs in preventing stroke in patients with NVAF looks promising, several practical issues, including the current lack of a reversal strategy and use of these agents in older patients with renal dysfunction, must be considered. Clinician and patient understanding of such issues will be important for the safe and effective use of NOACs.
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Affiliation(s)
- Steven Deitelzweig
- Ochsner Clinic Foundation, New Orleans, LA, USA; Tulane University School of Medicine, New Orleans, LA, USA
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Baker NC, O'Connell EW, Htun WW, Sun H, Green SM, Skelding KA, Blankenship JC, Scott TD, Berger PB. Safety of coronary angiography and percutaneous coronary intervention via the radial versus femoral route in patients on uninterrupted oral anticoagulation with warfarin. Am Heart J 2014; 168:537-44. [PMID: 25262264 DOI: 10.1016/j.ahj.2014.06.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 06/28/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate access site and other bleeding complications associated with radial versus femoral access in patients receiving oral anticoagulation (OAC) with warfarin. BACKGROUND Patients receiving OAC with warfarin undergoing coronary angiography and percutaneous coronary intervention (PCI) may have OAC continued despite the risk of bleeding. To what extent arterial access site impacts bleeding in such patients is not well studied. METHODS Over 6 years, we identified 255 consecutive patients in whom warfarin was continued who underwent coronary angiography with an international normalized ratio >1.8. A total of 97 patients also underwent PCI at the same setting (27% femoral vs 73% radial). The primary outcome was Bleeding Academic Research Consortium bleeds; a secondary end point was frequency of access site complications in the 72 hours post-PCI. Complications were evaluated based on the initial access site attempted. RESULTS Minimal baseline clinical characteristics differences existed between the groups. International normalized ratio was significantly higher in the radial group (2.42 ± 0.67 vs 2.24 ± 0.49, P = .02). Bivalirudin use was greater during radial PCI than femoral (76% vs 42%, P < .05), whereas unfractionated heparin alone was greater during femoral PCI than radial (46% vs 18%, P < .05). No significant difference was seen in the primary end point between femoral (2.8%) and radial (1.6%, P = .54) during coronary angiography alone. However, PCI via the femoral artery had significantly more Bleeding Academic Research Consortium bleeding (19.2% vs 1.4%, P = .005) and transfusions (15% vs 0%, P = .004) than via the radial artery. Patients who underwent PCI using radial access were less likely to have any vascular or bleeding complications (1% vs 23%, P = .001). CONCLUSIONS Patients who underwent coronary angiography during uninterrupted OAC had similar bleeding rates regardless of access site. However, when PCI was performed, radial access was associated with fewer bleeding and vascular complications than the femoral approach. CONDENSED ABSTRACT We retrospectively identified 255 consecutive patients on warfarin who underwent coronary angiography, 97 of whom underwent a percutaneous coronary intervention. The data reveal a reduction in Bleeding Academic Research Consortium bleeds (1.6% vs 8.1%, P = .02) with radial versus femoral access. The radial approach was associated with an overall lower rate of any vascular or bleeding complication than the femoral approach during percutaneous coronary intervention (1% vs 23%, P = .001).
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Affiliation(s)
- Nevin C Baker
- Department of Cardiology, Geisinger Medical Center, Danville, PA
| | - Erik W O'Connell
- Department of General Internal Medicine, Geisinger Medical Center, Danville, PA
| | - Wah Wah Htun
- Department of Cardiology, Geisinger Medical Center, Danville, PA
| | - Haiyan Sun
- Center for Health Research, Geisinger Medical Center, Danville, PA
| | - Sandy M Green
- Department of Cardiology, Geisinger Medical Center, Danville, PA
| | | | | | - Thomas D Scott
- Department of Cardiology, Geisinger Medical Center, Danville, PA
| | - Peter B Berger
- Department of Cardiology, Geisinger Medical Center, Danville, PA; Cardiovascular Center for Clinical Research, Geisinger Medical Center, Danville, PA.
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Qureshi W, Mittal C, Patsias I, Garikapati K, Kuchipudi A, Cheema G, Elbatta M, Alirhayim Z, Khalid F. Restarting anticoagulation and outcomes after major gastrointestinal bleeding in atrial fibrillation. Am J Cardiol 2014; 113:662-8. [PMID: 24355310 DOI: 10.1016/j.amjcard.2013.10.044] [Citation(s) in RCA: 146] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Revised: 10/24/2013] [Accepted: 10/24/2013] [Indexed: 02/08/2023]
Abstract
Data regarding the outcomes of restarting anticoagulation in patients who develop gastrointestinal bleeding (GIB) while anticoagulated are sparse. We hypothesized that restarting anticoagulation in these patients is associated with better outcomes. This is a retrospective cohort study that enrolled subjects who developed GIB while on anticoagulation from 2005 to 2010. Atrial fibrillation was defined by history and electrocardiography on presentation. GIB was defined as a decrease in hemoglobin by 2 g, visible bleeding, or positive endoscopic evaluation. Time-to-event adjusted analyses were performed to find an association of restarting warfarin and recurrent GIB, arterial thromboembolism, and mortality. Stratified analysis by duration of interruption of warfarin was also performed. Overall, 1,329 patients (mean age 76 years, women 45%) developed major GIB. Warfarin was restarted in 653 cases (49.1%). Restarting warfarin was associated with decreased thromboembolism (hazard ratio [HR] 1.18, 95% confidence interval [CI] 0.75 to 1.84, p = 0.47) [corrected] and reduced mortality (HR 0.67, 95% CI 0.56 to 0.81, p <0.0001) but not recurrent GIB (HR 1.18, 95% CI 0.94 to 1.10, p = 0.47). When the outcomes were stratified by duration of warfarin interruption, restarting warfarin after 7 days was not associated with increased risk of GIB but was associated with decreased risk of mortality and thromboembolism compared with resuming after 30 days of interruption. Decision to restart warfarin after an episode of major GIB is associated with improved survival and decreased thromboembolism without increased risk of GIB after 7 days of interruption.
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Abstract
OPINION STATEMENT Numerous risk factors for perioperative stroke have been identified and many are modifiable. Surgical patients with a history of cerebrovascular disease should be evaluated by a neurologist. Cardiac and cerebrovascular testing is critical in identifying patients at high risk for perioperative stroke. The identification and treatment of carotid disease in the context of upcoming surgery has been a source of controversy. Routine carotid revascularization performed with coronary artery bypass graft (CABG) surgery for incidentally discovered carotid stenosis is not recommended. Prior to aortic manipulation during CABG, epiaortic ultrasound should be performed to identify aortic atheromatous plaques. If possible, preoperative aspirin, beta blocker, statin, and angiotensin converting-enzyme (ACE) inhibitor therapy should be continued in the perioperative period. Patients who are prescribed anticoagulation at high risk of thromboembolism should receive bridging anticoagulation during the perioperative period. The identification and prevention of postoperative atrial fibrillation (AF) is central to stroke prevention. CABG patients should be initiated on beta blockade +/- amiodarone to prevent postoperative AF. Many practitioners have been traditionally nihilistic towards acute perioperative stroke treatment. Given the narrow therapeutic window of treatment options, candidacy is dependent on timely recognition. Intravenous and endovascular thrombolysis/therapies are viable options in selected patients under the guidance and expertise of a neurologist. This article will present the epidemiology of perioperative stroke, the pathophysiology, risk assessment and stratification for common surgeries. The article will additionally focus on treatment options including modifiable risk factor reduction and the perioperative management of medications.
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Li Q, Yang WY, Qu LL, Qi HY, Huang Y, Zhang Z. Interaction of Warfarin with Human Serum Albumin and Effect of Ferulic Acid on the Binding. JOURNAL OF SPECTROSCOPY 2014; 2014:1-7. [DOI: 10.1155/2014/834501] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
Angelica sinensis(Oliv.) Diels combined treatment with warfarin would increase the risk of bleeding. Ferulic acid is an abundant hydroxycinnamic acid inA. sinensisand warfarin is the most widely used oral anticoagulant. The studies on supermolecular interaction of warfarin with human serum albumin (HSA) and the influence of ferulic acid on the binding would contribute to the understanding of the metabolic processes of warfarin and the effect of ferulic acid. We focus on investigating the effect of warfarin on fluorescence spectrum of human serum albumin (HSA), fluorescence quenching mechanism, binding constant, Hill coefficient, binding mode, and the effect of different ferulic acid concentrations on the binding. Warfarin quenched the intrinsic fluorescence of HSA mainly by static quenching. Accession of ferulic acid reduced the binding of HSA-warfarin. By decreasing binding constant and the Hill coefficient of warfarin with HSA, ferulic acid could improve the plasma concentration of free warfarin, which would increase the risk of bleeding. Warfarin’s free concentration increased at least 50% under the condition of simulated human body. The results indicated thatA. sinensiscombined treatment with warfarin would increase the risk of bleeding. And the results provide an important theoretical support for warfarin used as oral anticoagulant.
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Affiliation(s)
- Qiang Li
- Heart Center, The First Hospital of Lanzhou University, Lanzhou, Gansu 730000, China
- The First Clinical Medical College of Lanzhou University, Lanzhou, Gansu 730000, China
| | - Wen-yue Yang
- Pharmaceutical College, Hebei Medical University, Shijiazhuang 050017, China
| | - Ling-ling Qu
- Pharmaceutical College, Hebei Medical University, Shijiazhuang 050017, China
| | - Huan-Yang Qi
- Lanzhou Institute of Chemical Physics, Chinese Academy of Sciences, Lanzhou, Gansu 730000, China
| | - Yun Huang
- Pharmaceutical College, Hebei Medical University, Shijiazhuang 050017, China
| | - Zheng Zhang
- Heart Center, The First Hospital of Lanzhou University, Lanzhou, Gansu 730000, China
- The First Clinical Medical College of Lanzhou University, Lanzhou, Gansu 730000, China
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YOKOTANI K, NAKANISHI T, CHIBA T, SATO Y, UMEGAKI K. Glucosamine and Chondroitin Sulfate do not Enhance Anticoagulation Activity of Warfarin in Mice in vivo. Food Hygiene and Safety Science (Shokuhin Eiseigaku Zasshi) 2014; 55:183-7. [DOI: 10.3358/shokueishi.55.183] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Sairaku A, Yoshida Y, Hirayama H, Nakano Y, Kihara Y. Periprocedural coagulability in patients undergoing ablation of atrial fibrillation: lessons from a periablation anticoagulation strategy of a brief withdrawal of warfarin without heparin bridging. J Thromb Thrombolysis 2013; 37:393-9. [DOI: 10.1007/s11239-013-0982-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
Arterial thrombosis is the leading causes of morbidity and mortality worldwide, whereas venous thrombosis is the most common preventable cause of hospital death. In either case, venous and arterial thrombosis should be considered autonomous entities, with only minor overlaps in terms of risk factors, predisposing conditions and pathogenesis. Besides the widespread perception of embolization originating from low-pressure venous system and triggering ischemic stroke or peripheral arterial occlusion, "paradoxical" thrombosis might also develop or occur within clinical or biological circumstances where the blood should be less predisposed to clot, and wherein this risk is mostly unpredictable or overlooked. In this article we review epidemiological evidence and potential pathogenetic mechanisms of paradoxical thrombosis developing during antithrombotic therapy with vitamin K antagonists and heparin (i.e. heparin-induced thrombocytopenia), or antiplatelet agents such as aspirin, glycoprotein IIb/IIIa inhibitors or clopidogrel, and mostly attributable to direct effect of the agent.
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Factor VII deficiency, masked by warfarin therapy, as a cause of bleeding after cardiovascular intervention. Cardiovasc Intervent Radiol 2012. [PMID: 23188558 DOI: 10.1007/s00270-012-0521-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Xiang C, Li DW, Qi ZD, Jiang FL, Ge YS, Liu Y. Synthesis of F16 conjugated with 5-fluorouracil and biophysical investigation of its interaction with bovine serum albumin by a spectroscopic and molecular modeling approach. LUMINESCENCE 2012; 28:865-72. [PMID: 23161820 DOI: 10.1002/bio.2447] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Revised: 08/16/2012] [Accepted: 09/09/2012] [Indexed: 11/10/2022]
Abstract
5-Fluorouracil (5-FU) has been widely used as a chemotherapy agent in the treatment of many types of solid tumors. Investigation of its antimetabolites led to the development of an entire class of fluorinated pyrimidines. However, the toxicity profile associated with 5-FU is significant and includes diarrhea, mucositis, hand-foot syndrome and myelosuppression. In aiming at reducing of the side effects of 5-FU, we have designed and synthesized delocalized lipophilic cations (DLCs) as a vehicle for the delivery of 5-FU. DLCs accumulate selectively in the mitochondria of cancer cells because of the high mitochondrial transmembrane potential (ΔΨm). Many DLCs exhibited anti-cancer efficacy and were explored as potential anti-cancer drugs based on their selective accumulation in the mitochondria of cancer cells. F16, the DLC we used as a vehicle, is a small molecule that selectively inhibits tumor cell growth and dissipates mitochondrial membrane potential. The binding of the conjugate F16-5-FU to bovine serum albumin (BSA) was investigated using spectroscopic and molecular modeling approaches. Fluorescence quenching constants were determined using the Stern-Volmer equation to provide a measure of the binding affinity between F16-5-FU and BSA. The activation energy of the interaction between F16-5-FU and BSA was calculated and the unusually high value was discussed in terms of the special structural block indicated by the molecular modeling approach. Molecular modeling showed that F16-5-FU binds to human serum albumin in site II, which is consistent with the results of site-competitive replacement experiments. It is suggested that hydrophobic and polar forces played important roles in the binding reaction, in accordance with the results of thermodynamic experiments.
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Affiliation(s)
- Chen Xiang
- State Key Laboratory of Virology & Key Laboratory of Analytical Chemistry for Biology and Medicine (MOE), College of Chemistry and Molecular Sciences, Wuhan University, Wuhan, 430072, People's Republic of China
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Abstract
The ability to recognize, manage, and, most importantly, prevent hemorrhagic complications is critical to performing dermatologic procedures that have safe and high quality outcomes. This article reviews the preoperative, intraoperative, and postoperative factors and patient dynamics that are central to preventing such an adverse outcome. Specifically, the role that anticoagulants and anti-platelet agents, hypertension, and other medical conditions play in the development of postoperative hemorrhage are discussed. In addition, this article provides practical guidelines on managing bleeding during and after surgery.
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Yokotani K, Chiba T, Sato Y, Taki Y, Yamada S, Shinozuka K, Murata M, Umegaki K. Hepatic cytochrome P450 mediates interaction between warfarin and Coleus forskohlii extract in vivo and in vitro. J Pharm Pharmacol 2012; 64:1793-801. [DOI: 10.1111/j.2042-7158.2012.01563.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Abstract
Objectives
This study aimed to determine whether Coleus forskohlii extract (CFE) influences the anticoagulant action of warfarin in mice in vivo and its relationship with hepatic cytochrome P450 (CYP).
Methods
Mice were fed various doses of CFE standardised with 10% forskolin in a normal diet for one week, or in protein diets containing 7% and 20% casein (low and normal) for four weeks. They were then administered with warfarin by gavage on the last two days of the treatment regimen, and blood coagulation parameters, as well as hepatic CYP, were analysed at 18 h after the last dose. Direct interaction between CFE and forskolin with CYP2C was evaluated in vitro.
Key findings
CFE dose dependently increased hepatic total CYP content and S-warfarin 7-hydroxylase activity at a dietary level of ≥0.05%. Warfarin-induced anticoagulation was attenuated by CFE in parallel with CYP induction. The findings were similar in mice fed diets containing CFE and different ratios of protein. CFE directly inhibited CYP2C activity in mouse and human liver microsomes in vitro, whereas forskolin was only slightly inhibitory.
Conclusions
CFE attenuates the anticoagulant action of warfarin by inducing hepatic CYP2C; thus, caution is required with the combination of warfarin and dietary supplements containing CFE.
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Affiliation(s)
- Kaori Yokotani
- Information Center, National Institute of Health and Nutrition, Shinjuku-ku, Japan
- Department of Nutrition and Food Science, Ochanomizu University, Bunkyo-ku, Tokyo, Japan
| | - Tsuyoshi Chiba
- Information Center, National Institute of Health and Nutrition, Shinjuku-ku, Japan
| | - Yoko Sato
- Information Center, National Institute of Health and Nutrition, Shinjuku-ku, Japan
| | - Yuko Taki
- Department of Pharmacokinetics and Pharmacodynamics and Global COE Program, School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka-shi, Shizuoka, Japan
| | - Shizuo Yamada
- Department of Pharmacokinetics and Pharmacodynamics and Global COE Program, School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka-shi, Shizuoka, Japan
| | - Kazumasa Shinozuka
- Department of Pharmacology, School of Pharmacy and Pharmaceutical Sciences, Mukogawa Women's University, Nishinomiya, Hyogo, Japan
| | - Masatsune Murata
- Department of Nutrition and Food Science, Ochanomizu University, Bunkyo-ku, Tokyo, Japan
| | - Keizo Umegaki
- Information Center, National Institute of Health and Nutrition, Shinjuku-ku, Japan
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Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, Dunn AS, Kunz R. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e326S-e350S. [PMID: 22315266 DOI: 10.1378/chest.11-2298] [Citation(s) in RCA: 1034] [Impact Index Per Article: 86.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND This guideline addresses the management of patients who are receiving anticoagulant or antiplatelet therapy and require an elective surgery or procedure. METHODS The methods herein follow those discussed in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines article of this supplement. RESULTS In patients requiring vitamin K antagonist (VKA) interruption before surgery, we recommend stopping VKAs 5 days before surgery instead of a shorter time before surgery (Grade 1B). In patients with a mechanical heart valve, atrial fibrillation, or VTE at high risk for thromboembolism, we suggest bridging anticoagulation instead of no bridging during VKA interruption (Grade 2C); in patients at low risk, we suggest no bridging instead of bridging (Grade 2C). In patients who require a dental procedure, we suggest continuing VKAs with an oral prohemostatic agent or stopping VKAs 2 to 3 days before the procedure instead of alternative strategies (Grade 2C). In moderate- to high-risk patients who are receiving acetylsalicylic acid (ASA) and require noncardiac surgery, we suggest continuing ASA around the time of surgery instead of stopping ASA 7 to 10 days before surgery (Grade 2C). In patients with a coronary stent who require surgery, we recommend deferring surgery > 6 weeks after bare-metal stent placement and > 6 months after drug-eluting stent placement instead of undertaking surgery within these time periods (Grade 1C); in patients requiring surgery within 6 weeks of bare-metal stent placement or within 6 months of drug-eluting stent placement, we suggest continuing antiplatelet therapy perioperatively instead of stopping therapy 7 to 10 days before surgery (Grade 2C). CONCLUSIONS Perioperative antithrombotic management is based on risk assessment for thromboembolism and bleeding, and recommended approaches aim to simplify patient management and minimize adverse clinical outcomes.
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Affiliation(s)
- James D Douketis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | | | - Michael Mayr
- Medical Outpatient Department, University Hospital Basel, Basel, Switzerland
| | - Amir K Jaffer
- Division of Hospital Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Mark H Eckman
- Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati Medical Center, Cincinnati, OH
| | - Andrew S Dunn
- Department of Medicine, Mount Sinai School of Medicine, New York, NY
| | - Regina Kunz
- Academy of Swiss Insurance Medicine, Department of Medicine, University Hospital Basel, Basel, Switzerland.
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Evidence does not support the discontinuation of warfarin before a dental extraction. Oral Surg Oral Med Oral Pathol Oral Radiol 2012; 113:148-9; author reply 150-2. [DOI: 10.1016/j.tripleo.2011.02.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2011] [Accepted: 02/01/2011] [Indexed: 11/18/2022]
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Douketis JD. Perioperative management of patients receiving anticoagulant or antiplatelet therapy: a clinician-oriented and practical approach. Hosp Pract (1995) 2012; 39:41-54. [PMID: 22056822 DOI: 10.3810/hp.2011.10.921] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The management of patients who are receiving warfarin, aspirin, clopidogrel, or combinations of these drugs and require their interruption because of an elective surgical or other invasive procedure is a common and sometimes challenging clinical problem. For the practicing clinician, there are 2 key issues for perioperative anticoagulant management: 1) having an approach to stratify patients according to their risk for thromboembolism when warfarin or antiplatelet drug therapy is interrupted, and also having an approach to stratify patients according to the risk of bleeding associated with the surgery or procedure; and 2) determining which patients may require bridging anticoagulation and, if required, how to administer bridging, typically with a low-molecular-weight heparin, before and after surgery in a manner that minimizes the risk for bleeding. The overall goal is to minimize patients' risk for thromboembolism and bleeding throughout the perioperative period. The objective of this article is to provide an evidence-based but practical approach relating to these 2 key issues in a manner than can be applied to everyday clinical practice.
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Taki Y, Yokotani K, Yamada S, Shinozuka K, Kubota Y, Watanabe Y, Umegaki K. Ginkgo biloba extract attenuates warfarin-mediated anticoagulation through induction of hepatic cytochrome P450 enzymes by bilobalide in mice. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2012; 19:177-182. [PMID: 21802929 DOI: 10.1016/j.phymed.2011.06.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Revised: 04/15/2011] [Accepted: 06/22/2011] [Indexed: 05/31/2023]
Abstract
Ginkgo biloba extract (GBE) is a popular herbal ingredient used worldwide, but it is reported to induce bleeding as a serious adverse event. In this study we examined whether GBE induced spontaneous bleeding or accelerated warfarin anticoagulation via herb-drug interaction. Mice were given GBE or various active components of GBE orally for 5 days and blood coagulation parameters and hepatic cytochrome P450 enzymes (CYPs) were measured. Mice also received warfarin (racemate, (S)- or (R)-enantiomer) for the last 3 days of the 5-day regimen to examine GBE-warfarin interactions. Neither GBE (up to 1000 mg/kg) nor ginkgolide B (up to 140 mg/kg), a platelet-activating factor antagonist, influenced blood coagulation parameters. In contrast, GBE attenuated the anticoagulant action of warfarin. Bilobalide, a component of GBE that markedly induced hepatic CYPs including (S)-warfarin hydroxylase, showed similar effects. For (S)-warfarin, the anticoagulation action and the interaction with GBE was clear, while the influence on metabolism was greater for (R)-warfarin than for (S)-warfarin, which corresponded to the CYP types induced by GBE. These results suggest that GBE and ginkgolide B have no influence on blood coagulation in vivo, and that GBE attenuates the anticoagulation action of warfarin via induction of hepatic CYPs by bilobalide.
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Affiliation(s)
- Yuko Taki
- National Institute of Health and Nutrition, Tokyo, Japan
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Human serum albumin: from bench to bedside. Mol Aspects Med 2011; 33:209-90. [PMID: 22230555 DOI: 10.1016/j.mam.2011.12.002] [Citation(s) in RCA: 1176] [Impact Index Per Article: 90.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Accepted: 12/21/2011] [Indexed: 02/07/2023]
Abstract
Human serum albumin (HSA), the most abundant protein in plasma, is a monomeric multi-domain macromolecule, representing the main determinant of plasma oncotic pressure and the main modulator of fluid distribution between body compartments. HSA displays an extraordinary ligand binding capacity, providing a depot and carrier for many endogenous and exogenous compounds. Indeed, HSA represents the main carrier for fatty acids, affects pharmacokinetics of many drugs, provides the metabolic modification of some ligands, renders potential toxins harmless, accounts for most of the anti-oxidant capacity of human plasma, and displays (pseudo-)enzymatic properties. HSA is a valuable biomarker of many diseases, including cancer, rheumatoid arthritis, ischemia, post-menopausal obesity, severe acute graft-versus-host disease, and diseases that need monitoring of the glycemic control. Moreover, HSA is widely used clinically to treat several diseases, including hypovolemia, shock, burns, surgical blood loss, trauma, hemorrhage, cardiopulmonary bypass, acute respiratory distress syndrome, hemodialysis, acute liver failure, chronic liver disease, nutrition support, resuscitation, and hypoalbuminemia. Recently, biotechnological applications of HSA, including implantable biomaterials, surgical adhesives and sealants, biochromatography, ligand trapping, and fusion proteins, have been reported. Here, genetic, biochemical, biomedical, and biotechnological aspects of HSA are reviewed.
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Chana R, Salmon L, Waller A, Pinczewski L. Warfarin management in patients on continuous anticoagulation therapy undergoing total knee replacement. ACTA ACUST UNITED AC 2011; 93:1497-502. [DOI: 10.1302/0301-620x.93b11.27255] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We evaluated the safety and efficacy of total knee replacement in patients receiving continuous warfarin therapy. We identified 24 consecutive patients receiving long-term warfarin therapy who underwent total knee replacement between 2006 and 2008 and compared them with a group of age- and gender-matched patients not on long-term anticoagulation. Primary observations were changes in haemoglobin, transfusion rates and complications. Secondary observations were fluctuations in the international normalised ratio (INR) and post-operative range of movement. There was no significant difference between the two groups in pre- or post-operative haemoglobin, incidence of transfusion or incidence of post-operative complications. There were no surgical delays due to a high INR level. The mean change in INR during the peri-operative phase was minimal (mean 0.4; sd 0.7). There was no significant difference in the range of movement between the two groups after day two post-operatively. Current American College of Chest Physicians guidelines recommend bridging therapy for high-risk patients receiving oral anticoagulation and undergoing major orthopaedic procedures. We have shown that a safe alternative is to continue the steady-state warfarin peri-operatively in patients on long-term anticoagulation requiring total knee replacement.
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Affiliation(s)
- R. Chana
- North Sydney Orthopaedic and Sports Medicine Centre, The
Mater Clinic, Suite 2, 3
Gillies St Wollstonecraft, Sydney, New
South Wales 2065, Australia
| | - L. Salmon
- North Sydney Orthopaedic and Sports Medicine Centre, The
Mater Clinic, Suite 2, 3
Gillies St Wollstonecraft, Sydney, New
South Wales 2065, Australia
| | - A. Waller
- North Sydney Orthopaedic and Sports Medicine Centre, The
Mater Clinic, Suite 2, 3
Gillies St Wollstonecraft, Sydney, New
South Wales 2065, Australia
| | - L. Pinczewski
- North Sydney Orthopaedic and Sports Medicine Centre, The
Mater Clinic, Suite 2, 3
Gillies St Wollstonecraft, Sydney, New
South Wales 2065, Australia
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Davis NF, Fanning DM, McGuire BB, Carroll GT, Flood HD. Perioperative management of chronic anticoagulation therapy in urological patients: a cross-sectional survey of practice. Ir J Med Sci 2011; 180:823-8. [DOI: 10.1007/s11845-011-0738-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Accepted: 07/09/2011] [Indexed: 10/17/2022]
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Perioperative management of patients who are receiving warfarin therapy: an evidence-based and practical approach. Blood 2011; 117:5044-9. [DOI: 10.1182/blood-2011-02-329979] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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Lip GYH, Durrani OM, Roldan V, Lip PL, Marin F, Reuser TQ. Peri-operative management of ophthalmic patients taking antithrombotic therapy. Int J Clin Pract 2011; 65:361-71. [PMID: 21314873 DOI: 10.1111/j.1742-1241.2010.02538.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Increasing number of patients presenting for ophthalmic surgery are using oral anti-coagulant and anti-platelet therapy. The current practice of discontinuing these drugs preoperatively because of a presumed increased risk of bleeding may not be evidence-based and could pose a significant risk to the patient's health. To provide an evidence-based review on the peri-operative management of ophthalmic patients who are taking anti-thrombotic therapy. In addition, we briefly discuss the underlying conditions that necessitate the use of these drugs as well as management of the operative field in anti-coagulated patients. A semi-systematic review of literature was performed. The databases searched included MEDLINE, EMBASE, database of abstracts of reviews of effects (DARE), Cochrane controlled trial register and Cochrane systematic reviews. In addition, the bibliographies of the included papers were also scanned for evidence. The published data suggests that aspirin did not appear to increase the risk of serious postoperative bleeding in any type of ophthalmic surgery. Topical, sub-tenon, peri-bulbar and retrobulbar anaesthesia appear to be safe in patients on anti-thrombotic (warfarin and aspirin) therapy. Warfarin does not increase the risk of significant bleeding in most types of ophthalmic surgery when the INR was within the therapeutic range. Current evidence supports the continued use of aspirin and with some exceptions, warfarin in the peri-operative period. The risk of thrombosis-related complications on disruption of anticoagulation may be higher than the risk of significant bleeding by continuing its use for most types of ophthalmic surgery.
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Affiliation(s)
- G Y H Lip
- Haemostasis Thrombosis and Vascular Biology Unit, University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK.
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