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Moser N, Omar MA, Koshman SL, Lin M, Youngson E, Kent W, Harten C. Direct oral anticoagulants for atrial fibrillation in early postoperative valve repair or bioprosthetic replacement. J Thorac Cardiovasc Surg 2024; 168:523-532.e3. [PMID: 37061910 DOI: 10.1016/j.jtcvs.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/30/2023] [Accepted: 03/07/2023] [Indexed: 04/17/2023]
Abstract
OBJECTIVE Despite increased use of direct oral anticoagulants (DOACs), limited evidence guides their use in the early postoperative period after bioprosthetic valve implantation in patients with atrial fibrillation. Our objective was to describe the efficacy and safety of DOACs and warfarin in the first 3 months after surgical bioprosthetic valve replacement or repair in patients with atrial fibrillation. METHODS This was a retrospective, registry-informed cohort study of surgical patients who underwent bioprosthetic valve replacement or repair, had concomitant atrial fibrillation and received oral anticoagulation at discharge. The primary efficacy outcome was a composite of death, ischemic stroke, transient ischemic attack, and systemic embolism; the primary safety outcome was a composite of major bleeding. Key secondary outcomes were comparative analyses of primary outcomes, temporal anticoagulation prescribing patterns, and 30-day readmission rates. RESULTS A total of 1743 patients were included. Of the 570 patients in the DOAC group, 17 (2%) met the composite efficacy outcome and 55 (10%) met the composite safety outcome. Of the 1173 patients receiving warfarin, 41 (3%) and 114 (10%) met the composite efficacy and safety outcomes, respectively. Comparative secondary analysis was not statistically significant for either the efficacy (adjusted odds ratio, 0.85; 95% confidence interval, 0.46-1.55, P = .59) or safety (adjusted odds ratio, 0.94; 95% confidence interval, 0.66-1.34, P = .76) outcomes. The 30-day readmission rates were similar between both groups. CONCLUSIONS Our results suggest DOACs may be safe and effective alternatives to warfarin in the early postoperative period after valve repair or surgical bioprosthetic replacement. Confirmation awaits adequately powered prospective studies.
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Affiliation(s)
- Nils Moser
- Pharmacy Services, Alberta Health Services, Edmonton, Alberta, Canada.
| | - Mohamed A Omar
- Pharmacy Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - Sheri L Koshman
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Mu Lin
- Data and Research Services, Alberta SPOR Support Unit and Provincial Research Data Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - Erik Youngson
- Data and Research Services, Alberta SPOR Support Unit and Provincial Research Data Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - William Kent
- Section of Cardiac Surgery, Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | - Cheryl Harten
- Pharmacy Services, Alberta Health Services, Edmonton, Alberta, Canada
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2
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Monga TS, Ekong M, Patrick K, Bommana Boyena TG, Ravanam AS, Vargas S, Mavus NB, Lakshmi AP, Singh K, Vegesna RR, Abbas K. Anticoagulation in Atrial Fibrillation Associated With Cardiac Amyloidosis: A Narrative Review. Cureus 2024; 16:e61557. [PMID: 38962633 PMCID: PMC11221388 DOI: 10.7759/cureus.61557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2024] [Indexed: 07/05/2024] Open
Abstract
Cardiac amyloidosis (CA) involves the abnormal deposition and accumulation of amyloid proteins in the heart muscle. A hallmark of disease progression is declining heart function, which can lead to structural irregularities, arrhythmias, and ultimately heart failure. Atrial fibrillation (AF) is the most common arrhythmia that presents in CA patients, and this arrhythmia is significant because it can moderately increase the risk of patients developing intracardiac thrombi, thereby putting them at risk for thromboembolic events. The management of this complication entails the use of anticoagulants like vitamin K antagonists and direct oral anticoagulants to reduce the risk of thrombus formation. This article seeks to review AF in CA and the use of anticoagulation therapy for the management and reduction of thromboembolic risk. The major conclusions of this review are centered around the need for safe administration of anticoagulant therapy to CA patients, regardless of their CHA2DS2-VASc risk score. This review highlights the importance of taking a multidisciplinary or collaborative approach to CA treatment to ensure that all aspects of this multifaceted disease can be properly managed while minimizing adverse events like bleeding risk and drug-drug interactions.
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Affiliation(s)
- Tejbir S Monga
- Internal Medicine, Spartan Health Sciences University, Vieux Fort, LCA
| | - Mfonido Ekong
- Internal Medicine, St. George's University School of Medicine, True Blue, GRD
| | - Kayé Patrick
- Anesthesiology, Spanish Town Hospital, Spanish Town, JAM
| | | | | | | | | | | | - Kanwaraj Singh
- Internal Medicine, Maharishi Markandeshwar Institute of Medical Sciences and Research, Ambala, IND
| | | | - Kiran Abbas
- Community Health Sciences, Aga Khan University, Karachi, PAK
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3
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Bosio G, Destrempes F, Roy Cardinal MH, Cloutier G. Effect of rt-PA on Shear Wave Mechanical Assessment and Quantitative Ultrasound Properties of Blood Clot Kinetics In Vitro. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:829-840. [PMID: 38205972 DOI: 10.1002/jum.16411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 12/21/2023] [Accepted: 12/26/2023] [Indexed: 01/12/2024]
Abstract
OBJECTIVE The consequences associated with blood clots are numerous and are responsible for many deaths worldwide. The assessment of treatment efficacy is necessary for patient follow-up and to detect treatment-resistant patients. The aim of this study was to characterize the effect of treatment on blood clots in vitro using quantitative ultrasound parameters. METHODS Blood from 10 pigs was collected to form three clots per pig in gelatin phantoms. Clots were subjected to 1) no treatment, 2) rt-PA (recombinant tissue plasminogen activator) treatment after 20 minutes of clotting, and 3) rt-PA treatment after 60 minutes of clotting. Clots were weighted before and after the experiment to assess the treatment effect by the mass loss. The clot kinetics was studied over 100 minutes using elastography (Young's modulus, shear wave dispersion, and shear wave attenuation). Homodyne K-distribution (HKD) parameters derived from speckle statistics were also studied during clot formation and dissolving (diffuse-to-total signal power ratio and intensity parameters). RESULTS Treated clots loosed significantly more mass than non-treated ones (P < .005). A significant increase in Young's modulus was observed over time (P < .001), and significant reductions were seen for treated clots at 20 or 60 minutes compared with untreated ones (P < .001). The shear wave dispersion differed for treated clots at 60 minutes versus no treatments (P < .001). The shear wave attenuation decreased over time (P < .001), and was different for clots treated at 20 minutes versus no treatments (P < .031). The HKD intensity parameter varied over time (P < .032), and was lower for clots treated at 20 and 60 minutes than those untreated (P < .001 and P < .02). CONCLUSION The effect of rt-PA treatment could be confirmed by a decrease in Young's modulus and HKD intensity parameter. The shear wave dispersion and shear wave attenuation were sensitive to late and early treatments, respectively. The Young's modulus, shear wave attenuation, and HKD intensity parameter varied over time despite treatment.
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Affiliation(s)
- Guillaume Bosio
- Laboratory of Biorheology and Medical Ultrasonics, University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec, Canada
- Institute of Biomedical Engineering, University of Montreal, Montreal, Quebec, Canada
| | - François Destrempes
- Laboratory of Biorheology and Medical Ultrasonics, University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec, Canada
| | - Marie-Hélène Roy Cardinal
- Laboratory of Biorheology and Medical Ultrasonics, University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec, Canada
| | - Guy Cloutier
- Laboratory of Biorheology and Medical Ultrasonics, University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec, Canada
- Institute of Biomedical Engineering, University of Montreal, Montreal, Quebec, Canada
- Department of Radiology, Radio-Oncology and Nuclear Medicine, University of Montreal, Montreal, Quebec, Canada
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4
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Wojtukiewicz MZ, Tesarova P, Karetová D, Windyga J. In Search of the Perfect Thrombosis and Bleeding-Associated Cancer Scale. Semin Thromb Hemost 2024; 50:443-454. [PMID: 37852295 DOI: 10.1055/s-0043-1776003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
Thrombosis and bleeding are commonly observed in cancer patients, and their management is crucial for positive patient outcomes. A comprehensive, prophylactic, and therapeutic management of venous thrombosis should focus on identifying the patients who would benefit most from treatment to reduce mortality and minimize the risk of thrombosis recurrence without significantly increasing the risk of bleeding. Existing cancer scales provide valuable information for assessing the overall burden of cancer and guiding treatment decisions, but their ability to predict thrombotic and bleeding events remains limited. With increasing knowledge of the pathophysiology of cancer and the availability of advanced anticancer therapies, new risk factors for cancer-associated thrombosis and bleeding are being identified. In this report, we analyze the current literature and identify new risk factors for venous thrombosis and bleeding which are not included in routinely used risk scores. While some existing cancer scales partially capture the risk of thrombosis and bleeding, there is a need for more specific and accurate scales tailored to these complications. The development of such scales could improve risk stratification, aid in treatment selection, and enhance patient care. Therefore, further research and development of novel cancer scales focused on thrombosis and bleeding are warranted to optimize patient management and outcomes.
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Affiliation(s)
- Marek Z Wojtukiewicz
- Department of Oncology, Medical University of Bialystok, Bialystok, Poland
- Comprehensive Cancer Center, Bialystok, Poland
| | - Petra Tesarova
- Department of Oncology, Institute of Radiation Oncology, First Faculty of Medicine, Charles University and Bulovka University Hospital, Prague, Czech Republic
| | - Debora Karetová
- Second Department of Medicine-Department of Cardiovascular Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine in Warsaw, Warsaw, Poland
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Netha A, Mazhar S, Azhar A, Moeez A, Choradia A, Mohtashim A, Anees U, Ejaz U, Tariq MU, Jawad S. Effectiveness of rivaroxaban in preventing cerebral venous thromboembolism: a systematic review and meta-analysis. Ann Med Surg (Lond) 2024; 86:2098-2104. [PMID: 38576935 PMCID: PMC10990339 DOI: 10.1097/ms9.0000000000001689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 12/27/2023] [Indexed: 04/06/2024] Open
Abstract
Background Cerebral venous thromboembolism (CVT) poses a significant risk of venous infarction and haemorrhage, which can lead to neurological deficits and, in severe cases, even death. The optimal treatment regimen for patients with CVT remains unclear. Methods MEDLINE, Embase, Google Scholar, Web of Science (WoS), and Cochrane Central databases were searched for randomized controlled trials (RCTs) and observational studies assessing the efficacy and safety of rivaroxaban in patients with CVT. All-site venous thromboembolism (VTE), risk of clinically relevant non-major bleeding, incidence of partial recanalization, complete recanalization and major haemorrhage were among outcomes of interest. Mantel-Haenszel weighted random-effects model was used to calculate relative risks (RRs) with 95% CIs. Results The analysis included 1 RCT and 3 observational studies containing 211 patients. Compared to vitamin K antagonists (VKAs), rivaroxaban did not significantly decrease the all-site VTE [RR 0.31 (95% CI 0.01, 8.43); P=0.49, I2=0%]. Compared with VKAs, patients on rivaroxaban did not show a significantly reduced risk of recurrent cerebral venous thrombosis. In terms of incidence of partial recanalization, there was no discernible difference between rivaroxaban and VKAs [RR 0.90 (95% CI 0.66, 1.22); P=0.49, I2=0%]. There was no discernible difference in incidence of complete recanalization [RR 0.98 (95% CI 0.32, 3.03); P=0.97, I2=28%] and incidence of major haemorrhage [RR 0.19 (95% CI 0.01, 4.54); P=0.30]. Conclusion Rivaroxaban was found to have similar efficacy to VKAs. Due to its lower risk of severe bleeding and no need for INR monitoring, rivaroxaban may be a preferable treatment option for CVT.
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Affiliation(s)
- Aadarsh Netha
- Department of Medicine, Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, Tamilnadu, India
| | - Saad Mazhar
- Department of Medicine, King Edward Medical University
| | - Aima Azhar
- Department of Medicine, Fatima Jinnah Medical University
| | - Abdul Moeez
- Department of Medicine, Services Institute of Medical Sciences
| | - Aakash Choradia
- Department of Medicine, Tribhuwan University, Kathmandu, Nepal
| | - Ali Mohtashim
- Department of Medicine, Allama Iqbal Medical College, Lahore
| | - Usama Anees
- Department of Medicine, Quaid-e-Azam Medical College, Bahawalpur
| | - Umer Ejaz
- Department of Medicine, Rawalpindi Medical College, Rawalpindi
| | | | - Sayed Jawad
- Department of Medicine, Kabul University of Medical Sciences, Kabul, Afghanistan
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Gackowski M, Jędrzejewski M, Medicharla SS, Kondabala R, Madriwala B, Mądra-Gackowska K, Studzińska R. Novel Thiourea and Oxime Ether Isosteviol-Based Anticoagulants: MD Simulation and ADMET Prediction. Pharmaceuticals (Basel) 2024; 17:163. [PMID: 38399378 PMCID: PMC10892930 DOI: 10.3390/ph17020163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/25/2024] Open
Abstract
Activated blood coagulation factor X (FXa) plays a critical initiation step of the blood-coagulation pathway and is considered a desirable target for anticoagulant drug development. It is reversibly inhibited by nonvitamin K antagonist oral anticoagulants (NOACs) such as apixaban, betrixaban, edoxaban, and rivaroxaban. Thrombosis is extremely common and is one of the leading causes of death in developed countries. In previous studies, novel thiourea and oxime ether isosteviol derivatives as FXa inhibitors were designed through a combination of QSAR studies and molecular docking. In the present contribution, molecular dynamics (MD) simulations were performed for 100 ns to assess binding structures previously predicted by docking and furnish additional information. Moreover, three thiourea- and six oxime ether-designed isosteviol analogs were then examined for their drug-like and ADMET properties. MD simulations demonstrated that four out of the nine investigated isosteviol derivatives, i.e., one thiourea and three oxime ether ISV analogs, form stable complexes with FXa. These derivatives interact with FXa in a manner similar to Food and Drug Administration (FDA)-approved drugs like edoxaban and betrixaban, indicating their potential to inhibit factor Xa activity. One of these derivatives, E24, displays favorable pharmacokinetic properties, positioning it as the most promising drug candidate. This, along with the other three derivatives, can undergo further chemical synthesis and bioassessment.
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Affiliation(s)
- Marcin Gackowski
- Department of Toxicology and Bromatology, Faculty of Pharmacy, L. Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, A. Jurasza 2 Street, 85089 Bydgoszcz, Poland
| | - Mateusz Jędrzejewski
- Department of Organic and Physical Chemistry, Faculty of Pharmacy, Medical University of Warsaw, Banacha 1 Street, 02093 Warsaw, Poland;
- Doctoral School, Medical University of Warsaw, Żwirki i Wigury 81 Street, 02093 Warsaw, Poland
| | - Sri Satya Medicharla
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, M. S. Ramaiah University of Applied Sciences, Bengaluru 560054, Karnataka, India; (S.S.M.); (B.M.)
| | - Rajesh Kondabala
- Thapar Institute of Engineering and Technology, Patiala 147004, Punjab, India;
| | - Burhanuddin Madriwala
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, M. S. Ramaiah University of Applied Sciences, Bengaluru 560054, Karnataka, India; (S.S.M.); (B.M.)
| | - Katarzyna Mądra-Gackowska
- Department of Geriatrics, Faculty of Health Sciences, L. Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Skłodowskiej Curie 9 Street, 85094 Bydgoszcz, Poland;
| | - Renata Studzińska
- Department of Organic Chemistry, Faculty of Pharmacy, L. Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, A. Jurasza 2 Street, 85089 Bydgoszcz, Poland;
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Hajra A, Ujjawal A, Ghalib N, Chowdhury S, Biswas S, Balasubramanian P, Gupta R, Aronow WS. Expanding Indications of Nonvitamin K Oral Anticoagulants Beyond Nonvalvular Atrial Fibrillation and Venous Thromboembolism: A Review of Emerging Clinical Evidence. Curr Probl Cardiol 2024; 49:102017. [PMID: 37544618 DOI: 10.1016/j.cpcardiol.2023.102017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 08/01/2023] [Indexed: 08/08/2023]
Abstract
Direct oral anticoagulants (DOAC) have emerged as a new therapy for patients who need and can tolerate oral anticoagulation. DOACs were initially approved for nonvalvular atrial fibrillation (NVAF) and treatment for deep vein thrombosis (DVT) and pulmonary embolism (PE). Ease of administration, no requirement of bridging with other anticoagulants, and less frequent dosing have made DOACs preferable choice for anticoagulation. Studies are showing promising results regarding use of DOACs beyond the common indications. Studies have been done to show the potential benefit of DOACs in valvular atrial fibrillation, heart failure, acute coronary syndrome, stroke, and peripheral arterial disease. Data have shown safety as well as comparable bleeding incidences with DOACs compared to vitamin K antagonist anticoagulants. Naturally interest is growing to see the use of DOACs apart from the NVAF, DVT, or PE. Authors have highlighted various study results to show the potential beneficial role of DOACs in the above-mentioned situations.
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Affiliation(s)
- Adrija Hajra
- Brigham and Women's Hospital/Harvard Medical School, Boston, MA.
| | | | - Natasha Ghalib
- Montefiore Medical Center/Albert Einstein College of Medicine, New York, NY
| | | | - Suman Biswas
- Calcutta National Medical College, Kolkata, West Bengal, India
| | | | | | - Wilbert S Aronow
- New York Medical College at Westchester Medical Center, New York, NY
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8
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Crowley AV, Banfield M, Gupta A, Raj R, Gorantla VR. Role of Surgical and Medical Management of Chronic Thromboembolic Pulmonary Hypertension: A Systematic Review. Cureus 2024; 16:e53336. [PMID: 38435894 PMCID: PMC10907114 DOI: 10.7759/cureus.53336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2024] [Indexed: 03/05/2024] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is underdiagnosed and has recently surfaced as one of the leading triggers of severe pulmonary hypertension. This disease process is described by structural changes of pulmonary arteries such as fibrous stenosis, complete obliteration, or the presence of a resistant intraluminal thrombus, resulting in increased pulmonary resistance and eventually progressing to right-sided heart failure. Hence, this study aims to describe the current treatments for CTEPH and their efficacy in hemodynamic improvement and prevention of recurring thromboembolic episodes in patients. This systematic review promptly follows the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. On February 13, 2022, our team searched through the following databases: PubMed, ProQuest, and ScienceDirect. The following keywords were used across all databases: CTEPH AND Pulmonary Endarterectomy (PEA), CTEPH AND Balloon Pulmonary Angioplasty (BPA), and CTEPH AND Medical Therapy OR Anticoagulation therapy. Twenty-nine thousand eighty-nine articles on current management techniques (PEA, Balloon angioplasty, anticoagulants) were selected, analyzed, and reviewed with each other. We found 19 articles concerning PEA, 15 concerning BPA, and six regarding anticoagulants. Most papers showed high success rates and promising evidence of PEA and anticoagulants as a post-operative regimen. BPA was the least preferred but is still reputable in patients unfit for invasive techniques. CTEPH is a condition presenting with either fibrous stenosis, complete obliteration of the artery, or a clogged thrombus. Recent studies have shown three techniques that physicians have used to treat CTEPH: balloon-pulmonary angioplasty, PEA, and medical management with anticoagulants. PEA followed by anticoagulants is preferred to balloon pulmonary angioplasties. CTEPH is an ongoing topic in research; as it continues to be researched, we hope to see more management techniques available.
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Affiliation(s)
- Alexandra V Crowley
- Medicine, St. George's University School of Medicine, True Blue, St. George's, GRD
| | - Megan Banfield
- Medicine, St. George's University School of Medicine, True Blue, St. George's, GRD
| | - Aditi Gupta
- Medicine, St. George's University School of Medicine, True Blue, St. George's, GRD
| | - Rhea Raj
- Medicine, St. George's University School of Medicine, True Blue, St. George's, GRD
| | - Vasavi R Gorantla
- Biomedical Sciences, West Virginia School of Osteopathic Medicine, Lewisburg, USA
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Gaspar P, Mittal P, Cohen H, Isenberg DA. Bleeding events in thrombotic antiphospholipid syndrome: prevalence, severity, and associated damage accrual. Res Pract Thromb Haemost 2024; 8:102327. [PMID: 38384985 PMCID: PMC10879794 DOI: 10.1016/j.rpth.2024.102327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 12/31/2023] [Accepted: 01/02/2024] [Indexed: 02/23/2024] Open
Abstract
Background Life-long anticoagulation increases bleeding risk in patients with antiphospholipid syndrome (APS). The Damage Index for Antiphospholipid Syndrome does not include bleeding events in damage accrual. Objectives We aimed to characterize the prevalence, severity, and damage associated with bleeding events in patients with APS. Methods This was a single-center retrospective analysis of patients with thrombotic APS (2006 Sydney criteria). Bleeding events were reviewed up to 43 years and classified according to the ISTH definitions into 2 groups: 1) major bleedings and 2) nonmajor bleedings (minor bleedings and clinically relevant nonmajor bleedings). Damage events were recorded as bleeding events a) resulting in permanent (>6 months) decrease in organ function and b) complicated by total/partial organ resection. Results Among 197 patients (2412 patient-years [PYs] of follow-up), all of whom had been exposed to antithrombotic therapy, 40.6% experienced 167 bleedings (6.9 events per 100 PYs), of whom 61.3% had nonmajor bleedings (77.2% of bleedings: 42.6% minor, 57.4% clinically relevant nonmajor) and 38.8% had major bleedings (22.8% of bleedings; 1.6 events per 100 PYs). Soft/connective tissue was affected in 44.3% of bleedings, and 94.6% were nonmajor bleedings. Central nervous system was affected in 20.9% of bleedings, and 62.9% were major bleedings. Bleeding events were spontaneous in 90.4% of cases, and thrombocytopenia was likely involved in 62.2% of bleedings. Damage occurred in 11.4% of bleedings and affected 7.6% of patients. Most of the damage was associated with central nervous system events (8.4% of all bleedings). Conclusion Approximately 40% of patients experienced at least 1 bleeding, and almost 8% of patients were left with organ damage not recognized by the current version of the Damage Index for Antiphospholipid Syndrome.
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Affiliation(s)
- Pedro Gaspar
- Department of Internal Medicine, Hospital Santa Maria, Unidade Local de Saúde Santa Maria, Lisbon, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Centro Académico de Medicina de Lisboa, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Prabal Mittal
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | - Hannah Cohen
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | - David A. Isenberg
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
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10
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Adelhelm JBH, Christensen R, Balbi GGM, Voss A. Therapy with direct oral anticoagulants for secondary prevention of thromboembolic events in the antiphospholipid syndrome: a systematic review and meta-analysis of randomised trials. Lupus Sci Med 2023; 10:e001018. [PMID: 37899090 PMCID: PMC10619019 DOI: 10.1136/lupus-2023-001018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 09/23/2023] [Indexed: 10/31/2023]
Abstract
OBJECTIVE Antiphospholipid syndrome (APS) is a systemic autoimmune disorder characterised by venous thrombosis (VT) or arterial thrombosis (AT) and/or pregnancy morbidity and the presence of antiphospholipid antibodies. Direct oral anticoagulants (DOACs) hold several advantages to vitamin K antagonists (VKAs) for prevention of thrombosis and we wish to evaluate DOACs compared with VKAs in secondary prevention of thromboembolic events in patients with APS. METHODS We conducted searches of the published literature using relevant data sources (MEDLINE, Embase and Cochrane CENTRAL), and of trial registers for unpublished data and ongoing trials. We included randomised trials examining individuals >18 years with APS classified according to the criteria valid when the trial was carried out. Randomised controlled trials had to examine any DOAC agent compared with any comparable drug. We tabulated all occurrences of events from all eligible randomised trials. Due to few events, ORs and 95% CIs were calculated using the Peto method. RESULTS 5 randomised trials comprising 624 patients met the predefined eligibility criteria. The primary outcome measure was new thrombotic events, a composite endpoint of any VT or AT, during the VKA-controlled phase of treatment. According to the I2 inconsistency index, there was evidence of statistical heterogeneity across the studies (I2=60%). Across trials, 29 and 10 thrombotic events were observed in 305 and 319 patients with APS treated with DOAC and VKA, respectively, corresponding to a combined Peto OR of 3.01 (95% CI 1.56 to 5.78, p=0.001). There was a significantly increased risk of AT while treated with DOACs compared with VKA (OR 5.5 (2.5, 12.1) p<0.0001), but no difference in the risk of VT (p=0.87). We found no significant difference in risk of bleeding. CONCLUSIONS DOACs were associated with a significant increase in the risk of a new thrombotic event, especially AT, favouring standard prophylaxis with warfarin. PROSPERO REGISTRATION NUMBER CRD42019126720.
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Affiliation(s)
| | - Robin Christensen
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
| | - Gustavo G M Balbi
- Department of Clinical Medicine, Federal University of Juiz de Fora, Juiz de Fora, Brazil
| | - Anne Voss
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
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11
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Atzemian N, Kareli D, Ragia G, Manolopoulos VG. Distinct pleiotropic effects of direct oral anticoagulants on cultured endothelial cells: a comprehensive review. Front Pharmacol 2023; 14:1244098. [PMID: 37841935 PMCID: PMC10576449 DOI: 10.3389/fphar.2023.1244098] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/13/2023] [Indexed: 10/17/2023] Open
Abstract
Direct Oral Anticoagulants (DOACs) have simplified the treatment of thromboembolic disease. In addition to their established anticoagulant effects, there are indications from clinical and preclinical studies that DOACs exhibit also non-anticoagulant actions, such as anti-inflammatory and anti-oxidant actions, advocating overall cardiovascular protection. In the present study, we provide a comprehensive overview of the existing knowledge on the pleiotropic effects of DOACs on endothelial cells (ECs) in vitro and their underlying mechanisms, while also identifying potential differences among DOACs. DOACs exhibit pleiotropic actions on ECs, such as anti-inflammatory, anti-atherosclerotic, and anti-fibrotic effects, as well as preservation of endothelial integrity. These effects appear to be mediated through inhibition of the proteinase-activated receptor signaling pathway. Furthermore, we discuss the potential differences among the four drugs in this class. Further research is needed to fully understand the pleiotropic effects of DOACs on ECs, their underlying mechanisms, as well as the heterogeneity between various DOACs. Such studies can pave the way for identifying biomarkers that can help personalize pharmacotherapy with this valuable class of drugs.
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Affiliation(s)
- Natalia Atzemian
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
- Individualised Medicine and Pharmacological Research Solutions Center (IMPReS), Alexandroupolis, Greece
| | - Dimitra Kareli
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
- Individualised Medicine and Pharmacological Research Solutions Center (IMPReS), Alexandroupolis, Greece
| | - Georgia Ragia
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
- Individualised Medicine and Pharmacological Research Solutions Center (IMPReS), Alexandroupolis, Greece
| | - Vangelis G. Manolopoulos
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
- Individualised Medicine and Pharmacological Research Solutions Center (IMPReS), Alexandroupolis, Greece
- Clinical Pharmacology Unit, Academic General Hospital of Alexandroupolis, Alexandroupolis, Greece
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12
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Han JM, Jang EJ, Yee J, Song TJ, Kim DH, Park J, Gwak HS. Association between SLCO1B1 genetic polymorphisms and bleeding risk in patients treated with edoxaban. Sci Rep 2023; 13:15967. [PMID: 37749323 PMCID: PMC10520058 DOI: 10.1038/s41598-023-43179-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 09/20/2023] [Indexed: 09/27/2023] Open
Abstract
Since SLCO1B1 encodes the uptake transporter OATP1B1, which can influence the pharmacokinetic and pharmacodynamic profiles of edoxaban, polymorphisms in SLCO1B1 may affect the edoxaban response. This study aimed to investigate the association between SLCO1B1 gene polymorphisms and the bleeding risk in patients receiving edoxaban. We genotyped 10 single-nucleotide polymorphisms (SNPs) from the SLCO1B1 gene in patients receiving edoxaban. We also analyzed rs3842 of ABCB1 as a confounder. The odds ratio (OR) and adjusted OR (AOR) were calculated from univariate and multivariable analysis, respectively. The area under the receiver operating characteristic curve (AUROC) was constructed for the discrimination of the model. A total of 159 patients receiving edoxaban were analyzed. Overdose and rs4149056 showed significant association with bleeding complications by around 11- and 5.5-fold, respectively. Additionally, patients with the rs4149057 variant allele (C) had a 3.9-fold increased bleeding risk compared with wild-type homozygote carriers (TT), whereas rs2306283 variant homozygote (GG) carriers had a 0.27-fold reduced bleeding risk compared with wild-type allele (A) carriers. Patients with the variant-type homozygote (CC) of ABCB1 rs3842 had a higher bleeding risk than T allele carriers (AOR = 5.3 and 5.9). The final models for multivariable analyses were acceptable based on the AUROC values (> 0.70). These findings may help predict bleeding risk in patients taking edoxaban and help personalize treatment.
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Affiliation(s)
- Ji Min Han
- College of Pharmacy, Chungbuk National University, Cheongju-Si, Korea
| | - Eun Jeong Jang
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, 52 Ewhayeodae-Gil, Seodaemun-Gu, Seoul, 03760, Republic of Korea
| | - Jeong Yee
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, 52 Ewhayeodae-Gil, Seodaemun-Gu, Seoul, 03760, Republic of Korea
| | - Tae-Jin Song
- Department of Neurology, Ewha Womans University Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Dong-Hyeok Kim
- Department of Cardiology, Ewha Womans University Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Junbeom Park
- Division of Cardiology, Department of Internal Medicine, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, 07985, Korea.
| | - Hye Sun Gwak
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, 52 Ewhayeodae-Gil, Seodaemun-Gu, Seoul, 03760, Republic of Korea.
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13
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Sandhu P, Mayor S, Sproat C, Kwok J, Beneng K, Patel V. The continuation of oral anticoagulation and antiplatelet therapy for dento-alveolar surgery: a service evaluation. Br Dent J 2023; 235:313-318. [PMID: 37684457 DOI: 10.1038/s41415-023-6227-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 07/10/2023] [Indexed: 09/10/2023]
Abstract
Background Patients taking oral anticoagulants (OACs) and oral antiplatelets (OAPs) have a risk of post-operative bleeding when dental extractions are required. Guidance exists to assist dental practitioners on how best to clinically manage these patients, but this is based upon low-quality evidence. The current service evaluation provides real world clinical data when these drugs are not discontinued for oral surgery procedures.Materials and methods All OACs and OAPs were continued and patients requiring dental extractions had local haemostatic measures (local anaesthesia with adrenaline, socket packing with haemostat and resorbable sutures). All patients were offered a follow-up via a telephone clinic service after surgery to assess any post-operative bleeding.Results A total of 439 patients underwent 513 surgical episodes, equating to 1,001 dental extractions. Overall, 412 (95.9%) patients reported no post-operative bleeding complications. A total of 18 (4.1%) patients reported post-operative bleeding requiring further intervention. All but two patients were managed with local haemostatic measures, and no patient required hospital admission. For the single novel OAC cohort of patients, 8/185 (4.3%) procedures had post-operative bleeding.Conclusion This current service evaluation highlights that the risk of significant or life-threatening bleeding following dental extraction when OACs or OAPs are continued remains rare.
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Affiliation(s)
- Pradeep Sandhu
- Speciality Registrar, Oral Surgery, Oral and Maxillofacial Surgery Department, Salisbury District Hospital, United Kingdom
| | - Serena Mayor
- Speciality Dentist, Oral Surgery, Oral Surgery Department, Guy´s and St Thomas´ Hospital, United Kingdom
| | - Christopher Sproat
- Consultant, Oral Surgery, Oral Surgery Department, Guy´s and St Thomas´ Hospital, United Kingdom
| | - Jerry Kwok
- Consultant, Oral Surgery, Oral Surgery Department, Guy´s and St Thomas´ Hospital, United Kingdom
| | - Kiran Beneng
- Consultant, Oral Surgery, Oral Surgery Department, Guy´s and St Thomas´ Hospital, United Kingdom
| | - Vinod Patel
- Consultant, Oral Surgery, Oral Surgery Department, Guy´s and St Thomas´ Hospital, United Kingdom.
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14
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Tran L, Brodeur MR. Optimizing Pharmacotherapy for Direct Oral Anticoagulants in Older Adults: Strategies for Managing Drug Interactions. J Gerontol Nurs 2023; 49:7-13. [PMID: 37650852 DOI: 10.3928/00989134-20230815-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Direct oral anticoagulants (DOACs) have been increasingly used by older adults. Although these medications offer several therapeutic advantages over traditional anticoagulants, such as warfarin, they have limitations. One significant concern associated with DOACs is their potential for drug-drug interactions. These interactions may compromise the safe and effective use of DOACs and can potentially lead to serious adverse events and complications, particularly major bleeding. Polypharmacy is common among older adults with chronic diseases, which can increase the risk of drug-drug interactions with DOACs. The current article discusses the impact and risks of drug-drug interactions with DOACs in the context of older adults and explores ways to improve and manage these interactions through the collaboration of an interprofessional team. [Journal of Gerontological Nursing, 49(9), 7-13.].
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15
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Abdulrahman B, Jabbour RJ, Curzen N. Is It Really Safe to Discontinue Antiplatelet Therapy 12 Months After Percutaneous Coronary Intervention in Patients with Atrial Fibrillation? Interv Cardiol 2023; 18:e22. [PMID: 37435601 PMCID: PMC10331563 DOI: 10.15420/icr.2022.40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 03/29/2023] [Indexed: 07/13/2023] Open
Abstract
The prevalence of AF in patients with coronary artery disease is high. The guidelines from many professional groups, including the European Society of Cardiology, American College of Cardiology/American Heart Association and Heart Rhythm Society, recommend a maximum duration of 12 months of combination single antiplatelet and anticoagulation therapy in patients who undergo percutaneous coronary intervention and who have concurrent AF, followed by anticoagulation alone beyond 1 year. However, the evidence that anticoagulation alone without antiplatelet therapy adequately reduces the well-documented attritional risk of stent thrombosis after coronary stent implantation is relatively sparse, particularly given that very late stent thrombosis (>1 year from stent implantation) is the commonest type. By contrast, the elevated risk of bleeding from combined anticoagulation and antiplatelet therapy is clinically important. The aim of this review is to assess the evidence for long-term anticoagulation alone without antiplatelet therapy 1 year post-percutaneous coronary intervention in patients with AF.
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Affiliation(s)
- Balen Abdulrahman
- Coronary Research Group, University Hospital Southampton NHS Foundation TrustSouthampton, UK
| | - Richard J Jabbour
- Coronary Research Group, University Hospital Southampton NHS Foundation TrustSouthampton, UK
| | - Nick Curzen
- Coronary Research Group, University Hospital Southampton NHS Foundation TrustSouthampton, UK
- Faculty of Medicine, University of SouthamptonSouthampton, UK
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16
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Górnicki T, Bułdyś K, Zielińska D, Chabowski M. Direct-Acting Oral Anticoagulant Therapy in Cancer Patients-A Review. Cancers (Basel) 2023; 15:2697. [PMID: 37345034 DOI: 10.3390/cancers15102697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/21/2023] [Accepted: 05/08/2023] [Indexed: 06/23/2023] Open
Abstract
Venous thromboembolism (VTE) is an important aspect in cancer patients. There are various pharmacological methods used for thrombotic event treatment. DOACs (direct-acting oral anticoagulants) are gaining popularity among both physicians and researchers and are slowly starting to replace VKAs (vitamin K antagonists), thus becoming a substitute or alternative option for LMWHs (low-molecular-weight heparins). In this article, we present DOACs' main therapeutic advantages and disadvantages in patients with cancer. The only major concern with using DOACs is the higher risk of bleeding; however, there are discrepancies in this matter. There are still some types of cancer for which DOACs are not recommended. Specific cancer types may influence the efficacy of DOAC therapy. Additionally, race and ethnicity may affect therapy in cancer patients with DOACs. A sizeable number of clinical trials are focused on comparing DOACs with other anticoagulants. The current guidelines of different scientific associations are not unanimous in their DOAC assessments. There is still a need for more evidence of DOACs' potential advantages over other methods of anticoagulation in cancer patients to facilitate their position in this recommendation. This literature review presents the current state of knowledge about the use of DOACs in patients with neoplastic growth.
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Affiliation(s)
- Tomasz Górnicki
- Student Research Club No. 180, Faculty of Medicine, Wroclaw Medical University, 50-367 Wroclaw, Poland
- Division of Histology and Embryology, Department of Human Morphology and Embryology, Wroclaw Medical University, 50-368 Wroclaw, Poland
| | - Kacper Bułdyś
- Student Research Club No. 180, Faculty of Medicine, Wroclaw Medical University, 50-367 Wroclaw, Poland
| | - Dorota Zielińska
- Department of Surgery, 4th Military Teaching Hospital, 50-981 Wroclaw, Poland
| | - Mariusz Chabowski
- Department of Surgery, 4th Military Teaching Hospital, 50-981 Wroclaw, Poland
- Division of Anesthesiological and Surgical Nursing, Department of Nursing and Obstetrics, Faculty of Health Science, Wroclaw Medical University, 51-618 Wroclaw, Poland
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17
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Kellam CJ, Derraj J, Furletti GM, Ren B, Patel T. Hypercoagulable State and Thrombosis of Bioprosthetic Transcatheter Aortic Valve Replacement (TAVR) Refractory to Common Anticoagulation Methods in the Setting of Protein S Deficiency. Cureus 2023; 15:e38754. [PMID: 37303358 PMCID: PMC10249060 DOI: 10.7759/cureus.38754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 05/08/2023] [Indexed: 06/13/2023] Open
Abstract
Protein S deficiency is a form of thrombophilia in which the anticoagulant protein S is underproduced or not produced at all by the body. Lifelong anticoagulation is the mainstay of treatment. Transcatheter aortic valve replacement (TAVR) is a current treatment modality for patients with severe aortic stenosis. We are reporting the case of a patient with this disease who underwent a TAVR procedure and experienced valve leaflet thrombosis and large arterial thrombosis in the following months while fully anticoagulated with typical anticoagulation methods including warfarin, apixaban, and enoxaparin. Literature-based guidance is lacking with regard to anticoagulation in the setting of TAVR patients, especially in those with protein S deficiency. Based on our observations, warfarin was the better long-term prophylactic management method for our patient's protein S deficiency. Enoxaparin was most useful during periods of elevated thrombosis risk, including intra-/post-operative care and prolonged hospitalization periods. In the setting of her TAVR, we observed that warfarin use with a target international normalized ratio (INR) of 2.5-3.5 was the most effective outpatient treatment for the reversal of thrombosed bioprosthetic valve and improvement of cardiac ejection fraction. It is also possible that initial post-operative warfarin use would have been the most effective means of preventing valve thrombosis entirely in our protein S-deficient patient.
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Affiliation(s)
- Caleb J Kellam
- Medical School, Liberty University College of Osteopathic Medicine, Lynchburg, USA
| | - Jurxhin Derraj
- Medical School, Liberty University College of Osteopathic Medicine, Lynchburg, USA
| | - Gregory M Furletti
- Medical School, Liberty University College of Osteopathic Medicine, Lynchburg, USA
| | - Bibai Ren
- Internal Medicine, Hospitalist Associates of Virginia, Lynchburg, USA
| | - Toral Patel
- Heart and Vascular Institute, Centra Health, Lynchburg, USA
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18
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Zaib A, Shaheryar M, Shakil M, Sarfraz A, Sarfraz Z, Cherrez-Ojeda I. Local Tranexamic Acid for Preventing Hemorrhage in Anticoagulated Patients Undergoing Dental and Minor Oral Procedures: A Systematic Review and Meta-Analysis. Healthcare (Basel) 2022; 10:healthcare10122523. [PMID: 36554047 PMCID: PMC9778130 DOI: 10.3390/healthcare10122523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/11/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022] Open
Abstract
Dental procedures have posed challenges in managing anticoagulated patients due to early reports of oral hemorrhage. This study aims to evaluate the risks of postoperative bleeding with the local application of tranexamic acid. A systematic search was conducted until 31 March 2022, with keywords including tranexamic acid, oral hemorrhage, dental, and/or coagulation. The following databases were searched: PubMed, Scopus, Web of Science, CINAHL Plus, and Cochrane Library. Statistical analysis was conducted using Review Manager 5.4. In total, 430 patients were pooled in with the local application of tranexamic acid using mouthwash, irrigation, and compression with a gauze/gauze pad. The mean age was 61.8 years in the intervention group and 58.7 in the control group. Only 4 patients in the intervened group out of the 210 discontinued the trial due to non-drug-related adverse events. The risk difference was computed as -0.07 (p = 0.05), meaning that patients administered with local antifibrinolytic therapy for postoperative bleeding reduction for dental procedures were at a 7% less risk of oral bleeding. Current evidence on managing anticoagulated patients undergoing dental or oral procedures remains unclear. The present study presents favorable outcomes of postoperative bleeding with local tranexamic acid used in the postoperative period.
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Affiliation(s)
- Asma Zaib
- Department of Research, University Medical & Dental College Faisalabad, Faisalabad 38800, Pakistan
| | - Muhammad Shaheryar
- Department of Research, Rawal Institute of Health Sciences, Islamabad 45550, Pakistan
| | - Muhammad Shakil
- Department of Research, Frontier Medical & Dental College, Abbottabad 22030, Pakistan
| | - Azza Sarfraz
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi 74800, Pakistan
- Correspondence: (A.S.); (I.C.-O.)
| | - Zouina Sarfraz
- Department of Research and Publications, Fatima Jinnah Medical University, Lahore 54000, Pakistan
| | - Ivan Cherrez-Ojeda
- Department of Allergy and Pulmonology, Universidad Espíritu Santo, Samborondón 092301, Ecuador
- Correspondence: (A.S.); (I.C.-O.)
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19
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Saviano A, Brigida M, Petruzziello C, Candelli M, Gabrielli M, Ojetti V. Gastrointestinal Bleeding Due to NOACs Use: Exploring the Molecular Mechanisms. Int J Mol Sci 2022; 23:ijms232213955. [PMID: 36430433 PMCID: PMC9698754 DOI: 10.3390/ijms232213955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 11/09/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
Novel oral anticoagulants (NOACs) are drugs approved for the prevention and treatment of many thromboembolic cardiovascular conditions as a safer alternative to warfarin. We reviewed studies published in PubMed®, UpToDate®, Web of Science®, and Cochrane® about NOACs' risks and benefits in patients requiring anticoagulation, with a focus on gastrointestinal bleeding and on molecular and pathophysiological mechanisms underlying the risk of bleeding in patients treated with them. Apixaban resulted in a lower rate of gastrointestinal bleeding compared to dabigatran and rivaroxaban. However, data reported that gastrointestinal bleeding in patients treated with NOACs was less severe compared to warfarin. Studies show promising results on the increased and widespread use of NOACs in patients who require anticoagulation (for example-in case of atrial fibrillation or high risk of venous thromboembolism), reporting an overall lower risk of major bleeding events. The profile of NOACs was more effective and secure compared to warfarin, but a more careful medical prescription is required in patients who are at high risk of gastrointestinal bleeding.
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Affiliation(s)
- Angela Saviano
- Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, 00168 Rome, Italy
| | - Mattia Brigida
- Gastroenterology Unit, Department of Systems Medicine, Tor Vergata University, 00133 Rome, Italy
| | - Carmine Petruzziello
- Department of Emergency Medicine, San Carlo di Nancy Hospital, GVM Research, 00165 Rome, Italy
| | - Marcello Candelli
- Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, 00168 Rome, Italy
| | - Maurizio Gabrielli
- Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, 00168 Rome, Italy
| | - Veronica Ojetti
- Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, 00168 Rome, Italy
- Department of Emergency Medicine, Catholic University of the Sacred Heart, 00168 Rome, Italy
- Correspondence:
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20
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Current Antithrombotic Therapy Strategies in Children with a Focus on Off-Label Direct Oral Anticoagulants—A Narrative Review. CHILDREN 2022; 9:children9071093. [PMID: 35884077 PMCID: PMC9319670 DOI: 10.3390/children9071093] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 07/20/2022] [Accepted: 07/20/2022] [Indexed: 11/29/2022]
Abstract
(1) Background: The incidence of thromboembolic events is relatively low in the general population, but it increases in hospitalized children and those who underwent thrombogenic procedures. Although the evidence regarding direct oral anticoagulants (DOACs) in children with venous thromboembolism (VTE) is growing, DOACs were excluded from existing guidelines due to the lack of reliable data at that moment. Therefore, current evidence on VTE management in children needs to be critically reviewed. (2) Methods: We have conducted a literature search in the Scopus, EMBASE, and MEDLINE databases using prespecified keywords to retrieve studies published between 2010 and 2022. (3) Results: Clinical trials highlighted that rivaroxaban and dabigatran had predictable pharmacokinetic and pharmacodynamic profiles in children, similar to those observed in adults. Dabigatran and rivaroxaban had a similar safety profile to standard therapy but improved thrombotic burden and resolution during follow-up. Most studies involving apixaban and edoxaban are ongoing, and results are awaited. (4) Conclusions: Dabigatran and rivaroxaban could be valid therapeutic options for VTE management in children. In the case of apixaban and edoxaban, results from ongoing clinical studies are required before using them in pediatric VTE.
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21
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Ghasemi MA, Ghadimi E, Shamabadi A, Mortazavi SMJ. The Perioperative Management of Antiplatelet and Anticoagulant Drugs in Hip Fractures: Do the Surgery as Early as Possible. THE ARCHIVES OF BONE AND JOINT SURGERY 2022; 10:490-500. [PMID: 35928910 PMCID: PMC9295588 DOI: 10.22038/abjs.2021.56396.2800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 09/29/2021] [Indexed: 01/24/2023]
Abstract
Hip fractures are among the most common fractures operated by orthopedic surgeons. Many elderly patients, who account for a significant percentage of hip fractures, suffer from medical conditions requiring antiplatelet and anticoagulant administration. Meanwhile, considerable evidence recommends early surgery within 48b hours of admission. We aim to review the existing evidence regarding the perioperative management of antiplatelet and anticoagulant drugs in hip fractures. It was concluded that surgery for hip fractures in patients with antiplatelet drug consumption should not be delayed unless a clear contraindication exists. Active reversal strategies are indicated for patients with hip fractures and warfarin therapy. However, evidence for the safety of these agents in pregnancy, breastfeeding state, and adolescence has not yet been established. Little data exists about perioperative management of direct-acting oral anticoagulants in hip fractures. Early surgery after 12-24 hours of drug cessation has been suggested in studies; however, it should be employed cautiously. Despite extensive research, the importance of the issue necessitates additional higher-quality studies.
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Affiliation(s)
- Mohammad Ali Ghasemi
- Joint Reconstruction Research Center, Tehran University of Medical Science, Tehran, Iran
| | - Ehsan Ghadimi
- Joint Reconstruction Research Center, Tehran University of Medical Science, Tehran, Iran
| | - Ahmad Shamabadi
- Joint Reconstruction Research Center, Tehran University of Medical Science, Tehran, Iran, School of Medicine, Tehran University of Medical Science, Tehran, Iran
| | - SM Javad Mortazavi
- Joint Reconstruction Research Center, Tehran University of Medical Science, Tehran, Iran
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22
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Chua CXK, Tan JHI, Bin Abd Razak HR. Enoxaparin Versus Direct Oral Anticoagulants for Venous Thromboembolism in Asians Undergoing Total Knee Arthroplasty: A Meta-Analysis and Systematic Review. J Arthroplasty 2022; 37:593-600.e1. [PMID: 34843908 DOI: 10.1016/j.arth.2021.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/15/2021] [Accepted: 11/22/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The introduction of direct oral anticoagulants (DOACs) shows promise for their role as a chemoprophylaxis agent after total knee arthroplasty (TKA) for the prevention of venous thromboembolism (VTE). However, existing studies are largely based on Western populations that do not account for the different risk profiles and lower rates of VTE in Asians. This systematic review and meta-analysis aimed to evaluate the efficacy of DOACs compared with enoxaparin in an Asian-based population study. METHODS The review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All studies that compared outcomes between enoxaparin and DOACs as VTE prophylaxis after TKA in the Asian population were included. RESULTS Five studies with 121,153 patients were included. DOACs demonstrated a convincing benefit over enoxaparin in overall VTE prevention (odds ratio [OR] = 0.42, 95% confidence interval [CI]: 0.24-0.74). However, although the OR trended in favor of DOACs for the reduction of deep vein thrombosis events (OR = 0.54, 95% CI: 0.20-1.48) and pulmonary embolism (OR = 0.75, 95% CI: 0.07-8.20), statistical significance was not reached. In terms of bleeding complications, both arms had similar rates of major (0.91% vs 0.20%), clinically relevant nonmajor (3.28% vs 2.94%), and minor bleeding complications (12.8 vs 13.3%). A nonsignificance advantage of enoxaparin over DOACs was revealed in the OR for major bleeding (OR = 3.17; 95% CI: 0.81-12.43), whereas DOACs were favored to reduce risk of clinically relevant nonmajor (OR = 0.82; 95% CI: 0.01-91.51) and minor bleeding (OR = 0.76; 95% CI: 0.11-5.33). CONCLUSION DOACs confer a significantly reduced rate of overall VTE compared with enoxaparin in Asians after TKA. No significant differences in deep vein thrombosis, pulmonary embolism, and rates of bleeding complications exist.
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Affiliation(s)
- Chen Xi Kasia Chua
- National University Hospital Sports Centre, Department of Orthopaedic Surgery, National University Health System, Singapore
| | - Joelle Hwee Inn Tan
- National University Hospital Sports Centre, Department of Orthopaedic Surgery, National University Health System, Singapore
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Milling TJ, Refaai MA, Sengupta N. Anticoagulant Reversal in Gastrointestinal Bleeding: Review of Treatment Guidelines. Dig Dis Sci 2021; 66:3698-3714. [PMID: 33403486 PMCID: PMC9245141 DOI: 10.1007/s10620-020-06728-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 11/17/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Patients receiving anticoagulant therapies, such as vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs), commonly experience gastrointestinal (GI) bleeding as a complication and may require anticoagulant reversal prior to endoscopic treatment. Anticoagulant reversal agents include prothrombin complex concentrates (PCCs; including 3 or 4 coagulation factors), plasma, vitamin K, and target-specific DOAC reversal agents (e.g., idarucizumab and andexanet alfa). AIM To review current US, as well as international, guidelines for anticoagulant reversal agents in patients on VKAs or DOACs presenting with GI bleeding prior to endoscopy, guideline-based management of coagulation defects, timing of endoscopy, and recommendations for resumption of anticoagulant therapy following hemostasis. Supporting clinical data were also reviewed. METHODS This is a narrative review, based on PubMed and Internet searches reporting GI guidelines and supporting clinical data. RESULTS GI-specific guidelines state that use of reversal agents should be considered in patients with life-threatening GI bleeding. For VKA patients presenting with an international normalized ratio > 2.5, guidelines recommend PCCs (specifically 4F-PCC), as they may exhibit greater efficacy/safety compared with fresh frozen plasma in reversal of VKA-associated GI bleeding. For DOAC patients, most guidelines recommend targeted specific reversal agents in the setting of GI bleeding; however, PCCs (primarily 4F-PCC) are often listed as another option. Resumption of anticoagulant therapy following cessation of GI bleeding is also recommended to reduce risks of future thromboembolic complications. CONCLUSIONS The utility of anticoagulant reversal agents in GI bleeding is recognized in guidelines; however, such agents should be reserved for use in truly life-threatening scenarios.
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Affiliation(s)
- Truman J. Milling
- Departments of Neurology and Surgery and Perioperative Care, Seton Dell Medical School Stroke Institute, Austin, TX, USA
| | - Majed A. Refaai
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Neil Sengupta
- Section of Gastroenterology Hepatology and Nutrition, The University of Chicago, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL 60637, USA
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24
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Tarar MY, Choo XY, Khan S. The Risk of Bleeding Complications in Intra-Articular Injections and Arthrocentesis in Patients on Novel Oral Anticoagulants: A Systematic Review. Cureus 2021; 13:e17755. [PMID: 34659968 PMCID: PMC8493764 DOI: 10.7759/cureus.17755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2021] [Indexed: 11/13/2022] Open
Abstract
Novel oral anticoagulants (NOACs) are increasingly prescribed blood-thinning medication. Surpassing Warfarin, NOACs are more favored and extensively used in paroxysmal atrial fibrillation, acute coronary syndrome, and in elderly patients. Well-known benefits of novel oral anticoagulants include predictable pharmacokinetics, pharmacodynamics, and shorter half-life. However, as with any anticoagulant, there are bleeding risks with NOACs. There is a lack of evidence and consensus on the management of novel anticoagulants for intraarticular injections and arthrocentesis. This systematic review aims to analyze the risk of bleeding complications in patients on novel oral anticoagulants who underwent joint injections and arthrocentesis to help physicians in the decision-making and consenting process. A literature search of three online databases was completed using the Cochrane methodology for systematic reviews. Eligibility criteria included any study that reported bleeding complication rates in adult patients on novel oral anticoagulants that had a joint injection or aspiration whilst continuing their regular oral anticoagulation. All studies with any number of patients and published in any language were included. Review articles and systematic reviews were excluded. The search of databases resulted in a total of 310 articles. After screening, a total of four articles were deemed suitable to be included in the analysis. These described a total of 668 patients undergoing injections/aspiration procedures with patients on three different novel oral anticoagulants namely Rivaroxaban, Apixaban, and Dabigatran. Only one patient joint had a bleeding complication and the patient was on Dabigatran. The results of this systematic review show that it is relatively safe to perform joint injections and arthrocentesis whilst continuing on Novel oral anticoagulation.
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Affiliation(s)
| | - Xin Yin Choo
- Trauma and Orthopaedics, Blackpool Victoria Hospital, Blackpool, GBR
| | - Shoaib Khan
- Trauma and Orthopaedic, St Helens and Knowsley NHS Trust, Manchester, GBR
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25
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Chun HS, Choe AR, Lee M, Cho Y, Kim HY, Yoo K, Kim TH. Treatment of direct oral anticoagulants in patients with liver cirrhosis and portal vein thrombosis. Clin Mol Hepatol 2021; 27:535-552. [PMID: 34130370 PMCID: PMC8524067 DOI: 10.3350/cmh.2021.0109] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/06/2021] [Indexed: 11/30/2022] Open
Abstract
Although patients with cirrhosis are known to be in a state of “rebalance” in that pro- and anticoagulant factors increase the risk for both bleeding and thrombosis, the prevalence of portal vein thrombosis (PVT) in patients with cirrhosis can be up to 26%. Therefore, physicians should consider anticoagulation for the prevention and management of PVT in patients with cirrhosis who are at high risk of PVT. Vitamin K antagonist or low molecular weight heparin is suggested as the standard treatment for PVT in cirrhosis. With the advent of new direct-acting oral anticoagulants (DOACs), there is a paradigm shift of switching to DOACs for the treatment of PVT in patients with cirrhosis. However, the safety and efficacy of DOACs in the treatment of PVT was not well-known in patients with cirrhosis. Therefore, this review focused on the current knowledge about the efficacy, safety concerns, and hepatic metabolism of DOACs in patients with cirrhosis and PVT.
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Affiliation(s)
- Ho Soo Chun
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Ewha Womans University Medical Center, Seoul, Korea
| | - A Reum Choe
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Ewha Womans University Medical Center, Seoul, Korea
| | - Minjong Lee
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Ewha Womans University Medical Center, Seoul, Korea
| | - Yuri Cho
- Center for Liver and Pancreatobiliary Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Hwi Young Kim
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Ewha Womans University Medical Center, Seoul, Korea
| | - Kwon Yoo
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Ewha Womans University Medical Center, Seoul, Korea
| | - Tae Hun Kim
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Ewha Womans University Medical Center, Seoul, Korea
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26
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Brooker V, Brown R, Thornton L, Wood E. Emergency fasciotomy in an anticoagulated patient with low energy posterior thigh injury. BMJ Case Rep 2020; 13:e232709. [PMID: 32900715 PMCID: PMC7478037 DOI: 10.1136/bcr-2019-232709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2020] [Indexed: 11/03/2022] Open
Abstract
We present a case of a 58-year-old patient with a low energy trauma developing compartment syndrome. He required multiple surgeries, including fasciotomy and removal of a large haematoma. He continued to bleed with a vacuum-assisted closure dressing in situ, requiring prothrombin complex Concentrate and blood transfusion. This case highlights the need for an increased awareness of possible development of compartment syndrome following low impact trauma in a patient who is anticoagulated and raises the question of a possible period of observation for those who may be at risk.
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Affiliation(s)
| | - Robert Brown
- General Surgery, Countess of Chester Hospital, Chester, UK
| | | | - Edward Wood
- Orthopaedics, Countess of Chester Hospital, Chester, UK
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27
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Zuily S, Cohen H, Isenberg D, Woller SC, Crowther M, Dufrost V, Wahl D, Doré CJ, Cuker A, Carrier M, Pengo V, Devreese KMJ. Use of direct oral anticoagulants in patients with thrombotic antiphospholipid syndrome: Guidance from the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis. J Thromb Haemost 2020; 18:2126-2137. [PMID: 32881337 DOI: 10.1111/jth.14935] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/20/2020] [Accepted: 05/18/2020] [Indexed: 01/17/2023]
Abstract
Clarity and guidance is required with regard to the use of direct oral anticoagulants in antiphospholipid syndrome (APS) patients, within the confines of the recent European Medicines Agency recommendations, discrepant recommendations in other international guidelines and the limited evidence base. To address this, the Lupus Anticoagulant/Antiphospholipid Antibodies Scientific and Standardization Committee (SSC) chair and co-chairs together with SSC Control of Anticoagulation members propose guidance for healthcare professionals to help them manage APS patients. Uncertainty in this field will be addressed. This guidance will also serve as a call and focus for research.
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Affiliation(s)
- Stéphane Zuily
- Division of Vascular Medicine and Regional Competence Centre for Rare Vascular and Systemic Autoimmune Diseases, Nancy Academic Hospital, Nancy, France
- Inserm UMR_S 1116, Lorraine University, Nancy, France
| | - Hannah Cohen
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | - David Isenberg
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
| | - Scott C Woller
- Department of Medicine, Intermountain Medical Center, Murray, UT, USA
- Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Virginie Dufrost
- Division of Vascular Medicine and Regional Competence Centre for Rare Vascular and Systemic Autoimmune Diseases, Nancy Academic Hospital, Nancy, France
- Inserm UMR_S 1116, Lorraine University, Nancy, France
| | - Denis Wahl
- Division of Vascular Medicine and Regional Competence Centre for Rare Vascular and Systemic Autoimmune Diseases, Nancy Academic Hospital, Nancy, France
- Inserm UMR_S 1116, Lorraine University, Nancy, France
| | - Caroline J Doré
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Adam Cuker
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Vittorio Pengo
- Cardiology Clinic, Department of Cardiac-Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Katrien M J Devreese
- Coagulation Laboratory, Department of Diagnostic Sciences, Ghent University Hospital, Ghent, Belgium
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28
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Gavín O, Grandes J, García MA, Marzo C, Curcio A, Arístegui R, González M, Cerezo-Manchado JJ. Treatment preferences as basis for decision making in patients using direct oral anticoagulants in Spain. J Thromb Thrombolysis 2020; 51:475-484. [PMID: 32594421 PMCID: PMC7886773 DOI: 10.1007/s11239-020-02194-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Treatment preferences are considered a relevant decision-making driver by the main atrial fibrillation (AF) guidelines. Direct Oral Anticoagulants (DOACs), considered as similar clinically, have administration differences useful for treatment individualization. Preferences, priorities and satisfaction of DOAC users were assessed through an observational, multicentric (25 hospitals), cross-sectional study including adult AF-patients (and/or caregivers) in Spain. Three study groups were considered according to DOAC posology preferences: (A) once-daily, with water; (B) once-daily, with food; (C) twice-daily. Overall, 332 patients and 55 caregivers were included. Mean (SD) age was 73.7 (10.7) years [58.7 (13.9) for caregivers]; 51.5% women [69.1% for caregivers]; 80.7% showed comorbidities and poly-pharmacy [6.6 (3.3) drugs/day]. No statistically significant differences were shown among study groups. Once-daily administration was preferred by 274 patients (82.5%) [60.8% (Group A); 21.7% (Group B); 17.5% (Group C)], and 47 caregivers (85.5%) [58.2% (Group A); 27.3% (Group B); 14.5% (Group C)]. Once-daily DOACs were prescribed in 42.8% of the patients. Bleeding risk was the main concern for both, patients and caregivers, followed by DOAC posology and interactions. Although treatment satisfaction (patients and caregivers) was high (9.0 and 9.1 points, respectively), match between individual treatment preferences and real prescriptions was only shown in 41.0% of AF-patients, evidencing a need for patient involvement on treatment decision-making. There is not a patient profile linked to treatment preferences, and clinical criteria must be the main driver for decision-making. However, for most AF-patients (elderly patients), aged, with comorbidity, poly-pharmacy and high cardiovascular risk, once-daily DOACs would be the preferred option.
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Affiliation(s)
- Olga Gavín
- Hematology and Hemotherapy Service, Hospital Clínico Universitario Lozano Blesa, Avda. San Juan Bosco, 15, 50009, Zaragoza, Spain.
| | - Jesús Grandes
- Internal Medicine Service, Complexo Hospitalario Universitario de Vigo, Vigo, Spain
| | - Ma Almudena García
- Hematology and Hemotherapy Unit, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Cristina Marzo
- Haematology Service, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Alejandro Curcio
- Cardiology Service, Hospital Universitario de Fuenlabrada, Madrid, Spain
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29
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Choudhury M, Chalil S, Abozguia K. Life-threatening pericardial bleed complicating atrial fibrillation ablation associated with edoxaban therapy successfully managed with prothrombin complex concentrate. HeartRhythm Case Rep 2020; 6:163-165. [PMID: 32181137 PMCID: PMC7064795 DOI: 10.1016/j.hrcr.2019.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Moinuddin Choudhury
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, United Kingdom
| | - Shajil Chalil
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, United Kingdom
| | - Khalid Abozguia
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, United Kingdom
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30
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Vitamin K as a Diet Supplement with Impact in Human Health: Current Evidence in Age-Related Diseases. Nutrients 2020; 12:nu12010138. [PMID: 31947821 PMCID: PMC7019739 DOI: 10.3390/nu12010138] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 12/24/2019] [Accepted: 12/31/2019] [Indexed: 12/12/2022] Open
Abstract
Vitamin K health benefits have been recently widely shown to extend beyond blood homeostasis and implicated in chronic low-grade inflammatory diseases such as cardiovascular disease, osteoarthritis, dementia, cognitive impairment, mobility disability, and frailty. Novel and more efficient nutritional and therapeutic options are urgently needed to lower the burden and the associated health care costs of these age-related diseases. Naturally occurring vitamin K comprise the phylloquinone (vitamin K1), and a series of menaquinones broadly designated as vitamin K2 that differ in source, absorption rates, tissue distribution, bioavailability, and target activity. Although vitamin K1 and K2 sources are mainly dietary, consumer preference for diet supplements is growing, especially when derived from marine resources. The aim of this review is to update the reader regarding the specific contribution and effect of each K1 and K2 vitamers in human health, identify potential methods for its sustainable and cost-efficient production, and novel natural sources of vitamin K and formulations to improve absorption and bioavailability. This new information will contribute to foster the use of vitamin K as a health-promoting supplement, which meets the increasing consumer demand. Simultaneously, relevant information on the clinical context and direct health consequences of vitamin K deficiency focusing in aging and age-related diseases will be discussed.
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31
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Abstract
Administration of direct oral anticoagulants (DOACs) for the treatment of venous thrombotic events (VTE) or non-valvular atrial fibrillation (AF) is now standard of care and has demonstrated clinical efficacy and safety in numerous clinical studies. Usually these substances have lower overall mortality and less risk of cerebral hemorrhage, but depending on the substance and study, they are more likely to cause gastrointestinal bleeding than vitamin K antagonists (VKA), the medication that used to be standard for VTE and AF. Since DOACs have very short plasma elimination half-lives compared to VKA, for most bleeding events, expert opinions suggest that withdrawal of DOACs and supportive care will likely suffice to stop a bleeding episode. Because there is a bleeding risk associated with DOACs, reversal strategies may be needed if a patient receiving DOAC therapy bleeds during surgery or an invasive procedure. So far, idarucizumab has been the only available antidote that binds specifically to dabigatran and safely and quickly reverses its anticoagulant effects. Idarucizumab has no effects on anti Xa inhibitors or other anticoagulants. To date, treatment of serious, life-threatening bleeds in patients with anti-Xa-inhibitor has involved 4 factor prothrombin complex concentrates (PCC). PCC restores normal hemostasis laboratory values in most patients with major bleeding events after anti Xa inhibitor intake. Recently, the US Food and Drug Administration (FDA) approved andexanet alfa as the first specific antidote for the anti-Xa inhibitors apixaban and rivaroxaban. So far clinical experience with this substance and data comparing it with PCC are lacking. Currently ciraparantag is under investigation as a universal reversal agent for all DOACs and low molecular weight heparin as well. Because it is so broadly applicable, ciraparantag might be a good future option for the management of most bleeding complications under anticoagulant treatment. The aim of this review is to summarize recent study data and recommendations on nonspecific and specific DOAC reversal strategies and to present the current evidence.
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Affiliation(s)
- Paul Gressenberger
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Austria
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32
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Spahn DR, Beer JH, Borgeat A, Chassot PG, Kern C, Mach F, Nedeltchev K, Korte W. NOACs in Anesthesiology. Transfus Med Hemother 2019; 46:282-293. [PMID: 31700511 DOI: 10.1159/000491400] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 06/17/2018] [Indexed: 12/29/2022] Open
Abstract
Background Due to increasing use of new oral anticoagulants (NOACs), clinicians are faced more and more frequently with clinical issues related to these drugs. Objective The objective of this publication is to make practical suggestions for the perioperative management of NOACs as well as for their handling in overdoses and bleedings. Recommendations In elective surgery and creatinine clearance ≥ 50 ml/min, a NOAC should be discontinued 24-36 h before the intervention, and even earlier in case of reduced kidney function. In emergency interventions that cannot be delayed, the management is dependent on the NOAC plasma levels. With levels ≤ 30 ng/ml, surgery can be performed. With levels >30 ng/ml, reversal agents should be considered. In low bleeding risk surgery, NOACs can be re-started 24 h after the intervention, which is prolonged to 48-72 h after surgery with high bleeding risk. In case of NOAC overdose and minor bleedings, temporary discontinuation and supportive care are usually sufficient to control the situation. In severe or life-threatening bleedings, nonspecific and specific reversal agents should be considered.
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Affiliation(s)
- Donat R Spahn
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Jürg-Hans Beer
- Department of Internal Medicine, Cantonal Hospital of Baden, Baden, Switzerland
| | - Alain Borgeat
- Department of Anesthesiology, Balgrist University Hospital, Zurich, Switzerland
| | - Pierre-Guy Chassot
- Formerly Department of Anesthesiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Christian Kern
- Department of Anesthesiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - François Mach
- Department of Internal Medicine, University Hospitals of Geneva (HUG), Geneva, Switzerland
| | | | - Wolfgang Korte
- Center for Laboratory Medicine; Hemostasis and Hemophilia Center, St. Gallen, Switzerland
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Müller M, Schlittler F, Schaller B, Nagler M, Exadaktylos AK, Sauter TC. Characteristics, treatment and outcome of bleeding after tooth extraction in patients on DOAC and phenprocoumon compared to non-anticoagulated patients-a retrospective study of emergency department consultations. Clin Oral Investig 2018; 23:2273-2278. [PMID: 30291493 DOI: 10.1007/s00784-018-2676-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 10/01/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Bleeding after tooth extraction range from minor bleeding to life-threating haemorrhagic shock and are among the leading complications in patients under oral anticoagulation with direct oral anticoagulants (DOACs) or phenprocoumon. Little is known about how anticoagulation in patients under DOAC or phenprocoumon alters the characteristics, treatment or outcome of bleeding events, in comparison to non-anticoagulated patients. METHODS Patients admitted to a tertiary ED in Bern, Switzerland, from June 1st 2012 to 31st May 2016 with bleeding related to tooth extraction under DOAC, phenprocoumon or without anticoagulation, were compared. RESULTS Out of 161,458 emergency consultations, 64 patients with bleeding from tooth extraction were included in our study. In anticoagulation groups, we found significantly more delayed bleeding events than in patients without anticoagulation (9 (81.3%) DOAC, 19 (86.4%) phenprocoumon, 8 (30.8%) no anticoagulation, p < 0.001). Anticoagulated patients had to stay longer in the ED than non-anticoagulated patients, with no significant difference between DOAC or phenprocoumon (hours: 4.8 (3.2-7.6 IQR) DOAC, 3.0 (2.0-5.5 IQR) phenprocoumon, p = 0.133; 2.7 (1.6-4.6) no anticoagulation; p = 0.039). More patients with anticoagulation therapy needed surgery than patients without anticoagulant therapy (11 (68.8%) DOAC, 12 (54.6%) VKA, p = 0.506; 7(26.9%) no anticoagulation; p = 0.020). CONCLUSIONS Delayed bleeding occur more often in anticoagulated patients with both DOAC and phenprocoumon compared to patients without anticoagulation. Bleeding events in anticoagulated patients with DOAC and phenprocoumon equally need longer ED treatment and more frequent surgical intervention. CLINICAL RELEVANCE Caution with delayed bleeding in anticoagulated patients with DOACs and phenprocoumon is necessary and treatment of bleeding is resource-demanding.
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Affiliation(s)
- Martin Müller
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fabian Schlittler
- Department of Cranio-Maxillofacial Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Benoit Schaller
- Department of Cranio-Maxillofacial Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael Nagler
- Department of Haematology and Central Haematology Laboratory, Inselspital University Hospital, Bern, Switzerland
| | - Aristomenis K Exadaktylos
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas C Sauter
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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