Incidence, clinical impact and risk of bleeding during oral anticoagulation therapy

Factor Xa inhibitors versus low-molecular-weight heparin for preventing coagulopathy following COVID-19: a systematic review and meta-analysis of randomized controlled trials

Background

Hospitalized patients with COVID-19 have shown a significant occurrence of thromboembolism and a heightened risk of death. It remains unclear whether factor Xa inhibitors are superior to enoxaparin in this context. Hence, there is a need for a direct comparison to assess the preventive effects and safety of factor Xa inhibitors versus enoxaparin in hospitalized COVID-19 patients.

Methods

MEDLINE, Embase, and Cochrane Central databases were searched for randomized controlled trials (RCTs) or retrospective studies that compared the effectiveness or safety of factor Xa inhibitors and enoxaparin in preventing thromboembolism in hospitalized patients with COVID-19. Embolic incidence, incidence of bleeding, and all-cause mortality were among the outcomes of interest. Mantel-Haenszel weighted random-effects model was used to calculate relative risks (RRs) with 95 percent CIs.

Results

The analysis included six RCTs and two retrospective studies containing 4048 patients. Meta-analysis showed a statistically significant reduction among patients on factor Xa inhibitors compared with low-molecular-weight heparin (LMWH) in the embolic incidence [risk ratio (RR) 0.64 (95%, CI 0.42, 0.98); P=0.04, I2=12%]. Upon subgroup analysis by type of study design, no significant reductions were noted in patients on factor Xa inhibitors in RCTs (RR: 0.62; 95% CI: 0.33-1.17; P=0.14) or observational studies (RR: 0.53; 95% CI: 0.23-1.26; P=0.15) when compared with enoxaparin Factor Xa inhibitors were not significantly associated with incidence of bleeding [RR 0.76 (95% CI 0.36, 1.61); P=0.47, I2=0%] or all-cause mortality (RR: 0.81; 95% CI: 0.48-1.36; P=0.43). Consistent results were obtained upon subgroup analysis by the type of study design.

Conclusion

Factor Xa inhibitors are more effective than enoxaparin in preventing thromboembolism among patients with COVID-19 who are not acutely ill and are hospitalized. Additional rigorous RCTs comparing factor Xa inhibitors with enoxaparin are warranted.

Challenges and advances in device-related thrombus in left atrial appendage occlusion

Oral anticoagulation therapy (OAC) is a mainstay for mitigating stroke and other embolic events in patients with atrial fibrillation (AF). Despite the demonstrated efficacy of OAC in reducing events, many patients are unable to tolerate OAC due to bleeding risks. Left atrial appendage occlusion (LAAO) devices were developed as implantable technologies to moderate stroke risk in patients with intolerance to OAC. Despite clinical data supporting near-comparable protection against thromboembolic events with OAC, device-related thrombus formation has emerged as a critical complication following LAAO that remains a potential limitation to the safety and efficacy of LAAO. Improved biocompatibility of LAAO devices with fluoropolymers, a well-established stent-coating technology used to reduce thrombus formation and promote endothelialization, may optimize outcomes after LAAO.

The risk of hemorrhagic complications after anticoagulation therapy in trauma patients: A multicenter evaluation

BACKGROUND

The use of anticoagulation therapy (ACT) in trauma patients during the postinjury period presents a challenge given the increased risk of hemorrhage. Guidelines regarding whether and when to initiate ACT are lacking, and as a result, practice patterns vary widely. The purpose of this study is to describe the incidence of hemorrhagic complications in patients who received ACT during their hospitalization, identify risk factors, and characterize the required interventions.

METHODS

In this retrospective cohort study, all trauma admissions at two Level I trauma centers between January 2015 and December 2020 were reviewed. Patients with preexisting ACT use or those who developed a new indication for ACT were included for analysis. Demographic and outcome data were collected for those who received ACT during their admission. Comparisons were then made between the complications and no complications groups. A subgroup analysis was performed for all patients started on ACT within 14 days of injury.

RESULTS

A total of 812 patients were identified as having an indication for ACT, and 442 patients received ACT during the postinjury period. The overall incidence of hemorrhagic complications was 12.7%. Of those who sustained hemorrhagic complications, 18 required procedural intervention. On regression analysis, male sex, severe injuries, and the need for hemorrhage control surgery on arrival were all found to be associated with hemorrhagic complications after the initiation of ACT. Waiting 7 days to 14 days from the time of injury to initiate ACT reduced the odds of complications by 46% and 71%, respectively.

CONCLUSION

The use of ACT in trauma during the postinjury period is not without risk. Waiting 7 days to 14 days postinjury might greatly reduce the risk of hemorrhagic complications.

LEVEL OF EVIDENCE

Therapeutic/Care Management Study; Level IV.

Developing a machine learning model for bleeding prediction in patients with cancer-associated thrombosis receiving anticoagulation therapy

BACKGROUND

Only 1 conventional score is available for assessing bleeding risk in patients with cancer-associated thrombosis (CAT): the CAT-BLEED score.

OBJECTIVES

Our aim was to develop a machine learning-based risk assessment model for predicting bleeding in CAT and to evaluate its predictive performance in comparison to that of the CAT-BLEED score.

METHODS

We collected 488 attributes (clinical data, biochemistry, and International Classification of Diseases, 10th Revision, diagnosis) in 1080 unique patients with CAT. We compared CAT-BLEED score, Ridge and Lasso logistic regression, random forest, and Extreme Gradient Boosting (XGBoost) algorithms for predicting major bleeding or clinically relevant nonmajor bleeding occurring 1 to 90 days, 1 to 365 days, and 90 to 455 days after venous thromboembolism (VTE).

RESULTS

The predictive performances of Lasso logistic regression, random forest, and XGBoost were higher than that of the CAT-BLEED score in the prediction of bleeding occurring 1 to 90 days and 1 to 365 days after VTE. For predicting major bleeding or clinically relevant nonmajor bleeding 1 to 90 days after VTE, the CAT-BLEED score achieved a mean area under the receiver operating characteristic curve (AUROC) of 0.48 ± 0.13, while Lasso logistic regression and XGBoost both achieved AUROCs of 0.64 ± 0.12. For predicting bleeding 1 to 365 days after VTE, the CAT-BLEED score achieved a mean AUROC of 0.47 ± 0.08, while Lasso logistic regression and XGBoost achieved AUROCs of 0.64 ± 0.08 and 0.59 ± 0.08, respectively.

CONCLUSION

This is the first machine learning-based risk model for bleeding prediction in patients with CAT receiving anticoagulation therapy. Its predictive performance was higher than that of the conventional CAT-BLEED score. With further development, this novel algorithm might enable clinicians to perform personalized anticoagulation strategies with improved clinical outcomes.

Oral Anticoagulation Versus Antiplatelet Treatment After Mitral Valve Repair: A Systematic Review and Meta-Analysis

Oral anticoagulation with vitamin K antagonists is currently advised for a period of 3 months after surgical mitral valve repair, regardless of the rhythm status. The evidence supporting this recommendation is weak and recent studies have challenged the safety and efficacy of this recommendation. A systematic review of literature was conducted by searching PubMed, Embase, Web of Science, Emcare, and Cochrane Library databases for original publications comparing the efficacy and safety of oral anticoagulation with vitamin K antagonists to antiplatelet treatment early after mitral valve surgery in patients with no atrial fibrillation. Study end points included thromboembolic complications, bleeding complications and survival. A total of 5 studies, including 5,093 patients, met the inclusion criteria; 2,824 patients were included in the oral anticoagulation and 2,269 in the antiplatelet treatment group. Pooled analyses demonstrated no beneficial effect of oral anticoagulation on the incidence of thromboembolic complications (risk ratio 1.14, 95% confidence interval 0.76 to 1.70, p = 0.53, I2 = 8%). Moreover, oral anticoagulation did not result in a significantly increased risk of bleeding complications (risk ratio 0.89, 95% confidence interval 0.32 to 2.44, p = 0.81, I2 = 87%). When combining the efficacy and safety end points, no difference was observed between groups (risk ratio 1.01, 95% confidence interval 0.51 to 1.97, p = 0.99 I2 = 85%). Likewise, mortality did not differ between groups (risk ratio 0.89, 95% confidence interval 0.15 to 5.23, p = 0.90 I2 = 71%). Our results confirmed the safety but failed to confirm the efficacy of oral anticoagulation in patients who underwent mitral valve surgery. A randomized controlled trial would provide the evidence needed to support treatment recommendations.

Apixaban or Warfarin in Patients with an On-X Mechanical Aortic Valve

BACKGROUND: Vitamin K antagonists are the only oral anticoagulants approved to prevent valve thrombosis and valve-related thromboembolism in patients with mechanical heart valves. Whether patients with an On-X mechanical aortic valve can be safely anticoagulated with apixaban is unknown. METHODS: Patients with an On-X aortic valve implanted at least 3 months before enrollment were randomly assigned to receive apixaban 5 mg twice daily or warfarin (target international normalized ratio 2.0 to 3.0). The primary efficacy end point was the composite of valve thrombosis or valve-related thromboembolism with coprimary analyses comparing apixaban with warfarin for noninferiority and comparing the apixaban event rate with an objective performance criterion (OPC). RESULTS: The trial was stopped after 863 participants were enrolled owing to an excess of thromboembolic events in the apixaban group. Most (94%) participants took aspirin. A total of 26 primary end-point events occurred, 20 (in 16 participants) in the apixaban group (4.2%/patient-year; 95% confidence interval [CI], 2.3 to 6.0) and 6 (in 6 participants) in the warfarin group (1.3%/patient-year; 95% CI, 0.3 to 2.3). The difference in primary end-point rates between the apixaban and warfarin groups was 2.9 (95% CI, 0.8 to 5.0); noninferiority and OPC success criteria were not met. Major bleeding rates were 3.6%/patient-year with apixaban and 4.5%/patient-year with warfarin. CONCLUSIONS: Apixaban did not demonstrate noninferiority to warfarin and is less effective than warfarin for the prevention of valve thrombosis or thromboembolism in patients with an On-X mechanical aortic valve. (Funded by Artivion; ClinicalTrials.gov number, NCT04142658.)

Spontaneous periocular ecchymosis: a major review

Periocular ecchymosis, or periocular bruising, is a common clinical finding. Periocular skin is thin with an extensive vascular network, making this anatomical region prone to bruising. The most common etiology is trauma, but rarely, patients can present with spontaneous periocular ecchymosis (SPE). The pathophysiology of SPE is complex and varied. In this literature review of 121 articles, we assessed the frequency and variety of causation of this infrequent entity. The main finding was that by far the most common diagnosis causing SPE is amyloidosis and neoplasm, most notably neuroblastoma. Amyloidosis accounted for 23% articles (28/121) and neuroblastoma for 17% articles (21/121). Overall, neoplastic processes accounted for 30% of the articles (36/121), raised intracranial pressure and vascular malformations for 19% of the articles (23/121), migraine and atypical headache for 7% of the articles (8/121), while iatrogenic accounted for 5% of the articles (6/121). Through exploration and appreciation of the pathophysiology, we hope to foster a greater understanding in the clinician to establish underlying etiology, from benign to life-threatening, when presented with SPE.

Low-Dose vs Standard Warfarin After Mechanical Mitral Valve Replacement: A Randomized Trial

BACKGROUND

Current guidelines recommend a target international normalized ratio (INR) range of 2.5 to 3.5 in patients with a mechanical mitral prosthesis. The Prospective Randomized On-X Anticoagulation Clinical Trial (PROACT) Mitral randomized controlled noninferiority trial assessed safety and efficacy of warfarin at doses lower than currently recommended in patients with an On-X (Artivion, Inc) mechanical mitral valve.

METHODS

After On-X mechanical mitral valve replacement, followed by at least 3 months of standard anticoagulation, 401 patients at 44 North American centers were randomized to low-dose warfarin (target INR, 2.0-2.5) or standard-dose warfarin (target INR, 2.5-3.5). All patients were prescribed aspirin, 81 mg daily, and encouraged to use home INR testing. The primary end point was the sum of the linearized rates of thromboembolism, valve thrombosis, and bleeding events. The design was based on an expected 7.3% event rate and 1.5% noninferiority margin.

RESULTS

Mean patient follow-up was 4.1 years. Mean INR was 2.47 and 2.92 (P <.001) in the low-dose and standard-dose warfarin groups, respectively. Primary end point rates were 11.9% per patient-year in the low-dose group and 12.0% per patient-year in the standard-dose group (difference, -0.07%; 95% CI, -3.40% to 3.26%). The CI >1.5%, thus noninferiority was not achieved. Rates (percentage per patient-year) of the individual components of the primary end point were 2.3% vs 2.5% for thromboembolism, 0.5% vs 0.5% for valve thrombosis, and 9.13% vs 9.04% for bleeding.

CONCLUSIONS

Compared with standard-dose warfarin, low-dose warfarin did not achieve noninferiority for the composite primary end point. (PROACT Clinicaltrials.gov number, NCT00291525).

Intestinal Spontaneous Intramural Hematoma Secondary to Anticoagulation Therapy: A Case Report

A common complication of anticoagulation therapy is bleeding, especially in patients receiving long-term vitamin K antagonists. Spontaneous intramural hematoma is a rare etiology among life-threatening major bleeds. An 80-year-old female patient presented with diffuse abdominal pain. Her history included ischemic heart disease and chronic atrial fibrillation treated with 3 mg of acenocoumarol per day. Three days before her admission, she developed diffuse abdominal pain with fecaloid vomiting, bloating, and not passing gas. Palpation of the abdomen revealed asymmetrical distension and pain, with no signs of peritoneal irritation or bleeding. Investigations showed anemia with a hemoglobin level of 9.2 g/dL, a white blood cell count of 14200/mm³, a C-reactive protein of 112.6 mg/L, and a prothrombin time of 75.1 seconds with an international normalized ratio (INR) of 8.5. Abdominal contrast-enhanced computed tomography (CT) showed segmental parietal thickening, luminal narrowing, and partial small bowel obstruction secondary to an intramural jejunum hematoma responsible for a gallbladder occlusion with infiltration of the mesenteric fat in front. The patient recovered two days after conservative treatment. In this case, we report an unusual small bowel intramural hematoma of the jejunum secondary to anticoagulant therapy. Physicians should be aware of this unusual cause of abdominal pain. Early diagnosis may avoid unnecessary surgical exploration.

Risk factors and management outcomes in epistaxis: a tertiary centre experience

BACKGROUND

Risk factors and outcomes associated with severe epistaxis are not well understood. This study explores the associations between epistaxis severity, comorbidities, use of antiplatelets or anticoagulants and management outcomes.

METHODS

This is a retrospective cross-sectional study of all epistaxis cases presenting to the emergency department at a tertiary academic hospital from January 2016 to December 2019. Epistaxis severity was defined as mild (no intervention), moderate (required cautery and/or packing) and severe (clinical instability with reversal products, surgical or radiological intervention). Univariable and multivariable regression analyses were undertaken, with risk factors and management outcomes analysed according to severity.

RESULTS

A total of 543 patients with epistaxis (54.2% male, mean age 74.4 ± 15.7 years) were included in this study, with 14.7% (80) having severe epistaxis. Of these presentations 216 (39.8%) were on antiplatelets, while 207 (38.1%) were on anticoagulants. In univariate analyses, clopidogrel use, hereditary haemorrhagic telangiectasia (HHT), haematological malignancy, bleeding disorders and chronic liver disease (CLD) were associated with moderate to severe epistaxis (P < 0.05), while the use of rivaroxaban was inversely associated severity (P = 0.002). Only HHT, haematological malignancy and CLD remained significant in multivariate models. Cautery as first-line management was infrequently utilized while anticoagulation was frequently withheld. A longer length of stay (1.1 days vs. 4.3 days; P < 0.001) and higher 2-week readmission rates (2.2% vs. 12.5%; P < 0.001) were noted with severe epistaxis compared with mild presentations.

CONCLUSION

Epistaxis severity is associated with certain clinical conditions and poor outcomes. Despite recommended guidelines, variations in first-line management were evident.

Large Burden of Stroke Incidence in People with Cardiac Disease: A Linked Data Cohort Study

Purpose

People with cardiac disease have 2-4 times greater risk of stroke than the general population. We measured stroke incidence in people with coronary heart disease (CHD), atrial fibrillation (AF) or valvular heart disease (VHD).

Methods

We used a person-linked hospitalization/mortality dataset to identify all people hospitalized with CHD, AF or VHD (1985-2017), and stratified them as pre-existing (hospitalized 1985-2012 and alive at October 31, 2012) or new (first-ever cardiac hospitalization in the five-year study period, 2012-2017). We identified first-ever strokes occurring from 2012 to 2017 in patients aged 20-94 years and calculated age-specific and age-standardized rates (ASR) for each cardiac cohort.

Results

Of the 175,560 people in the cohort, most had CHD (69.9%); 16.3% had multiple cardiac conditions. From 2012-17, 5871 first-ever strokes occurred. ASRs were greater in females than males in single and multiple condition cardiac groups, largely driven by rates in females aged ≥75 years, with stroke incidence in this age group being at least 20% greater in females than males in each cardiac subgroup. In females aged 20-54 years, stroke incidence was 4.9-fold greater in those with multiple versus single cardiac conditions. This differential declined with increasing age. Non-fatal stroke incidence was greater than fatal stroke in all age groups except in the 85-94 age group. Incidence rate ratios were up to 2-fold larger in new versus pre-existing cardiac disease.

Conclusion

Stroke incidence in people with cardiac disease is substantial, with older females, and younger patients with multiple cardiac conditions, at elevated risk. These patients should be specifically targeted for evidence-based management to minimize the burden of stroke.

The association between cancer diagnosis, care, and outcomes in 1 million patients hospitalized for acute pulmonary embolism

OBJECTIVES

To evaluate the clinical care provided to cancer patients hospitalized for acute pulmonary embolism (PE), as well as the association between type of cancer, in-hospital care, and clinical outcomes.

METHODS

This study examined the in-hospital care (systemic thrombolysis, catheter-directed thrombolysis, and surgical thrombectomy/embolectomy) and clinical outcomes (mortality, major bleeding, and hemorrhagic stroke) among adults hospitalized due to acute PE between October 2015 to December 2018 using the National Inpatient Sample (NIS). Multivariable logistic regression analysis was used to determine adjusted odds ratios (aOR) with 95% confidence interval (95% CI).

RESULTS

Of 1,090,130 hospital records included in the analysis, 216,825 (19.9%) had current cancer diagnoses, including lung (4.7%), hematological (2.5%), colorectal (1.6%), breast (1.3%), prostate (0.8%), and 'other' cancer (9.0%). Cancer patients had lower adjusted odds of receiving systemic thrombolysis, catheter-directed therapy, and surgical thrombectomy/embolectomy compared with their non-cancer counterparts (P < 0.001), except for systemic thrombolysis (aOR 0.96, 95% CI 0.85-1.09, P = 0.553) and catheter-directed therapy (aOR 0.82, 95% CI 0.67-1.00, P = 0.053) for prostate cancer. Cancer patients had greater odds of mortality (P < 0.05). Lung cancer patients had the highest odds of mortality (aOR 2.68, 95% CI 2.61-2.76, P < 0.001) and hemorrhagic stroke (aOR 1.75, 95% CI 1.61-1.90, P < 0.001), while colorectal cancer patients had the greatest odds of bleeding (aOR 2.04, 95% CI 1.94-2.15, P < 0.001).

CONCLUSION

Among those hospitalized for PE, cancer diagnoses were associated with lower odds of invasive management and poorer in-hospital outcomes, with metastatic status being an especially important determinant. Appropriateness of care could not be assessed in this study.

Evidence-based Management of Major Bleeding in Patients Receiving Direct Oral Anticoagulants: An Updated Narrative Review on the Role of Specific Reversal Agents

The indications of direct oral anticoagulants (DOACs) have expanded over the past 15 years. DOACs are effective and safe oral anticoagulants associated with lower bleeding risks and mortality than vitamin K antagonists. However, DOAC users are prone to a considerable bleeding risk, which can occur at critical sites or lead to severe life-threatening conditions. Recent statistics indicated that major bleeding occurs in up to 6.62 DOAC users per 100 treatment years. With the increased use of DOACs in clinical practice, DOAC-associated major bleeding is expected to be encountered more frequently in the emergency department. The current international guidelines recommend specific reversal agents for the management of DOAC users with severe bleeding to reverse the anticoagulant effect and restore normal hemostasis. An individualized assessment was incorporated in specific clinical situations to guide the decision pathway of major bleeding management. However, specific reversal agents are unavailable or have limited availability in many countries, which is expected to negatively impact the clinical outcomes of DOAC-associated major bleeding. Limited real-world evidence is available from these countries regarding the clinical outcomes of patients with DOAC-associated major bleeding. This narrative review provided an updated assessment of the evidence-based approaches for the management of major bleeding in DOAC users. We also explored the clinical outcomes of patients with major bleeding from clinical settings where specific reversal agents are unavailable.

Challenges in managing patients on anticoagulation: Thrombocytopenia, resumption after bleeding and recurrent thrombosis

Prescribing of anticoagulation is increasing worldwide. This is partly reflective of an aging population with cardiovascular comorbidities such as arrhythmias and prosthetic heart valves, alongside improvements in cancer treatments and survival. In this review, we discuss three common challenges faced by clinicians. These concern the management of patients with thrombosis and thrombocytopenia, resumption of anticoagulation in patients with a history of gastrointestinal or intracranial haemorrhage, and how to approach and treat a patient with recurrent thrombosis on anticoagulation. We consider the available evidence including relevant published recommendations and propose practical management suggestions to aid clinicians faced with these dilemmas.

Effectiveness and safety of apixaban vs warfarin among venous thromboembolism patients at high-risk of bleeding

This study evaluated effectiveness and safety of apixaban versus warfarin among venous thromboembolism patients at high-risk of bleeding (defined as having at least one of the following bleeding risk factors: ≥75 years; used antiplatelet, NSAIDs, or corticosteroids; had prior gastrointestinal bleeding or gastrointestinal-related conditions; late stage chronic kidney disease). Adult venous thromboembolism patients initiating apixaban or warfarin with ≥1 bleeding risk factor were identified from Medicare and four commercial claims databases in the United States. To balance characteristics between apixaban and warfarin patients, stabilized inverse probability treatment weighting was conducted. Cox proportional hazards models were used to estimate the risk of recurrent venous thromboembolism, major bleeding, and clinically relevant non-major bleeding. In total, 88,281 patients were identified. After inverse probability treatment weighting, the baseline patient characteristics were well-balanced between the two cohorts. Among venous thromboembolism patients at high-risk of bleeding, apixaban was associated with significantly lower risk of recurrent venous thromboembolism, major bleeding and clinically relevant non-major bleeding. No significant interactions were observed between treatment and number of risk factors on major bleeding and clinically relevant non-major bleeding or between treatment and type of bleeding risk factors on any of the outcomes. In conclusion, apixaban was associated with significantly lower risk of recurrent venous thromboembolism and bleeding among venous thromboembolism patients at high-risk of bleeding. Effects were generally consistent across subgroups of patients with different number or type of bleeding risk factors.

In Search of the Appropriate Anticoagulant-Associated Bleeding Risk Assessment Model for Cancer-Associated Thrombosis Patients

Simple Summary

Patients with venous thromboembolism events in the context of cancer should receive anticoagulants as long as the cancer is active. Therefore, a tailor-made anticoagulation strategy should rely on an individualized assessment of the risks of recurrent venous thromboembolism and anticoagulant-associated bleeding. No existing risk assessment model for anticoagulant-associated bleeding risk has been validated for cancer-associated thrombosis. To obtain a better risk assessment model to assess anticoagulant-associated bleeding risk in cancer-associated thrombosis patients, we deemed it necessary to answer questions related to how and when to assess anticoagulant-associated bleeding risk as well as what factors to assess for which patients.

Abstract

Patients with venous thromboembolism events (VTE) in the context of cancer should receive anticoagulants as long as the cancer is active. Therefore, a tailor-made anticoagulation strategy should rely on an individualized risk assessment model (RAM) of recurrent VTE and anticoagulant-associated bleeding. The aim of this review is to investigate the applicability of the currently available RAMs for anticoagulant-associated bleeding after VTE in the CAT population and to provide new insights on how we can succeed in developing a new anticoagulant-associated bleeding RAM for the current medical care of CAT patients. A systematic search for peer-reviewed publications was performed in PubMed. Studies, including systematic reviews, were eligible if they comprised patients with VTE and used a design for developing a prediction model, score, or other prognostic tools for anticoagulant-associated bleeding during anticoagulant treatment. Out of 15 RAMs, just the CAT-BLEED was developed for CAT patients and none of the presented RAMs developed for the VTE general population were externally validated in a population of CAT patients. The current review illustrates the limitations of the available RAMs for anticoagulant-associated bleeding in CAT patients. The development of a RAM for bleeding risk assessment in patients with CAT is warranted.

Bleeding Risk Following Stereotactic Body Radiation Therapy for Localized Prostate Cancer in Men on Baseline Anticoagulant or Antiplatelet Therapy

Purpose

Patients on anticoagulant/antiplatelet medications are at a high risk of bleeding following external beam radiation therapy for localized prostate cancer. SBRT may reduce the bleeding risk by decreasing the volume of bladder/rectum receiving high doses. This retrospective study sought to evaluate the rates of hematuria and hematochezia following SBRT in these patients.

Methods

Localized prostate cancer patients treated with SBRT from 2007 to 2017 on at least one anticoagulant/antiplatelet at baseline were included. The minimum follow-up was 3 years with a median follow-up of 72 months. Patients who had a rectal spacer placed prior to SBRT were excluded. Radiotherapy was delivered in 5 fractions to a dose of 35 Gy or 36.25 Gy utilizing the CyberKnife system. Hematuria and hematochezia were prospectively assessed before and after treatment using the Expanded Prostate Cancer Index Composite (EPIC-26). Toxicities were scored using the CTCAE v4. Cystoscopy and colonoscopy findings were retrospectively reviewed.

Results

Forty-four men with a median age of 72 years with a history of taking at least one anticoagulant and/or antiplatelet medication received SBRT. Warfarin (46%), clopidogrel (34%) and rivaroxaban (9%) were the most common medications. Overall, 18.2% experienced hematuria with a median time of 10.5 months post-SBRT. Altogether, 38.6% experienced hematochezia with a median time of 6 months post-SBRT. ≥ Grade 2 hematuria and hematochezia occurred in 4.6% and 2.5%, respectively. One patient required bladder neck fulguration and one patient underwent rectal cauterization for multiple non-confluent telangiectasia. There were no grade 4 or 5 toxicities. Cystoscopy revealed bladder cancer (40%) and benign prostatic bleeding (40%) as the most common hematuria etiology. Colonoscopy demonstrated hemorrhoids (54.5%) and radiation proctitis (9.1%) as the main causes of hematochezia. There was no significant change from the mean baseline EPIC-26 hematuria and hematochezia scores at any point during follow up.

Conclusion

In patients with baseline anticoagulant usage, moderate dose prostate SBRT was well tolerated without rectal spacing. High grade bleeding toxicities were uncommon and resolved with time. Baseline anticoagulation usage should not be considered a contraindication to prostate SBRT.

Impact of anticoagulation and antiplatelet drugs on surgery rates and mortality in trauma patients

Preinjury anticoagulation therapy (AT) is associated with a higher risk for major bleeding. We aimed to evaluated the influence of preinjury anticoagulant medication on the clinical course after moderate and severe trauma. Patients in the TraumaRegister DGU ≥ 55 years who received AT were matched with patients not receiving AT. Pairs were grouped according to the drug used: Antiplatelet drugs (APD), vitamin K antagonists (VKA) and direct oral anticoagulants (DOAC). The primary end points were early (< 24 h) and total in-hospital mortality. Secondary endpoints included emergency surgical procedure rates and surgery rates. The APD group matched 1759 pairs, the VKA group 677 pairs, and the DOAC group 437 pairs. Surgery rates were statistically significant higher in the AT groups compared to controls (APD group: 51.8% vs. 47.8%, p = 0.015; VKA group: 52.4% vs. 44.8%, p = 0.005; DOAC group: 52.6% vs. 41.0%, p = 0.001). Patients on VKA had higher total in-hospital mortality (23.9% vs. 19.5%, p = 0.026), whereas APD patients showed a significantly higher early mortality compared to controls (5.3% vs. 3.5%, p = 0.011). Standard operating procedures should be developed to avoid lethal under-triage. Further studies should focus on detailed information about complications, secondary surgical procedures and preventable risk factors in relation to mortality.

Fixed-dose prothrombin complex concentrate for emergent warfarin reversal among patients with intracranial hemorrhage

INTRODUCTION

Four-factor prothrombin complex concentrate (4PCC) is the preferred reversal agent for warfarin reversal, although the ideal dose is unknown. Fixed-dose 4PCC offers simplified dosing compared to standard-dosing algorithms with potentially lower risks of thromboembolic complications given lower doses are typically utilized.

METHODS

Retrospective, observational, multicentered, pre- post- study of patients who received 4PCC for warfarin reversal among four hospitals within the same regional health system. Standard-dose patients received variable doses ranging from 25 to 50 units/kg based on total body weight and initial INR and fixed-dose patients received 2000 units. The primary outcome was achievement of a target INR ≤ 1.4 on the first post-4PCC INR result.

RESULTS

After exclusions, 48 and 42 patients were analyzed in the standard-dose and fixed-dose groups, respectively. There was no difference in the ability to achieve a target INR of ≤1.4 (82.6% vs 81.5%, p = 0.14). Both groups received the same median dose of 2000 units, although fixed-dose patients actually received a higher weight-based dose than standard-dose patients (27 units/kg vs 24.5 units/kg).

CONCLUSION

A fixed-dose 4PCC regimen of 2000 units among patients with ICH was as effective as standard-dose 4PCC for INR reversal among patients with ICH. However, fixed-doses of 2000 units at times exceeded standard 4PCC doses which may be contradictory to the goals of fixed-dose 4PCC for warfarin reversal.

Self-care training and informational support of patients with a mechanical heart valve on the international normalized ratio and bleeding complications

AIM

The aim of the study was to determine the effect of self-care training and informational support of patients with a mechanical heart valve on the international normalized ratio (INR) and bleeding complications.

MATERIAL AND METHODS

Design: A quasi-experimental study. Participants were recruited via convenience sampling and were randomly divided into two groups: control (n = 80) and intervention (n = 80). Participants in the control group received only routine training; in addition, the intervention group received 6 sessions of self-care training and 6 months of informational support. Monthly the level of INR and incidence of bleeding were determined. Data were analyzed using the independent t-test and χ2 in SPSS16 software at a significance level of 0.05.

RESULTS

During 6 months of follow-up, except for the third month, the frequency of INR levels in the therapeutic target range (2.5-3.5) in the intervention group was significantly higher than that in the control group (p < 0.05). Also in the intervention group, the incidence of bleeding complications was lower than that in the control group, but this difference was not statistically significant (p > 0.05).

CONCLUSIONS

Proper self-care training and informational support in patients with mechanical heart valve replacement have positive results. By maintaining self-care, the level of a therapeutic target range of INR can be maintained and the incidence of bleeding complications can be reduced.

The impact of frailty on epistaxis admission, a retrospective cohort study

OBJECTIVES

Epistaxis is frequently managed with intra-nasal packing devices, traditionally requiring patient admission. Current COVID-19 guidelines encourage ambulatory care where possible in this patient cohort. This paper aims to establish the impact of the Clinical Frailty Scale, anticoagulant/antiplatelet therapeutics and season variation on pre-pandemic admissions to help identify patients suitable for ambulatory epistaxis management.

DESIGN

Retrospective cohort study SETTING: Scottish Regional Health Board PARTICIPANTS: Adult patients attending secondary care with epistaxis between March 2019 and March 2020.

MAIN OUTCOME MEASURES

Likelihood of epistaxis hospital admission based on Clinical Frailty Scale.

RESULTS

299 epistaxis presentations were identified, of which 122 (40.8%) required admission. Clinical Frailty Scale of ≥4 had an increased likelihood of admission (OR 3.15 (95% CI:1.94-5.16), P < .05). In the majority of presentations (66.2%), patients were taking either an antiplatelet or anticoagulant. Of these presentations, the use of an anticoagulant (OR: 2.00 (95% CI: 1.20-3.33), P < .05 and dual antiplatelet (OR: 2.82 (95% CI: 1.02-7.86), P < .05) demonstrated increased likelihood of admission.

CONCLUSIONS

We have shown that frailty increases the risk of admission in adult patients presenting with epistaxis. Clinical Frailty Scale (CFS) could be utilised in risk stratification to identify suitable patients for outpatient management. Patients with CFS ≤ 3 could be considered for outpatient management of their epistaxis. It is likely that patients with CFS ≥4 on anticoagulant or dual antiplatelet will require admission.

Role of Inferior Vena Cava Filter Retrieval in Patients on Chronic Anticoagulation Therapy

Purpose of review

Describe the role of inferior vena cava filter (IVCF) retrieval in patients on chronic anticoagulation given the overlap of these treatment options in the management of patients with venous thromboembolic disease.

Recent findings

Despite the increase in IVCF retrievals since the Food and Drug Administration safety communications in 2010 and 2014, retrieval rates remain low. Previous studies have shown that longer filter dwell times are associated with greater risk for filter complications and more difficulty with filter retrievals. Recent findings suggest that complications are more frequent in the first 30 days after placement.

Summary

The decision to retrieve an optional IVCF is individualized and requires diligent follow-up with consistent re-evaluation of the need for the indwelling IVCF, particularly in those on long-term anticoagulation therapy.

Retrospective Review on the Safety and Efficacy of Direct Oral Anticoagulants Compared With Warfarin in Patients With Cirrhosis

Purpose

Patients with cirrhosis needing anticoagulation therapy have historically been prescribed warfarin. New retrospective research has concluded that in patients with cirrhosis direct oral anticoagulants (DOACs) have similar or lower bleeding rates compared with that of warfarin. This study compares the safety and efficacy of DOACs with that of warfarin in patients with cirrhosis.

Methods

A retrospective chart review was conducted in adult patients with cirrhosis taking either apixaban, dabigatran, edoxaban, rivaroxaban, or warfarin. Exclusion criteria consisted of patients prescribed triple antithrombotic therapy (dual antiplatelet therapy plus an anticoagulant) and indications other than nonvalvular atrial fibrillation (NVAF) and venous thromboembolism (VTE). The primary endpoint was all-cause bleeding, and the secondary endpoints were failed efficacy and major bleeding as defined by the International Society on Thrombosis and Haemostasis in 2005. Failed efficacy was a combination endpoint including the development of VTE, stroke, myocardial infarction and/or death. Patient data were collected from the Computerized Patient Record System from October 31, 2014 to October 31, 2018.

Results

The study included 42 patients in the DOAC group and 37 patients in the warfarin group. Baseline characteristics were not significantly different between groups except for the Child-Turcotte-Pugh score, Model for End-Stage Liver Disease score, international normalized ratio, and number of days on anticoagulation therapy. The rate of all-cause bleeding in the DOAC group was 16.7% (n = 7) vs 21.6% (n = 8) in the warfarin group (P = .7). The rate of major bleeding in the DOAC group was 2.4% (n = 1) vs 5.4% (n = 2) in the warfarin group (P = .6). The rate of failed efficacy in the DOAC group was 7.1% (n = 3) compared with 8.1% (n = 3) in the warfarin group (P = .9). Subgroup analysis of allcause bleeding did not identify any significant trends between groups.

Conclusions

There were no statistically significant differences identified between the rates of all-cause bleeding, major bleeding, and failed efficacy between the DOACs and warfarin groups. DOACs may be a safe alternative to warfarin in patients with cirrhosis requiring anticoagulation for NVAF or VTE, but large randomized trials are required to confirm these results.

Outcomes of oesophageal variceal bleeding among patients with atrial fibrillation: a propensity-matched analysis of a nationwide inpatient sample

Introduction

We aimed to determine the influence of atrial fibrillation (AF) on mortality, morbidity, length of hospital stay, and resource utilisation in patients with oesophageal variceal bleeding (OVB).

Material and methods

The National Inpatient Sample database (2016 and 2017) was used for data analysis using the International Classification of Diseases, Tenth Revision codes to identify patients with the principal diagnosis of OVB and AF. We assessed the all-cause in-hospital mortality, morbidity, predictors of mortality, length of hospital stay (LOS), and total costs between propensity-matched groups of OVB with AF vs. OVB alone.

Results

We identified 80,325 patients with OVB, of whom 4285 had OVB with AF, and 76,040 had OVB only. The in-hospital mortality was higher in OVB with AF (OR = 1.4, 95% CI: 1.09–1.83; p < 0.001). OVB with AF had higher odds of sepsis (OR = 1.4, 95% CI: 1.1–1.8; p = 0.007), acute kidney injury (OR = 1.2, 95% CI: 1.12–1.32; p < 0.001), and mechanical ventilation (OR = 1.2, 95% CI: 1.12–1.32; p < 0.001). Advanced age (OR = 1.06, 95% CI: 1.05–1.07; p < 0.001), congestive heart failure (OR = 1.7, 95% CI: 1.3–2.3; p < 0.001), coronary artery disease (OR = 1.4, 95% CI: 1.03–1.92; p = 0.02), and sepsis (OR = 1.3, 95% CI: 1.06–1.70; p = 0.01) were identified as predictors of mortality in OVB with AF. Mean LOS (7.5 ±7.4 vs. 6.0 ±7.2, p < 0.001) and mean total costs ($25,452 vs. $21,109, p < 0.001) were also higher.

Conclusions

In this propensity-matched analysis, OVB with AF was associated with higher odds of in-hospital mortality, sepsis, acute kidney injury, and mechanical ventilation.

Evaluation of Venous Thromboembolism Recurrence Scores in an Unprovoked Pulmonary Embolism Population: A Post-hoc Analysis of the PADIS-PE trial

BACKGROUND

We aimed to validate the Men Continue and HERDOO2 (HERDOO2), D-dimer, age, sex, hormonal therapy (DASH), and updated Vienna recurrent venous thromboembolism prediction models in a population composed entirely of first unprovoked pulmonary embolism, and to analyze the impact of the addition of the pulmonary vascular obstruction index (PVOI) on score accuracy.

METHODS

Analyses were based on the double-blind, randomized PADIS-PE trial, which included 371 unprovoked pulmonary embolism patients initially treated for 6 months, successively randomized to receive an additional 18 months of warfarin or placebo, and subsequently followed-up for 2 years.

RESULTS

The HERDOO2, DASH, and updated Vienna scores displayed C-statistics of 0.61 (95% CI 0.54-0.68), 0.60 (95% CI 0.53-0.66), and 0.58 (95% CI 0.51-0.66), respectively. Only the HERDOO2 score identified low recurrence risk patients (<3%/year) after anticoagulation was stopped. When added to either of the prediction models, PVOI measured at pulmonary embolism diagnosis, after 6 months of anticoagulation, or both, improved scores' C-statistics between +0.06 and +0.11 points and consistently led to identifying at least 50% of patients who experienced recurrence but in whom the scores would have indicated against extended anticoagulation.

CONCLUSIONS

In patients with a first unprovoked pulmonary embolism, the HERDOO2 score is able to identify patients with a low recurrence risk after treatment discontinuation. Addition of PVOI improves accuracy of all scores.

CLINICAL TRIALS REGISTRATION

URL: http://www.controlled-trials.com. Unique identifier: NCT00740883.

Dabigatran as an oral anticoagulant in patients with Budd-Chiari syndrome post-percutaneous endovascular intervention

BACKGROUND AND AIM

Anticoagulants play an important role in the management of Budd-Chiari syndrome. There is a paucity of data on the efficacy and safety of direct-acting oral anticoagulants-dabigatran, among patients with Budd-Chiari syndrome.

METHODS

In a retrospective analysis of prospectively maintained data, the stent patency rates, major bleeding episode, and a composite endpoint of major bleed and/or mortality rates were compared between Budd-Chiari syndrome patients treated with dabigatran (n = 36) or vitamin K antagonists (n = 62) following endovascular intervention.

RESULTS

The baseline characteristics, including sites of block and types of interventions, were similar between the two groups. The mean duration of follow-up in the dabigatran and vitamin K antagonist groups was 10.5 ± 6.7 and 14.1 ± 6.9 months (P = 0.006), respectively. The endovascular stent patency rates were comparable between the dabigatran and vitamin K antagonist groups at 6 months (91% vs 96.5%) and 12 months (91% vs 93%), P = 0.296 (log-rank test), respectively. Major bleeding events were comparable between the dabigatran and vitamin K antagonist groups at 6 months (3.5% vs 2%) and 12 months (3.5% vs 6.5%), P = 0.895 (log-rank test), respectively. The composite endpoint of mortality and major bleed was comparable between dabigatran and vitamin K antagonists at 6 months (4% vs 5%) and 12 months (4% vs 8%), P = 0.875 (log-rank test), respectively.

CONCLUSIONS

Dabigatran, as compared with vitamin K antagonists, is associated with similar stent patency rates and complications among patients with Budd-Chiari syndrome post-endovascular intervention.

Determinants of health-related quality of life: a cross-sectional investigation in physician-managed anticoagulated patients using vitamin K antagonists

BACKGROUND

Literature has paid little attention in describing the specific contribution of each modifiable and non-modifiable characteristics on health-related quality of life (HRQoL) in physician-managed anticoagulated patients using vitamin K antagonists (VKAs). To describe how patients' treatment-specific knowledge, health literacy, treatment beliefs, clinical, and socio-demographic characteristics influence HRQoL in Italian physician-managed anticoagulated patients using VKAs.

METHODS

Cross-sectional multicentre study with a consecutive sampling strategy, enrolling 164 long-term anticoagulated patients. Clinical and socio-demographic characteristics were collected from electronic medical records. Valid and reliable questionnaires were used to collect patients' treatment-specific knowledge, health literacy, beliefs about VKAs, physical and health perceptions.

RESULTS

Obtaining and understanding health information (i.e., communicative health literacy) positively predicts both adequate mental (ORadjusted = 10.9; 95%CI = 1.99-19.10) and physical (ORadjusted = 11.54; 95%CI = 1.99-34.45) health perceptions. Conversely, the ability to perform proper health decision making (i.e., critical health literacy) was associated with lower rates of adequate mental health perception (ORadjusted = 0.13; 95%CI = 0.03-0.63). Further, age negatively predicted physical health perception (ORadjusted = 0.87; 95%CI = 0.81-0.93).

CONCLUSIONS

Health literacy plays an interesting role in predicting HRQoL. The relationship between critical health literacy and mental health perception could be influenced by some psychological variables, such as distress and frustration, which could be present in patients with higher levels of critical health literacy, as they could be more inclined for self-monitoring. For this reason, future research are needed to identify the most suitable patients' profile for each OAC-management model, by longitudinally describing the predictive performance of each modifiable and non-modifiable determinant of HRQoL.

Hospitalization for epistaxis: a population-based healthcare research study in Thuringia, Germany

Purpose

Epistaxis is the most common ENT emergency. The aim was to determine population-based data on severe epistaxis needing inpatient treatment.

Methods

Retrospective population-based cohort study in the federal state Thuringia in 2016 performed on all 840 inpatients treated for epistaxis in otolaryngology departments (60.1% male, median age: 73 years; 63.9% under anticoagulation). The association between patients’ and treatment characteristics and longer inpatient stay (≥ 4 days) as well as readmission for recurrent epistaxis was analyzed using univariable and multivariable statistics.

Results

The overall incidence of epistaxis needing inpatient treatment was higher for men (42 per 100,000) than for women (28 per 100,000). The highest incidence was reached for men > 85 years (222 per 100,000). Most important independent predictors for longer inpatient stay were localization of the bleeding not in the anterior nose (OR = 2.045; CI = 1.534–2.726), recurrent bleeding during inpatient treatment (OR = 2.142; CI = 1.508–3.042), no electrocoagulation (OR = 2.810; CI = 2.047–3.858), and blood transfusion (OR = 2.731; CI = 1.324–5.635). Independent predictors for later readmission because of recurrent epistaxis were male gender (OR = 1.756; CI = 1.155–2.668), oral anticoagulant use (OR = 1.731; CI = 1.046–2.865), and hereditary hemorrhagic telangiectasia (OR = 13.216; CI 5.102–34.231).

Conclusions

Inpatient treatment of epistaxis seems to be variable in daily routine needing standardization by clinical guidelines and strategies to shorten inpatient treatment and to reduce the risk of readmission.

Electronic supplementary material

The online version of this article (10.1007/s00405-020-05875-2) contains supplementary material, which is available to authorized users.

Equivalent inpatient mortality among direct-acting oral anticoagulant and warfarin users presenting with major hemorrhage

BACKGROUND

Extrapolation of clinical trial results comparing warfarin and direct-acting oral anticoagulant (DOAC) users experiencing major hemorrhage to clinical care is challenging due to differences seen among non-randomized oral anticoagulant users, bleed location, and etiology. We hypothesized that inpatient all-cause-mortality among patients presenting with major hemorrhage differed based on the home-administered anticoagulant medication class, DOAC versus warfarin.

METHODS

More than 1.5 million hospitalizations were screened and 3731 patients with major hemorrhage were identified in the REDS-III Recipient Database. Propensity score matching and stratification were used to account for potentially confounding factors.

RESULTS

Inpatient all-cause-mortality was lower for DOAC (HR = 0.60, 95%CI 0.45-0.80, p = 0.0005) before accounting for confounding and competing events. Inpatient all-cause-mortality for 1266 propensity-score-matched patients compared using proportional hazards regression did not differ (HR = 0.84, 95%CI 0.58-1.22, p = 0.36). Inpatient all-cause-mortality in stratified analyses (warfarin as reference) produced: HR = 0.69 (95%CI 0.31-1.55) for traumatic head injuries; HR = 1.10 (95%CI 0.62-1.95) for non-traumatic head injuries; HR = 0.62 (95%CI 0.20-1.94) for traumatic, non-head injuries; and HR = 0.69 (95%CI 0.29-1.63) for non-traumatic, non-head injuries. Mean time to discharge was shorter for DOAC (HR = 1.17, 95%CI 1.05-1.30, p = 0.0034) in the propensity score matched analysis. Plasma transfusion occurred in 42% of warfarin hospitalizations and 11% of DOAC hospitalizations. Vitamin K was administered in 63% of warfarin hospitalizations.

CONCLUSIONS

After accounting for differences in patient characteristics, location of bleed, and traumatic injury, inpatient survival was no different in patients presenting with major hemorrhage while on DOAC or warfarin.

Pain in the hip: Spontaneous retroperitoneal hemorrhage in an elderly patient on apixaban

As many as 5% of patients using oral anticoagulants suffer from a major bleeding event annually. Spontaneous retroperitoneal hemorrhage is a rare but serious complication, with a mortality rate as high as 20%. Oral anticoagulants were responsible for 2.83 million office visits per quarter in 2014 and use is increasing, therefore, rapid recognition of life threatening complications is critical. We present a case of an 86-year-old female taking apixaban for atrial fibrillation who presented with right hip pain upon standing. Laboratory tests revealed leukocytosis and anemia. A CT scan of the right hip revealed a moderately sized retroperitoneal hematoma. She was transferred to the intensive care unit, treated with supportive care, and was discharged two days later without any invasive intervention needed. Due to vague presentations, spontaneous retroperitoneal hemorrhages can be misdiagnosed as a number of abdominal or pelvic processes. While our patient presented with hip pain, other presentations include abdominal masses, back pain, or hypotension. Some patients may progress to hemodynamic instability, femoral neuropathy, or abdominal compartment syndrome requiring rapid intervention to prevent further morbidity. In patients with vague abdominal or pelvic complaints who have risk factors such as advanced age and the use of anticoagulation therapy, spontaneous retroperitoneal hemorrhage should be considered to allow for early diagnosis before severe complications arise.

On-label compared to off-label four-factor prothrombin complex concentrate use: a retrospective, observational study

BACKGROUND

Four-factor prothrombin complex concentrate (4F-PCC) is US Food and Drug Administration approved for the urgent reversal of coagulation factor deficiency induced by a vitamin K antagonist complicated by acute major bleeding or in situations in which invasive procedures are urgently needed. Although recent evidence suggests the superiority of 4F-PCC over plasma for on-label indications, the off-label use of 4F-PCC has not been rigorously studied.

STUDY DESIGN AND METHODS

Eighty-nine patients receiving 4F-PCC at a single institution from July 2016 to December 2017 were retrospectively analyzed. Two cohorts, "On-Label" and "Off-Label" uses of 4F-PCC, were evaluated, comparing patient characteristics, blood utilization, and clinical outcomes including in-hospital mortality.

RESULTS

Patients receiving 4F-PCC for off-label reasons (n = 46) were younger and sicker compared to those receiving 4F-PCC for on-label reasons (n = 43). Notably, the mortality rate for off-label use was approximately twofold greater than the mortality rate for on-label use (26 of 46 [56.5%] vs. 12 of 43 [27.9%]; p = 0.006). Patients receiving 4F-PCC for off-label reasons received more units per patient of each blood component than their on-label counterparts. The average cost estimate per patient for 4F-PCC was similar (approx. $4300) in each cohort.

CONCLUSION

4F-PCC is an effective but expensive treatment option for those requiring urgent reversal of vitamin K antagonist-induced coagulopathy. However, providers should be conscious of the high costs and questionable efficacy when using 4F-PCC off-label.

Management of epistaxis in patients with ventricular assist device: a retrospective review

Background

Patients with a ventricular assist device (VAD) are at risk for epistaxis due to the need for anticoagulation. Additionally, these patients develop acquired von Willebrand syndrome (AvWS) due to these devices. Management is complicated by the risk of thrombosis if anticoagulation is reversed. This study sought to characterize the clinical features and management of epistaxis in this high-risk population.

Methods

Retrospective review of adults with VAD and epistaxis necessitating inpatient consultation with the otolaryngology service were included.

Results

49 patients met inclusion criteria. All patients had a presumed diagnosis of AvWS. An elevated INR (> 2.0) was present in 18 patients (36.7%). Anticoagulation was held in 14 (28.6%) patients, though active correction was not necessary. Multiple encounters were required in 16 (32.7%) patients. Spontaneous epistaxis was associated with multiple encounters (p = 0.02). The use of hemostatic material was associated with a lower likelihood of bleeding recurrence (p = 0.05), whereas cauterization with silver nitrate alone was associated with a higher likelihood of re-intervention (p = 0.05). Surgery or embolization was not required urgently for any patient. Endoscopy under general anesthesia was performed for one patient electively. Mean follow up time was 16.6 months (σ = 6.3). At six months, 18 (36.7%) patients were deceased.

Conclusion

While these patients are at risk for recurrent spontaneous epistaxis, nonsurgical treatment without active correction of INR or AvWS was largely successful. Placement of hemostatic material, as opposed to cautery with silver nitrate, should be considered as a first-line treatment in this group. Multidisciplinary collaboration is critical for successful management.

The role of oral anticoagulants in epistaxis

Purpose

The purpose of this retrospective study was to identify the impact of oral anticoagulants on epistaxis with the focus on new oral anticoagulants.

Methods

The study was conducted at the Department  for Ear- Nose- and Throat (ENT), Head and Neck Surgery, Technical University Munich, Germany. All patients presenting in 2014 with the diagnosis of epistaxis to a specialized ENT accident and emergency department were identified and analyzed in clinical data and medication.

Results

600 adult cases, with a median age of 66.6 years were identified with active bleeding. 66.8% of all cases were anticoagulated. Classic oral anticoagulants (COAC) were three times more common in patients than new-generation oral anticoagulants (NOAC). Recurrent bleeding was significantly associated with oral anticoagulants (OAC) (p = 0.014) and bleeding location was most often anterior (p = 0.006). In contrast, severe cases, which required surgery or embolization were significantly more likely in non-anticoagulated middle-aged patients with posterior bleedings (p < 0.05). In our epistaxis cohort, OAC were highly overrepresented (40%) when compared to the general German population (1%) but COAC as well as NOAC played only a minor role in severe courses of epistaxis.

Conclusion

Oral anticoagulation, especially with new-generation drugs, is not associated with more complicated and severe courses of epistaxis, but rather with recurrent bleeding. One should keep this information in mind when triaging the patient in the emergency room and when planning further procedures.

Clinical effect of enoxaparin on international normalized ratio following hepato-pancreatico-biliary and gastroesophageal resection

BACKGROUND AND OBJECTIVES

Enoxaparin inactivates factor Xa via a complex formed after binding to circulating anti-thrombin III. This mechanism is reported not to alter hemostatic measures such as clotting time, PT, or PTT. To date, no clinical trials have shown a causal relationship between the clinical/pharmacological effects of enoxaparin on international normalized ratio (INR). The aim of our study is to show the clinical effect of enoxaparin on INR.

METHODS

Patients (N = 350) were reviewed from our prospective IRB approved databases undergoing gastroesophageal or hepatobiliary surgeries. INR levels were recorded for 6 days: pre-operative to 5 days after surgery.

RESULTS

Patients (N = 289) received enoxaparin daily starting post-operative day 1, while 61 patients who did not receive enoxaparin were used as controls. The mean post-operative INR in both the 30 and 40 mg groups were both significantly higher than the mean post-operative INR of the control group (P = 0.015 and P = 0.00075, respectively); however postoperative hemoglobin levels were not significantly lower in the enoxaparin versus control.

CONCLUSION

This is the first clinical evidence of the effect of enoxaparin on INR in patients undergoing abdominal surgeries for malignancies. We demonstrate an increase in the INR for patients who received enoxaparin for post-operative VTE prophylaxis.

Benefit, risk and cost of new oral anticoagulants and warfarin in atrial fibrillation; A multicriteria decision analysis

Introduction

Warfarin and new oral anticoagulants are effective in reducing stroke in atrial fibrillation; however, the benefits and risks rates in clinical trials show heterogeneity for each anticoagulant, and is unknown the cost influence on a model considering most of the treatment consequences. We designed a benefit-risk and cost assessment of oral anticoagulants.

Design

We followed the roadmap proposed by IMI-PROTECT and the considerations of emerged good practice to perform Multi-Criteria Decision Analysis (MCDA). The roadmap defines the following steps: (1) planning, (2) evidence gathering and data preparation, (3) analyses, (4) explorations, and (5) conclusions. We defined two reference points (0–100) to allocate numerical values for scores and weights, and used an analogue numeric scale to assess physicians’ preferences.

As benefits of the anticoagulant therapy, we included reductions in stroke and all-cause mortality; intracranial haemorrhage, gastrointestinal haemorrhage, minor bleeding and myocardial infarction were considered risks. We also made an estimation of the annual drug cost per person.

Main results

The scores were: Apixaban 33, Dabigatrán 25, warfarin 18 and Rivaroxaban 14 this score reveals the most preferred up to the less preferred option, considering the benefit-risk ratio and drug costs altogether. The relative model weights were: 51.1% for risks, 40.4% for benefits and 8.5% for cost. The sensitivity analysis confirms the model robustness.

Conclusions

From this analysis, apixaban should be considered as the preferred anticoagulant option -due to a better benefit-risk balance and a minor cost influence- followed by dabigatran, warfarin and rivaroxaban.

Genotype-guided warfarin therapy: current status

Warfarin pharmacogenomics has been an extensively studied field in the last decades as it is focused on personalized therapy to overcome the wide interpatient warfarin response variability and decrease the risk of side effects. In this expert review, besides briefly summarizing the current knowledge about warfarin pharmacogenetics, we also present an overview of recent studies that aimed to assess the efficacy, safety and economic issues related to genotype-based dosing algorithms used to guide warfarin therapy, including randomized and controlled clinical trials, meta-analyses and cost-effectiveness studies. To date, the findings still present disparities, mostly because of standard limitations. Thus, further studies should be encouraged to try to demonstrate the benefits of the application of warfarin pharmacogenomic dosing algorithms in clinical practice.

Risk of major bleeding in patients with non-valvular atrial fibrillation treated with oral anticoagulants: a systematic review of real-world observational studies

OBJECTIVE

To conduct a systematic review of real-world (RWD) studies comparing the risk of major bleeding (MB) among patients with non-valvular atrial fibrillation (NVAF) on direct oral anticoagulants (DOACs) or warfarin.

METHODS

MEDLINE, Embase, NHS-EED, and EconLit were searched for RWD studies published between January 2003 and November 2016 comparing MB risk among DOACs and warfarin. Proceedings of clinical conferences from 2012 to 2016 were reviewed.

RESULTS

A total of 4218 citations were identified, 26 of which met eligibility criteria. Most studies were retrospective analyses of administrative claims databases and patient registries (n = 23 of 26); about half were based in the United States (n = 15). Apixaban showed a significantly lower risk of MB versus warfarin in all eight included studies. MB risk was either significantly lower (n = 9 of 16) or not significantly different (n = 7 of 16) between dabigatran and warfarin; there was no significant difference between rivaroxaban and warfarin in all seven included studies. The risk was significantly lower with apixaban versus rivaroxaban (n = 7 of 7) but not significantly different from dabigatran (n = 6 of 7). MB risk was significantly lower (n = 3 of 4) or not significantly different (n = 1 of 4) with dabigatran versus rivaroxaban. No evidence was identified for edoxaban.

CONCLUSION

DOACs were associated with similar or lower risks of MB versus warfarin. A lower MB risk was consistently observed for apixaban, but less consistently for dabigatran; MB risk was similar between rivaroxaban and warfarin. Among DOACs, the risk of MB with apixaban was consistently lower than with rivaroxaban, but similar to dabigatran.

What to do after the bleed: resuming anticoagulation after major bleeding

Resuming anticoagulation therapy after a potentially life-threatening bleeding complication evokes high anxiety levels among clinicians and patients trying to decide whether resuming oral anticoagulation to prevent devastating and potentially fatal thromboembolic events or discontinuing anticoagulation in hopes of reducing the risk of recurrent bleeding is best. The available evidence favors resumption of anticoagulation therapy for gastrointestinal tract bleeding and intracranial hemorrhage survivors, and it is reasonable to begin postbleeding decision making with resuming anticoagulation therapy as the default plan. After considering factors related to the index bleeding event, the underlying thromboembolic risk, and comorbid conditions, a decision to accept or modify the default plan can be made in collaboration with other care team members, the patient, and their caregivers. Although additional information is needed regarding the optimal timing of anticoagulation resumption, available evidence indicates that waiting ∼14 days may best balance the risk of recurrent bleeding, thromboembolism, and mortality after gastrointestinal tract bleeding. When to resume anticoagulation after intracranial hemorrhage is less clear, but most studies indicate that resumption within the first month of discharge is associated with better outcomes.

Apixaban-Induced Resolution of A Massive Left Atrial and Appendage Thrombosis in a Very Elderly Patient

A 86-year-old woman with first diagnosed atrial fibrillation (AF) underwent mitral valve annuloplasty 10 years before was admitted to our Unit due to congestive heart failure. Trans-thoracic echocardiogram (TTE) revealed a large fluctuant echogenic mass in the posterior wall of the left atrium. Trans-esophageal echo (TEE) showed the origin of the mass within the left atrial appendage. An adjusted dose of the novel oral anticoagulant (NOAC) apixaban, was prescribed. A complete disappearance was appreciated by examination at 12 weeks after the first drug administration. Although apixaban, resulted superior to warfarin in preventing stroke and thrombo-embolic events in patients with non valvular AF, while causing less bleeding, few data are actually available regarding the efficacy and safety of this drug in left atrium and appendage thrombosis management. Our report shows that this NOAC could be a simple and useful option to manage huge atrial thrombosis in very elderly patients.

Results of surgery in general surgical patients receiving warfarin: retrospective analysis of 61 patients

The aim of this study is to investigate postoperative complications, mortality rates, and to determine the factors affecting mortality on the patients receiving warfarin therapy preoperatively, as well as comparing the results obtained from emergency and elective surgeries. Surgical outcomes of 61 patients on long-term oral anticoagulation with warfarin who underwent surgery in our center were retrospectively reviewed over an 8-year period. Thirty-three (54.1%) patients were female, with a mean age of 53 years. Mitral valve replacement (62.3%) was the most frequent indication for chronic anticoagulation therapy. Twelve out of 61 (19.2%) patients underwent emergency surgery; 59 (96.7%) operations were classified as major surgery. We did not observe any thromboembolic events on patients receiving our bridging therapy protocol. Cardiopulmonary dysfunction (CPD; 19.7%) and hemorrhage (16.4%) were the most encountered postoperative complications. Presence of CPD, bleeding, endocarditis, and mortality were statistically significant for emergency surgeries when compared with the results obtained from elective surgeries. There were 5 (8.2%) deaths observed during follow-up. It was found that advanced age, prolonged duration of operations, and presence of CPD had a statistically significant effect on mortality (P < 0.05). The patients receiving oral anticoagulant had high postoperative complication and mortality rates. This case was more evident in emergency surgeries. It is recommendable that as mortality is more apparent in the patients who undergo emergency surgeries-being older, having long duration of operations as well as CPD. Therefore during the postoperative follow-up process, the patients should be closely monitored.

Severe Extra-Cerebral Anticoagulant-Related Bleeding in Intensive Care Unit: A Retrospective Study From 2000 to 2013

Bleeding is the most frequent complication of anticoagulant therapy, responsible for a number of hospitalizations or deaths. However, studies describing the management and prognosis factors of extra-cerebral anticoagulant-related bleedings in intensive care unit (ICU) are lacking.Retrospective observational study in an 18-bed ICU in a tertiary teaching hospital. From January 2000 to December 2013, all consecutive patients, older than 18 years, admitted for severe anticoagulant-related bleeding (SAB) except intracerebral site were included.A total of 100 patients were included, the mean age was 77 ± 11 years and 62% were women. SAB incidence in ICU doubled over 10 years (P = 0.03). In ICU, the average length of stay was 5 ± 6 days and mortality was 30%. Nonsurviving patients had a higher SAPS II (78 ± 24 vs 53 ± 24, P < 0.0001), a higher SOFA (9.0 ± 3.6 vs 4.7 ± 3.4, P < 0.0001) and received more frequently support therapy such as mechanical ventilation (87% vs 16%, P < 0.0001) and vasopressors (90% vs 27%, P < 0.0001). The volume of blood-derived products transfused was more important in nonsurvivors mainly during the first 24 hours of resuscitation. Rapid anticoagulant reversal therapy was associated with better prognosis (ICU survivors 66% vs 39%, Fisher test P = 0.04). Anterior abdominal wall was identified as a frequent site of bleeding (22%) due to epigastric artery injury during subcutaneous injection of heparin and was associated with a large mortality (55%).Extra-cerebral SAB is a life-threatening complication that requires rapid resuscitation and anticoagulant reversal therapy. Injection of heparin should be done carefully in the subcutaneous tissue thereby avoiding artery injury.

Warfarin-related nephropathy: possible role for the warfarin pharmacogenetic profile

Warfarin-related nephropathy (WRN) is a renal complication of warfarin treatment associated with over-anticoagulation. We describe a case of a 73-year-old man affected by chronic kidney disease, essential hypertension and atrial fibrillation treated with warfarin. The patient presented a rapid course of kidney failure after many episodes of over-anticoagulation, and renal biopsy demonstrated WRN. Interestingly, the patient's warfarin pharmacogenetic profile showed that he was warfarin sensitive. This is the first report describing the presence of gene polymorphisms affecting warfarin metabolism in a subject with a biopsy-proven WRN. The patient was treated with corticosteroids obtaining a partial clinical response.