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Last J, Herrmann E, Birschmann I, Lindau S, Konstantinides S, Grottke O, Nowak-Göttl U, Zydek B, von Heymann C, Sümnig A, Beyer-Westendorf J, Schellong S, Meybohm P, Greinacher A, Lindhoff-Last E. Clinical Course and Management of Patients with Emergency Surgery Treated with Direct Oral Anticoagulants or Vitamin K Antagonists-Results of the German Prospective RADOA-Registry. J Clin Med 2024; 13:272. [PMID: 38202279 PMCID: PMC10780086 DOI: 10.3390/jcm13010272] [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: 11/26/2023] [Revised: 12/23/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024] Open
Abstract
(1) Background: The clinical management of anticoagulated patients treated with direct oral anticoagulants (DOAC) or Vitamin K antagonists (VKA) needing emergency surgery is challenging. (2) Methods: The prospective German RADOA registry investigated treatment strategies in DOAC- or VKA-treated patients needing emergency surgery within 24 h after admission. Effectiveness was analysed by clinical endpoints including major bleeding. Primary observation endpoint was in hospital mortality until 30 days after admission. (3) Results: A total of 78 patients were included (DOAC: 44; VKA: 34). Median age was 76 years. Overall, 43% of the DOAC patients and 79% of the VKA patients were treated with prothrombin complex concentrates (PCC) (p = 0.002). Out of the DOAC patients, 30% received no hemostatic treatment compared to 3% (1/34) of the VKA patients (p = 0.002), and 7% of the DOAC patients and 21% of the VKA patients developed major or clinically relevant non-major bleeding at the surgical site (p = 0.093). In-hospital mortality was 13% with no significant difference between the two treatment groups (DOAC: 11%, VKA: 15%; p > 0.20). (4) Conclusions: The 30-day in-hospital mortality rate was comparable between both patient groups. VKA patients required significantly more hemostatic agents than DOAC patients in the peri- and postoperative surgery period.
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Affiliation(s)
- Jana Last
- Coagulation Research Centre Bethanien Hospital, 63089 Frankfurt, Germany; (B.Z.); (E.L.-L.)
- Deutsches Herzzentrum der Charité (DHZC) Berlin, Department of Cardiology, Angiology and Intensive Care Medicine, Charité Berlin, 12203 Berlin, Germany
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modelling, Goethe University Frankfurt, 60596 Frankfurt, Germany;
| | - Ingvild Birschmann
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Centre, Ruhr University, 44801 Bochum, Germany;
| | - Simone Lindau
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, 60596 Frankfurt, Germany;
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, 55122 Mainz, Germany;
| | - Oliver Grottke
- Department of Anaesthesiology, RWTH Aachen University Hospital, 52062 Aachen, Germany;
| | - Ulrike Nowak-Göttl
- Institute of Clinical Chemistry, Thrombosis & Hemostasis Treatment Centre, University Hospital, Kiel-Lübeck, 24105 Kiel, Germany;
| | - Barbara Zydek
- Coagulation Research Centre Bethanien Hospital, 63089 Frankfurt, Germany; (B.Z.); (E.L.-L.)
- Coagulation Centre at the Cardiology Angiology Centre Bethanien Hospital (CCB), 63089 Frankfurt, Germany
| | - Christian von Heymann
- Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, 10249 Berlin, Germany;
| | - Ariane Sümnig
- Institute for Transfusions Medicine, Universitätsmedizin Greifswald, 17489 Greifswald, Germany; (A.S.); (A.G.)
| | - Jan Beyer-Westendorf
- Department of Medicine 1, Division of Thrombosis & Hemostasis, Dresden University Clinic, 01307 Dresden, Germany;
| | | | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, 97080 Wuerzburg, Germany;
| | - Andreas Greinacher
- Institute for Transfusions Medicine, Universitätsmedizin Greifswald, 17489 Greifswald, Germany; (A.S.); (A.G.)
| | - Edelgard Lindhoff-Last
- Coagulation Research Centre Bethanien Hospital, 63089 Frankfurt, Germany; (B.Z.); (E.L.-L.)
- Coagulation Centre at the Cardiology Angiology Centre Bethanien Hospital (CCB), 63089 Frankfurt, Germany
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Meinig R, Jarvis S, Salottolo K, Nwafo N, McNair P, Harrison P, Morgan S, Duane T, Woods B, Nentwig M, Kelly M, Cornutt D, Bar-Or D. Propensity matched analysis examining the effect of passive reversal of direct oral anticoagulants on blood loss and the need for transfusions among traumatic geriatric hip fractures. Eur J Med Res 2023; 28:241. [PMID: 37475008 PMCID: PMC10360353 DOI: 10.1186/s40001-023-01053-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/08/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Reversal of direct oral anticoagulants (DOACs) is currently recommended prior to emergent surgery, such as surgical intervention for traumatic geriatric hip fractures. However, reversal methods are expensive and timely, often delaying surgical intervention, which is a predictor of outcomes. The study objective was to examine the effect of DOAC reversal on blood loss and transfusions among geriatric patients with hip fractures. METHODS This retrospective propensity-matched study across six level I trauma centers included geriatric patients on DOACs with isolated fragility hip fractures requiring surgical intervention (2014-2017). Outcomes included: intraoperative blood loss, intraoperative pRBCs, and hospital length of stay (HLOS). RESULTS After matching there were 62 patients (31 reversed, 31 not reversed), 29 patients were not matched. The only reversal method utilized was passive reversal (waiting ≥ 24 hours for elimination). Passively reversed patients had a longer time to surgery (mean, 43 vs. 18 hours, p < 0.01). Most patients (92%) had blood loss (90% passively reversed, 94% not reversed); the median volume of blood loss was 100 mL for both those groups, p = 0.97. Thirteen percent had pRBCs transfused (13% passively reversed and 13% not reversed); the median volume of pRBCs transfused was 525 mL for those passively reversed and 314 mL for those not reversed, p = 0.52. The mean HLOS was significantly longer for those passively reversed (7 vs. 5 days, p = 0.001). CONCLUSIONS Passive DOAC reversal for geriatric patients with isolated hip fracture requiring surgery may be contributing to delayed surgery and an increased HLOS without having a significant effect on blood loss or transfusions. These data suggest that passive DOAC reversal may not be necessary prior to surgical repair of isolated hip fracture.
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Affiliation(s)
- Richard Meinig
- Penrose Hospital, 2222 N Nevada Ave, Colorado Springs, CO, 80907, USA
| | - Stephanie Jarvis
- Injury Outcomes Network (ION) Research, 501 East Hampden Ave, Englewood, CO, 80113, USA
| | - Kristin Salottolo
- Injury Outcomes Network (ION) Research, 501 East Hampden Ave, Englewood, CO, 80113, USA
| | - Nnamdi Nwafo
- Swedish Medical Center, 501 East Hampden Ave, Englewood, CO, 80113, USA
| | - Patrick McNair
- St. Anthony Hospital, 11600 W 2nd Plaza, Lakewood, CO, 80228, USA
| | - Paul Harrison
- Wesley Medical Center, 550 North Hillside St. Wichita, Wichita, KS, 67214, USA
| | - Steven Morgan
- Swedish Medical Center, 501 East Hampden Ave, Englewood, CO, 80113, USA
| | - Therese Duane
- Medical City Plano, 3901 West 15th Street, Plano, TX, 75075, USA
| | - Bradley Woods
- Research Medical Center, 2316 East Meyer Blvd, Kansas City, MO, 64132, USA
| | - Michelle Nentwig
- Wesley Medical Center, 550 North Hillside St. Wichita, Wichita, KS, 67214, USA
| | - Michael Kelly
- Penrose Hospital, 2222 N Nevada Ave, Colorado Springs, CO, 80907, USA
| | - David Cornutt
- Regional West Medical Center, 4021 Ave B, Scottsbluff, NE, 69361, USA
| | - David Bar-Or
- Injury Outcomes Network (ION) Research, 501 East Hampden Ave, Englewood, CO, 80113, USA.
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Burger A, Studt JD, Mendez A, Alberio L, Fontana P, Wuillemin WA, Schmidt A, Graf L, Gerber B, Bovet C, Sauter TC, Binder NB, Nagler M. Determination of Anti-Xa Inhibitor Plasma Concentrations Using a Universal Edoxaban Calibrator. Diagnostics (Basel) 2023; 13:2128. [PMID: 37371023 DOI: 10.3390/diagnostics13122128] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/18/2023] [Accepted: 06/19/2023] [Indexed: 06/29/2023] Open
Abstract
A universal calibrator for the determination of all anti-Xa inhibitors would support laboratory processes. We aimed to test the clinical performance of an anti-Xa assay utilizing a universal edoxaban calibrator to determine clinically relevant concentrations of all anti-Xa inhibitors. Following a pilot study, we enrolled 553 consecutive patients taking rivaroxaban, edoxaban, or apixaban from nine study centers in a prospective cross-sectional study. The Technochrom® anti-Xa assay was conducted using the Technoview® edoxaban calibrator. Using ultra-high-performance liquid chromatography-tandem mass spectrometry (LC-MS/MS), anti-Xa inhibitor drug concentrations were determined. Sensitivities and specificities to detect three clinically relevant drug concentrations (30 µgL-1, 50 µgL-1, 100 µgL-1) were determined. Overall, 300 patients treated with rivaroxaban, 221 with apixaban, and 32 with edoxaban were included. The overall correlation coefficient (rs) was 0.95 (95% CI 0.94, 0.96). An area under the receiver operating characteristic curve of 0.96 for 30 µgL-1, 0.98 for 50 µgL-1, and 0.99 for 100 µgL-1 was found. The sensitivities were 92.3% (95% CI 89.2, 94.6), 92.7% (89.4, 95.1), and 94.8% (91.1, 97.0), respectively (specificities 82.2%, 93.7%, and 94.4%). In conclusion, the clinical performance of a universal, edoxaban-calibrated anti-Xa assay was solid and most drug concentrations were predicted correctly.
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Affiliation(s)
- Annika Burger
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Jan-Dirk Studt
- Division of Medical Oncology and Hematology, University Hospital Zurich, University of Zurich, 8006 Zurich, Switzerland
| | - Adriana Mendez
- Institute for Laboratory Medicine, Kantonsspital Aarau, 5001 Aarau, Switzerland
| | - Lorenzo Alberio
- Service and Central Laboratory of Hematology, Centre Hospitalier Universitaire Vaudois (CHUV), 1011 Lausanne, Switzerland
| | - Pierre Fontana
- Division of Angiology and Hemostasis, Geneva University Hospital, 1205 Geneva, Switzerland
| | - Walter A Wuillemin
- Division of Hematology, Hematology Laboratory, Cantonal Hospital of Lucerne, University of Bern, 3012 Bern, Switzerland
| | - Adrian Schmidt
- Institute of Laboratory Medicine, Clinic of Medical Oncology and Hematology, Municipal City Hospital Zurich Triemli, 8063 Zurich, Switzerland
| | - Lukas Graf
- Centre for Laboratory Medicine, 9001 St. Gallen, Switzerland
| | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, 6500 Bellinzona, Switzerland
| | - Cédric Bovet
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Thomas C Sauter
- Department of Emergency Medicine, Inselspital, Bern University Hospital, 3010 Bern, Switzerland
| | - Nikolaus B Binder
- Technoclone Herstellung von Diagnostika und Arzneimitteln GmbH, 1230 Vienna, Austria
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
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Lindhoff-Last E, Birschmann I, Bidenharn AJ, Kuhn J, Lindau S, Konstantinides S, Grottke O, Nowak-Göttl U, Lucks J, Zydek B, von Heymann C, Sümnig A, Beyer-Westendorf J, Schellong S, Meybohm P, Greinacher A, Herrmann E. Pharmacokinetics of Phenprocoumon in Emergency Situations-Results of the Prospective Observational RADOA-Registry (Reversal Agent Use in Patients Treated with Direct Oral Anticoagulants or Vitamin K Antagonists Registry). Pharmaceuticals (Basel) 2022; 15:ph15111437. [PMID: 36422567 PMCID: PMC9692621 DOI: 10.3390/ph15111437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/03/2022] [Accepted: 11/11/2022] [Indexed: 11/22/2022] Open
Abstract
Background: Phenprocoumon has been used as an oral anticoagulant in patients with thromboembolic disease for more than 40 years. So far its pharmacokinetics have not been analyzed in emergency situations. Methods: Phenprocoumon-treated patients with major bleeding or urgent surgery were included in a prospective, observational registry. Phenprocoumon drug concentrations were analyzed in samples, collected as part of routine care using ultraperformance liquid chromatography tandem mass spectrometry. Moreover, anticoagulant intensity and drug half-life (t1/2) were calculated. Results: 115 patients were included. Phenprocoumon levels declined over time with a half-life of 5.27 and 5.29 days in patients with major bleedings (n = 82) and with urgent surgery (n = 33). Baseline phenprocoumon levels were 2.2 times higher in the bleeding group compared to the surgery group (1.92 vs. 0.87 ng/mL, p < 0.0001). International normalized ratio (INR) values decreased rapidly during the first 24 h. In 27.6% of patients a rebound of INR (recurrent increase > 1.5) was observed which was associated with significantly increased bleeding rates (22% vs. 4.2% in patients with or without INR rebound, p = 0.012). Conclusions: In emergency situations, the long half-life of phenprocoumon may cause INR rebound and associated recurrent bleedings. Optimal management may need to include repeated vitamin K supplementation over days.
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Affiliation(s)
- Edelgard Lindhoff-Last
- Coagulation Centre, Cardiology Angiology Centre Bethanien Hospital (CCB), 60389 Frankfurt, Germany
- Coagulation Research Centre, Cardiology Angiology Centre Bethanien Hospital (CCB), 60389 Frankfurt, Germany
- Correspondence: (E.L.-L.); (I.B.); Tel.: +49-69-9450280 (E.L.-L.); +49-5731-973819 (I.B.); Fax: +49-69-461613 (E.L.-L.); +49-5731-972307 (I.B.)
| | - Ingvild Birschmann
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Centre, Ruhr University, 44789 Bochum, Germany
- Correspondence: (E.L.-L.); (I.B.); Tel.: +49-69-9450280 (E.L.-L.); +49-5731-973819 (I.B.); Fax: +49-69-461613 (E.L.-L.); +49-5731-972307 (I.B.)
| | - Antonia J. Bidenharn
- Institute of Biostatistics and Mathematical Modelling, Goethe University Frankfurt, 60590 Frankfurt, Germany
| | - Joachim Kuhn
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Centre, Ruhr University, 44789 Bochum, Germany
| | - Simone Lindau
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, 60590 Frankfurt, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center, Johannes Gutenberg University, 55131 Mainz, Germany
| | - Oliver Grottke
- Department of Anaesthesiology, RWITH Aachen University Hospital, 52074 Aachen, Germany
| | - Ulrike Nowak-Göttl
- Institute of Clinical Chemistry, Thrombosis & Haemostasis Treatment Centre, University Hospital, 24105 Kiel-Lübeck, Germany
| | - Jessica Lucks
- Coagulation Research Centre, Cardiology Angiology Centre Bethanien Hospital (CCB), 60389 Frankfurt, Germany
| | - Barbara Zydek
- Coagulation Research Centre, Cardiology Angiology Centre Bethanien Hospital (CCB), 60389 Frankfurt, Germany
| | - Christian von Heymann
- Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, 10249 Berlin, Germany
| | - Ariane Sümnig
- Department of Immunology and Transfusion Medicine, Universitätsmedizin, 17475 Greifswald, Germany
| | - Jan Beyer-Westendorf
- Department of Medicine 1, Division of Thrombosis & Hemostasis, Dresden University Clinic, 01307 Dresden, Germany
| | | | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, 60590 Frankfurt, Germany
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, 97080 Wuerzburg, Germany
| | - Andreas Greinacher
- Department of Immunology and Transfusion Medicine, Universitätsmedizin, 17475 Greifswald, Germany
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modelling, Goethe University Frankfurt, 60590 Frankfurt, Germany
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5
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Sathanantham V, Alberio L, Bovet C, Fontana P, Gerber B, Graf L, Mendez A, Sauter TC, Schmidt A, Studt JD, Wuillemin WA, Nagler M. Prothrombinase-Induced Clotting Time to Measure Drug Concentrations of Rivaroxaban, Apixaban, and Edoxaban in Clinical Practice: A Cross-Sectional Study. LIFE (BASEL, SWITZERLAND) 2022; 12:life12071027. [PMID: 35888115 PMCID: PMC9324795 DOI: 10.3390/life12071027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/05/2022] [Accepted: 07/05/2022] [Indexed: 11/17/2022]
Abstract
Prothrombinase-induced clotting time (PiCT) is proposed as a rapid and inexpensive laboratory test to measure direct oral anticoagulant (DOAC) drug levels. In a prospective, multicenter cross-sectional study, including 851 patients, we aimed to study the accuracy of PiCT in determining rivaroxaban, apixaban, and edoxaban drug concentrations and assessed whether clinically relevant drug levels could be predicted correctly. Citrated plasma samples were collected, and the Pefakit® PiCT was utilized. Ultra-high performance liquid chromatography-tandem mass spectrometry (LC-MS/MS) was performed to measure drug concentrations. Cut-off levels were established using receiver-operating characteristics curves. We calculated sensitivities and specificities with respect to clinically relevant drug concentrations. Spearman’s correlation coefficient between PiCT and drug concentrations was 0.85 in the case of rivaroxaban (95% CI 0.82, 0.88), 0.66 for apixaban (95% CI 0.60, 0.71), and 0.78 for edoxaban (95% CI 0.65, 0.86). The sensitivity to detect clinically relevant drug concentrations was 85.1% in the case of 30 µg L−1 (95% CI 82.0, 87.7; specificity 77.9; 72.1, 82.7), 85.7% in the case of 50 µg L−1 (82.4, 88.4; specificity 77.3; 72.5, 81.5), and 85.1% in the case of 100 µg L−1 (80.9, 88.4; specificity 73.2%; 69.1, 76.9). In conclusion, the association of PiCT with DOAC concentrations was fair, and the majority of clinically relevant drug concentrations were correctly predicted.
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Affiliation(s)
- Vepusha Sathanantham
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, 3010 Bern, Switzerland; (V.S.); (C.B.)
| | - Lorenzo Alberio
- Service and Central Laboratory of Hematology, CHUV, Lausanne University Hospital, 1011 Lausanne, Switzerland;
| | - Cédric Bovet
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, 3010 Bern, Switzerland; (V.S.); (C.B.)
| | - Pierre Fontana
- Division of Angiology and Hemostasis, Geneva University Hospital, 1205 Geneva, Switzerland;
| | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, 6500 Bellinzona, Switzerland;
- Faculty of Medicine, University of Zurich, 8091 Zurich, Switzerland
| | - Lukas Graf
- Centre for Laboratory Medicine St. Gallen, 9001 St. Gallen, Switzerland;
| | - Adriana Mendez
- Department of Laboratory Medicine, Cantonal Hospital Aarau, 5001 Aarau, Switzerland;
| | - Thomas C. Sauter
- Department of Emergency Medicine, Inselspital, Bern University Hospital, 3010 Bern, Switzerland;
| | - Adrian Schmidt
- Clinic of Medical Oncology and Hematology, Institute of Laboratory Medicine, City Hospital Waid and Triemli, 8063 Zurich, Switzerland;
| | - Jan-Dirk Studt
- Division of Medical Oncology and Hematology, University and University Hospital Zurich, 8091 Zurich, Switzerland;
| | - Walter A. Wuillemin
- Division of Hematology and Central Hematology Laboratory, Cantonal Hospital of Lucerne, 6000 Lucerne, Switzerland;
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
- Correspondence:
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Pfeilschifter W, Lindhoff-Last E, Alhashim A, Zydek B, Lindau S, Konstantinides S, Grottke O, Nowak-Göttl U, von Heymann C, Birschmann I, Beyer-Westendorf J, Meybohm P, Greinacher A, Herrmann E. Intracranial bleeding under vitamin K antagonists or direct oral anticoagulants: results of the RADOA registry. Neurol Res Pract 2022; 4:16. [PMID: 35491419 PMCID: PMC9059415 DOI: 10.1186/s42466-022-00183-y] [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: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 11/22/2022] Open
Abstract
Background and purpose The use of direct oral anticoagulants (DOAC) has increased sharply and DOAC are the oral anticoagulant therapy (OAT) of choice for the majority of patients with newly-diagnosed atrial fibrillation. Intracranial hemorrhage is the most severe adverse event of OAT. Systematic data on the course of intracranial hemorrhage under DOAC compared to vitamin K antagonists (VKA) are warranted to enable shared decision making in AF patients needing OAT. Methods This is a secondary analysis of the patients with intracranial bleedings from the prospective multicenter emergency department-based RADOA registry, which collected data on patients admitted with major bleeding while taking VKA or DOAC. The primary endpoint was in-hospital mortality until day 30. We evaluated hematoma volume and short-term clinical outcomes in relation to the extent of active OAT according to coagulation parameters and OAT plasma levels measured by UPLC-MS/MS. Results Of 193 patients with major bleeding, 109 (56.5%) had intracranial hemorrhage [52.3% intracerebral (ICH), 33.9% subdural (SDH), 11.0% subarachnoidal (SAH)]. 64 (58.7%) were on VKA and 45 (41.2%) were on DOAC. On admission, we could confirm active anticoagulation in 97.7% of VKA-treated patients based on either INR > 1.3 or phenprocoumon levels and in 75.8% of DOAC-treated patients based on DOAC levels. Patients suffering an intracranial hemorrhage under VKA showed significantly larger hematoma volumes and a higher in-hospital mortality. Especially in intracerebral hemorrhage, we observed a higher initial severity and numerically greater proportion of early changes towards palliative therapy under VKA, which coincided with a numerically higher case fatality. Conclusions We show significantly smaller hematoma volumes for ICH and SDH under DOAC in comparison to VKA and a significantly lower 30-day in-hospital mortality rate of DOAC-ICH, even before the introduction of specific antidotes. These data strongly support the use of DOAC whenever possible in patients requiring OAT. Trial Registration: http://www.clinicaltrials.gov; Unique identifier: NCT01722786.
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Affiliation(s)
- Waltraud Pfeilschifter
- Department of Neurology and Clinical Neurophysiology, Klinikum Lueneburg, Bögelstr. 1, 21339, Lüneburg, Germany. .,Pharmazentrum Frankfurt, Institute of General Pharmacology and Toxicology, Goethe University, Frankfurt am Main, Germany. .,Department of Neurology, University Hospital Frankfurt, Frankfurt, Germany.
| | - Edelgard Lindhoff-Last
- Coagulation Centre and Coagulation Research Center at the Cardiology Angiology Centre Bethanien Hospital (CCB), Im Prüfling 23, 60389, Frankfurt, Germany.
| | - Ali Alhashim
- Department of Neurology, University Hospital Frankfurt, Frankfurt, Germany.,Neurology Department, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Barbara Zydek
- Coagulation Centre and Coagulation Research Center at the Cardiology Angiology Centre Bethanien Hospital (CCB), Im Prüfling 23, 60389, Frankfurt, Germany
| | - Simone Lindau
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Haemostasis (CTH), Johannes Gutenberg University, Mainz, Germany
| | - Oliver Grottke
- Department of Anaesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Ulrike Nowak-Göttl
- Institute of Clinical Chemistry, Thrombosis and Haemostasis Treatment Centre, University Hospital, Kiel-Lübeck, Germany
| | - Christian von Heymann
- Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Ingvild Birschmann
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Centre, Ruhr University, Bochum, Germany
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Department of Medicine 1; Division Haematology, Dresden University Clinic, Dresden, Germany.,Department of Haematology and Oncology, Kings College, London, UK
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany.,Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Andreas Greinacher
- Department of Immunology and Transfusion Medicine, Universitätsmedizin, Greifswald, Germany
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modelling, Goethe University, Frankfurt, Germany
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7
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Meihandoest T, Studt JD, Mendez A, Alberio L, Fontana P, Wuillemin WA, Schmidt A, Graf L, Gerber B, Amstutz U, Bovet C, Sauter TC, Asmis LM, Nagler M. Accuracy of a Single, Heparin-Calibrated Anti-Xa Assay for the Measurement of Rivaroxaban, Apixaban, and Edoxaban Drug Concentrations: A Prospective Cross-Sectional Study. Front Cardiovasc Med 2022; 9:817826. [PMID: 35369293 PMCID: PMC8969025 DOI: 10.3389/fcvm.2022.817826] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 02/22/2022] [Indexed: 11/13/2022] Open
Abstract
Background Applying a single anti-Xa assay, calibrated to unfractionated heparin to measure rivaroxaban, apixaban, and edoxaban would simplify laboratory procedures and save healthcare costs. Aim We hypothesized that a heparin-calibrated anti-Xa assay would accurately measure rivaroxaban, apixaban, and edoxaban drug concentrations and correctly predict clinically relevant drug levels. Methods This analysis is part of the Simple-Xa study, a prospective multicenter cross-sectional study conducted in clinical practice. Patients treated with rivaroxaban, apixaban, or edoxaban were included. Anti-Xa activity was measured using the Siemens INNOVANCE® Heparin assay. Drug concentrations were determined using ultra-high performance liquid chromatography-tandem mass spectrometry (LC-MS/MS). Cut-off levels were determined in a derivation dataset (50% of patients) and sensitivities and specificities were calculated in a verification dataset (50% of patients). Results Overall, 845 patients were available for analysis. Correlation coefficients (r s ) between the heparin-calibrated anti-Xa assay and drug concentrations were 0.97 (95% CI 0.97, 0.98) for rivaroxaban, 0.96 (0.96, 0.97) for apixaban, and 0.96 (0.94, 0.99) for edoxaban. The area under the receiver operating characteristics curve (ROC) was 0.99 for all clinically relevant drug concentrations. In the verification dataset, the sensitivity was 94.2% (95% CI 90.8-96.6) for 30 μg L-1, 95.8% (92.4-98.0) for 50 μg L-1, and 98.7% (95.5-99.9) for 100 μg L-1. Specificities were 86.3% (79.2-91.7), 89.8% (84.5-93.7), and 88.7% (84.2-92.2), respectively. Conclusion In a large prospective study in clinical practice, a strong correlation of heparin-calibrated anti-Xa measurements with LC-MS/MS results was observed and clinically relevant drug concentrations were predicted correctly.
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Affiliation(s)
- Tamana Meihandoest
- Department of Epidemiology, Maastricht University, Maastricht, Netherlands.,Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Jan-Dirk Studt
- Department of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Adriana Mendez
- Institute for Laboratory Medicine, Kantonsspital Aarau AG, Aarau, Switzerland
| | - Lorenzo Alberio
- Service and Central Laboratory of Hematology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Pierre Fontana
- Division of Angiology and Hemostasis, Geneva University Hospitals, Geneva, Switzerland
| | - Walter A Wuillemin
- Division of Hematology and Central Hematology Laboratory, Cantonal Hospital of Lucerne and University of Bern, Bern, Switzerland
| | - Adrian Schmidt
- Institute of Laboratory Medicine and Clinic of Medical Oncology and Hematology, City Hospital Zurich, Zurich, Switzerland
| | - Lukas Graf
- Center for Laboratory Medicine, St. Gallen, Switzerland
| | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Ursula Amstutz
- Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Cedric Bovet
- Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Thomas C Sauter
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Lars M Asmis
- Centre for Perioperative Thrombosis and Haemostasis, Zurich, Switzerland
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
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8
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Lindhoff-Last E, Birschmann I, Kuhn J, Lindau S, Konstantinides S, Grottke O, Nowak-Göttl U, Lucks J, Zydek B, von Heymann C, Sümnig A, Beyer-Westendorf J, Schellong S, Meybohm P, Greinacher A, Herrmann E. Pharmacokinetics of Direct Oral Anticoagulants in Emergency Situations: Results of the Prospective Observational RADOA-Registry. Thromb Haemost 2021; 122:552-559. [PMID: 34256392 PMCID: PMC9113852 DOI: 10.1055/a-1549-6556] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are increasingly used worldwide. Little is known so far about their pharmacokinetics in emergency situations. METHODS A prospective, observational registry was performed to determine the clinical course in consecutive patients with major bleeding or urgent surgery treated with DOACs. In samples collected as part of routine care DOAC drug concentrations were measured using ultraperformance liquid chromatography-tandem mass spectrometry. Anticoagulant intensity at first presentation and drug half-life (t 1/2), tested in repeat samples, were evaluated. RESULTS A total of 140 patients were prospectively included. Pharmacokinetic data were available in 94% (132/140) of patients. Note that 67% (89/132) experienced life-threatening bleeding and 33% (43/132) needed an urgent surgery. For pharmacokinetic analysis a total of 605 blood samples was available. Median concentration on admission was 205 ng/mL for rivaroxaban and 108 ng/mL for apixaban. All treatment groups showed a high variation of drug concentrations at baseline. In rivaroxaban-treated patients t ½ was 17.3 hours (95% confidence interval [CI]: 15.4-19.7) without significant difference in both groups (major bleeding: t ½ 16.7 hours, 95% CI: 14.7-19.3; urgent surgery: t ½ 19.7 hours, 95% CI: 15.2-27.9; p = 0.292). In apixaban-treated patients t ½ was 25.0 hours (95% CI: 22.9-27.6) with a longer t ½ after urgent surgery (t 1/2: 30.8 hours; 95% CI: 26.9-36.4) compared with severe bleeding (t 1/2: 20.8 hours; 95% CI: 18.8-23.2; p < 0.001). CONCLUSION Emergency patients under DOAC treatment show a high variation of anticoagulant concentrations at baseline. Compared with rivaroxaban, apixaban showed a lower median concentration on admission and a longer t ½.
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Affiliation(s)
- Edelgard Lindhoff-Last
- Coagulation Centre at the Cardiology Angiology Centre Bethanien Hospital (CCB), Frankfurt, Germany,Coagulation Research Centre Bethanien Hospital, Frankfurt, Germany,Address for correspondence Edelgard Lindhoff-Last, MD Cardiology Angiology Center Bethanien Hospital (CCB)Im Prüfling 23, 60389 FrankfurtGermany
| | - Ingvild Birschmann
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Centre, Ruhr University, Bochum, Germany
| | - Joachim Kuhn
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Centre, Ruhr University, Bochum, Germany
| | - Simone Lindau
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Haemostasis (CTH), Johannes Gutenberg University, Mainz, Germany
| | - Oliver Grottke
- Department of Anaesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Ulrike Nowak-Göttl
- Institute of Clinical Chemistry, Thrombosis & Haemostasis Treatment Centre, University Hospital, Kiel-Lübeck, Germany
| | - Jessica Lucks
- Coagulation Research Centre Bethanien Hospital, Frankfurt, Germany
| | - Barbara Zydek
- Coagulation Research Centre Bethanien Hospital, Frankfurt, Germany
| | - Christian von Heymann
- Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Ariane Sümnig
- Department of Immunology and Transfusion Medicine, Universitätsmedizin, Greifswald, Germany
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Department of Medicine 1, Dresden, Germany,Division of Haematology, Dresden University Clinic, Dresden, Germany,Department of Haematology and Oncology, Kings College, London, United Kingdom
| | | | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany,Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Andreas Greinacher
- Department of Immunology and Transfusion Medicine, Universitätsmedizin, Greifswald, Germany
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modelling, Goethe University, Frankfurt, Germany
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9
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Fong AYY, Tiong LL, Tan SSN, Geruka D, Apil GG, Choo CW, Ong TK. Effect of Dabigatran on Clotting Time in the Clotpro Ecarin Clotting Assay: A Prospective, Single-Arm, Open-Label Study. Clin Appl Thromb Hemost 2021; 26:1076029620972473. [PMID: 33284050 PMCID: PMC7724398 DOI: 10.1177/1076029620972473] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Routine coagulation tests do not enable rapid, accurate determination of direct
oral anticoagulant (DOAC) therapy. The ecarin clotting assay (ECA), performed on
the ClotPro viscoelastic testing device, may enable sensitive and specific
detection of dabigatran. We assessed the association between trough plasma
dabigatran concentration and clotting time (CT) in the ClotPro ECA, in patients
with non-valvular atrial fibrillation (NVAF). Each patient provided a single
venous blood sample, ∼1 hour before dabigatran dosing. The study included 118
patients, of whom 64 were receiving dabigatran 110 mg twice daily and 54 were
receiving 150 mg twice daily. ECA CT was moderately correlated with trough
plasma dabigatran concentration (r = 0.80, p < 0.001).
Slight trends toward increased plasma dabigatran concentration and prolonged ECA
CT were apparent with 150 mg versus the 110 mg dose (differences not
statistically significant). Individuals with creatinine clearance below 50
mL/minute had significantly higher plasma dabigatran concentrations and
significantly prolonged ECA CT versus those with creatinine clearance ≥50
mL/minute. In conclusion, this preliminary study has demonstrated that CT in the
ClotPro ECA reflects the plasma concentration of dabigatran in patients with
NVAF. The ECA could potentially be used to assess the impact of dabigatran on a
patient’s coagulation status.
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Affiliation(s)
- Alan Yean Yip Fong
- Clinical Research Center, 58986Sarawak General Hospital, Institute for Clinical Research, National Institutes of Health, Shah Alam, Malaysia.,Department of Cardiology, Sarawak Heart Center, Kota Samarahan, Sarawak, Malaysia
| | - Lee Len Tiong
- Clinical Research Center, 58986Sarawak General Hospital, Institute for Clinical Research, National Institutes of Health, Shah Alam, Malaysia
| | - Shirley Siang Ning Tan
- Clinical Research Center, 58986Sarawak General Hospital, Institute for Clinical Research, National Institutes of Health, Shah Alam, Malaysia.,Department of Pharmacy, 58986Sarawak General Hospital, Kuching, Sarawak, Malaysia
| | - Dominic Geruka
- Clinical Research Center, 58986Sarawak General Hospital, Institute for Clinical Research, National Institutes of Health, Shah Alam, Malaysia
| | - Gerald Grino Apil
- Clinical Research Center, 58986Sarawak General Hospital, Institute for Clinical Research, National Institutes of Health, Shah Alam, Malaysia
| | - Chee Wei Choo
- Clinical Research Center, 58986Sarawak General Hospital, Institute for Clinical Research, National Institutes of Health, Shah Alam, Malaysia
| | - Tiong Kiam Ong
- Department of Cardiology, Sarawak Heart Center, Kota Samarahan, Sarawak, Malaysia
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10
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Raimann FJ, Lindner ML, Martin C, Jennewein L, Lustenberger T, Piekarski F, Zacharowski K, Weber CF. Role of POC INR in the early stage of diagnosis of coagulopathy. Pract Lab Med 2021; 26:e00238. [PMID: 34095419 PMCID: PMC8167296 DOI: 10.1016/j.plabm.2021.e00238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 05/07/2021] [Accepted: 05/10/2021] [Indexed: 01/02/2023] Open
Abstract
Background Acute bleeding requires fast and targeted therapy. Therefore, knowledge of the patient's potential to form a clot is crucial. Point-of-care testing (POCT) provides fast and reliable information on coagulation. Structural circumstances, such as person-bound sample transport, can prolong the reporting of the results. The aim of the present study was to investigate the diagnostic quality and accuracy between POCT INR diagnostics and standard laboratory analysis (SLA) as well as the time advantage between a pneumatic tube and a personal-based transport system. Methods Two groups of haemorrhagic patients (EG: emergency department; OG: delivery room; each n = 12) were examined in the context of bleeding emergencies using POCT and SLA. Samples were transported via a pneumatic tube system or by a personal transport service. Results INR results between POCT and SLA showed a high and significant correlation (EG: p < 0.001; OG: p < 0.001). POCT results were reported significantly more quickly (EG: 1.1 vs. 39.6 min; OG: 2.0 vs. 75.0 min; p < 0.001) and required less time for analysis (EG: 0.3 vs. 24.0 min; OG: 0.5 vs. 45.0 min; p < 0.001) compared to SLA. The time for transportation with the pneumatic tube was significantly shorter (8.0 vs. 18.5 min; p < 0.001) than with the personal-based transport system. Conclusion The results of the present study suggest that POCT may be a suitable method for the emergency diagnosis and may be used as prognostic diagnostic elements in haemotherapy algorithms to initiate targeted haemotherapy at an early point in time.
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Affiliation(s)
- Florian J Raimann
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, Germany
| | - Marie-Louise Lindner
- Department of Anaesthesiology, Intensive Care Medicine and Emergency Medicine, Asklepios Clinics Hamburg, AK Wandsbek, Alphonsstraße 14, 22043, Hamburg, Germany
| | - Christoph Martin
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, Germany
| | - Lukas Jennewein
- Department of Gynecology and Obstetrics, University Hospital Frankfurt, Goethe University Frankfurt, Germany
| | - Thomas Lustenberger
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe University Frankfurt, Germany
| | - Florian Piekarski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, Germany
| | - Christian F Weber
- Department of Anaesthesiology, Intensive Care Medicine and Emergency Medicine, Asklepios Clinics Hamburg, AK Wandsbek, Alphonsstraße 14, 22043, Hamburg, Germany
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11
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Douxfils J, Adcock DM, Bates SM, Favaloro EJ, Gouin-Thibault I, Guillermo C, Kawai Y, Lindhoff-Last E, Kitchen S, Gosselin RC. 2021 Update of the International Council for Standardization in Haematology Recommendations for Laboratory Measurement of Direct Oral Anticoagulants. Thromb Haemost 2021; 121:1008-1020. [PMID: 33742436 DOI: 10.1055/a-1450-8178] [Citation(s) in RCA: 96] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In 2018, the International Council for Standardization in Haematology (ICSH) published a consensus document providing guidance for laboratories on measuring direct oral anticoagulants (DOACs). Since that publication, several significant changes related to DOACs have occurred, including the approval of a new DOAC by the Food and Drug Administration, betrixaban, and a specific DOAC reversal agent intended for use when the reversal of anticoagulation with apixaban or rivaroxaban is needed due to life-threatening or uncontrolled bleeding, andexanet alfa. In addition, this ICSH Working Party recognized areas where additional information was warranted, including patient population considerations and updates in point-of-care testing. The information in this manuscript supplements our previous ICSH DOAC laboratory guidance document. The recommendations provided are based on (1) information from peer-reviewed publications about laboratory measurement of DOACs, (2) contributing author's personal experience/expert opinion and (3) good laboratory practice.
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Affiliation(s)
- Jonathan Douxfils
- Department of Pharmacy-Namur Thrombosis and Hemostasis Center, University of Namur, Namur, Belgium.,Qualiblood SA, Namur, Belgium
| | - Dorothy M Adcock
- Laboratory Corporation of America, Burlington North Carolina, United States
| | - Shannon M Bates
- Department of Medicine, McMaster University Medical Centre, Hamilton, Ontario, Canada
| | - Emmanuel J Favaloro
- Department of Haematology, Sydney Centres for Haemostasis and Thrombosis, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia
| | | | - Cecilia Guillermo
- Hospital de Clínicas "Dr Manuel Quintela," Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Yohko Kawai
- Sanno Hospital, Laboratory Medicine, Tokyo, Japan
| | - Edelgard Lindhoff-Last
- Cardiology Angiology Center Bethanien, CCB Vascular Center, CCB Coagulation Center, Frankfurt, Germany
| | - Steve Kitchen
- Royal Hallamshire Hospital, Coagulation Sheffield, South Yorks, United Kingdom
| | - Robert C Gosselin
- Hemophilia Treatment Center, University of California, Davis Health System, Sacramento, California, United States
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12
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Groene P, Wagner D, Kammerer T, Kellert L, Giebl A, Massberg S, Schäfer ST. Viscoelastometry for detecting oral anticoagulants. Thromb J 2021; 19:18. [PMID: 33726769 PMCID: PMC7962229 DOI: 10.1186/s12959-021-00267-w] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/01/2021] [Indexed: 12/26/2022] Open
Abstract
Background Determination of anticoagulant therapy is of pronounced interest in emergency situations. However, routine tests do not provide sufficient insight. This study was performed to investigate the impact of anticoagulants on the results of viscoelastometric assays using the ClotPro device. Methods This prospective, observational study was conducted in patients receiving dabigatran, factor Xa (FXa)-inhibitors, phenprocoumon, low molecular weight heparin (LMWH) or unfractionated heparin (UFH) (local ethics committee approval number: 17–525-4). Healthy volunteers served as controls. Viscoelastometric assays were performed, including the extrinsic test (EX-test), intrinsic test (IN-test) Russel’s viper venom test (RVV-test), ecarin test (ECA-test), and the tissue plasminogen activator test (TPA-test). Results 70 patients and 10 healthy volunteers were recruited. Clotting time in the EX-test (CTEX-test) was significantly prolonged versus controls by dabigatran, FXa inhibitors and phenprocoumon. CTIN-test was prolonged by dabigatran, FXa inhibitors and UFH. Dabigatran, FXa inhibitors and UFH significantly prolonged CTRVV-test in comparison with controls (median 200, 207 and 289 vs 63 s, respectively; all p < 0.0005). Only dabigatran elicited a significant increase in CTECA-test compared to controls (median 307 vs 73 s; p < 0.0001). CTECA-test correlated strongly with dabigatran plasma concentration (measured by anti-IIa activity; r = 0.9970; p < 0.0001) and provided 100% sensitivity and 100% specificity for detecting dabigatran. Plasma concentrations (anti-XA activity) of FXa inhibitors correlated with CTRVV-test (r = 0.7998; p < 0.0001), and CTRVV-test provided 83% sensitivity and 64% specificity for detecting FXa inhibitors. Conclusions In emergency situations, ClotPro viscoelastometric assessment of whole-blood samples may help towards determining the presence and type of anticoagulant class that a patient is taking. Trial registration German clinical trials database ID: DRKS00015302. Supplementary Information The online version contains supplementary material available at 10.1186/s12959-021-00267-w.
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Affiliation(s)
- Philipp Groene
- Department of Anaesthesiology, University Hospital Munich, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany.
| | - Daniela Wagner
- Department of Anaesthesiology, University Hospital Munich, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Tobias Kammerer
- Department of Anaesthesiology, University Hospital Munich, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany.,Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Lars Kellert
- Department of Neurology, University Hospital Munich, LMU Munich, Munich, Germany
| | - Andreas Giebl
- Department of Transfusion Medicine and Hemostaseology, University Hospital Augsburg, Augsburg, Germany
| | - Steffen Massberg
- Department of Internal Medicine I - Cardiology, University Hospital Munich, LMU Munich, Munich, Germany
| | - Simon Thomas Schäfer
- Department of Anaesthesiology, University Hospital Munich, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
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13
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Lindhoff-Last E, Herrmann E, Lindau S, Konstantinides S, Grottke O, Nowak-Goettl U, Lucks J, Zydek B, Heymann CV, Birschmann I, Sümnig A, Beyer-Westendorf J, Schellong S, Meybohm P, Greinacher A. Severe Hemorrhage Associated With Oral Anticoagulants. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 117:312-319. [PMID: 32605708 DOI: 10.3238/arztebl.2020.0312] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 11/01/2019] [Accepted: 03/09/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Few data have been published to date on outcomes after the common clinical experience of severe hemorrhage in orally anticoagulated patients. METHODS A prospective, multicenter observational study was carried out to investigate outcomes and management in a series of consecutive patients who sustained a severe hemorrhage under treatment with vitamin K antagonists (VKA) or direct oral anticoagulant drugs (DOAC). The primary endpoint was in-hospital death up to and including day 30 after hospital admission. The secondary endpoints were the duration of bleeding, in-hospital death due to hemorrhage (as defined by the study physician examining the patient's records), the use of antagonists, the extent of supportive measures used to stop the hemorrhage, and an assessment of causality. Consecutive patients were recruited until a predefined number of patients was reached in both groups. RESULTS Among 193 patients with severe hemorrhage, 97 had been taking a VKA, and 96 had been taking a DOAC. 13.0 % (95% confidence interval [8.6; 18.5]; 25/193) of the overall group patients died in the first 30 days after hospital admission, including 17.5% ([10.6; 26.6]; 17/97) in the VKA group and 8.3% ([3.7; 15.8]; 8/96) in the DOAC group (p = 0.085). The median duration of bleeding was 19.8 hours in the VKA group and 27.8 hours in the DOAC group (p = 0.632). The in-hospital mortality due to hemorrhage was higher in the VKA group than in the DOAC group (15.5% [15/97] versus 4.2% [4/97]; p = 0.014). Only the use of prothrombin complex concentrates (PCCs) lowered the median duration of hemorrhage in the two patient groups. In 35% (68/193) of the patients, the hemorrhage was caused by an external influence, most commonly a fall. CONCLUSION The in-hospital mortality was higher among patients treated with VKA than among patients treated with DOAC, although the difference failed to reach statistical significance.
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Affiliation(s)
- Edelgard Lindhoff-Last
- Coagulation Center and Research Center, Cardioangiology Center Bethanien Hospital (CCB), Frankfurt/Main; Institute of Biostatistics und Mathematical Modelling, Goethe University, Frankfurt; Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt/Main; Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz; Department of Anesthesiology, RWTH Aachen University Hospital, Aachen; Department of Clinical Chemistry, Thrombosis and Hemostasis Unit, University Hospital of Kiel and Lübeck, Kiel; Research Center of the Cardioangiology Center Bethanien Hospital (CCB), Frankfurt/Main; Department of Anesthesiology, Intensive Care and Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin; Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Ruhr University Bochum, Bochum; Department of Immunology and Transfusion medicine, University Medicine Greifswald, Greifswald; Thrombosis Research Unit, Center for Internal Medicine 1, Department of Hematology, University Hospital Dresden, Dresden, Germany, and Department of Haematology and Oncology, Kings College London, England; Medical Department 2, Municipal Hospital Dresden-Friedrichstadt, Dresden; Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, and Department of Anesthesiology, University Hospital Würzburg, Würzburg; Department of Immunology and Transfusion Medicine, University Medicine Greifswald, Greifswald
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14
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[Perioperative management of trauma surgery patients treated with direct oral anticoagulants]. Unfallchirurg 2019; 122:633-645. [PMID: 31367841 DOI: 10.1007/s00113-019-0693-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
As the population gets older the prevalence of atrial fibrillation and venous thromboembolism also increases. Therefore, more patients require anticoagulation and currently direct oral anticoagulants (DOAC), such as dabigatran etexilate, apixaban, rivaroxaban and edoxaban are preferred to vitamin K antagonists (VKA), mainly because of the more favorable risk-benefit profile with respect to bleeding. Older patients in particular frequently present at the accident and emergency department due to falls and an increased risk of fractures. The perioperative management of these patients who are treated with DOACs is a challenge in the clinical routine and needs special consideration. This article discusses these issues in an interdisciplinary approach and develops strategies for the perioperative management of patients treated with DOACs and undergoing trauma or orthopedic surgery.
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15
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Hoffman M, Goldstein JN, Levy JH. The impact of prothrombin complex concentrates when treating DOAC-associated bleeding: a review. Int J Emerg Med 2018; 11:55. [PMID: 31179943 PMCID: PMC6326120 DOI: 10.1186/s12245-018-0215-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 11/11/2018] [Indexed: 12/18/2022] Open
Abstract
Background Bleeding complications are a risk associated with all anticoagulants. Currently, the treatment options for the management of direct oral anticoagulant (DOAC)-associated bleeding are limited. Prothrombin complex concentrates (PCCs) have been proposed as a potential therapeutic option, and evidence regarding their use is increasing. Review Many studies supporting PCC have used preclinical models and healthy volunteers; however, more recently, observational studies have further improved insight into current DOAC reversal strategies. Multiple clinical practice guidelines now specifically suggest use of PCCs for this indication. Specific reversal agents for Factor Xa inhibitors may become available in the near future, but data on their efficacy are still emerging. Conclusions Ultimately, a multimodal approach may be the optimal strategy to restore haemostasis in patients presenting with DOAC-associated coagulopathy. Electronic supplementary material The online version of this article (10.1186/s12245-018-0215-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Maureane Hoffman
- Department of Pathology, Duke University School of Medicine, Durham, NC, USA.
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, USA
| | - Jerrold H Levy
- Department of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, NC, USA
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16
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Tromeur C, van der Pol LM, Mairuhu ATA, Leroyer C, Couturaud F, Huisman MV, Klok FA. Novel Anticoagulant Treatment for Pulmonary Embolism with Direct Oral Anticoagulants Phase 3 Trials and Clinical Practice. Semin Intervent Radiol 2018; 35:83-91. [PMID: 29872242 DOI: 10.1055/s-0038-1642622] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Anticoagulant therapy is the cornerstone of therapeutic management in acute venous thromboembolism (VTE), consisting of pulmonary embolism and deep vein thrombosis. Direct oral anticoagulants (DOACs) have become the standard of care because of their good safety profile and ease of use in clinical practice. Indeed, phase 3 randomized trials (AMPLIFY, EINSTEIN, RECOVER, and HOKUSAI studies) showed that DOACs provided a similar efficacy and a better safety than conventional treatment with parenteral heparin with overlapping loading dose of vitamin K antagonists in acute VTE therapeutic management. The results of published data from real-world registries confirm the safety and efficacy of DOACs demonstrated in the phase 3 trials.
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Affiliation(s)
- Cécile Tromeur
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.,Department of Internal Medicine and Chest Diseases, Groupe d'Etude de la Thrombose de Bretagne Occidentale, Equipe d'Accueil 3878, Hôpital de la Cavale Blanche, CHRU, Brest, France.,Centre d'Investigation Clinique INSERM 1412, University of Brest, Brest, France
| | - Liselotte M van der Pol
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.,Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Albert T A Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Christophe Leroyer
- Department of Internal Medicine and Chest Diseases, Groupe d'Etude de la Thrombose de Bretagne Occidentale, Equipe d'Accueil 3878, Hôpital de la Cavale Blanche, CHRU, Brest, France.,Centre d'Investigation Clinique INSERM 1412, University of Brest, Brest, France
| | - Francis Couturaud
- Department of Internal Medicine and Chest Diseases, Groupe d'Etude de la Thrombose de Bretagne Occidentale, Equipe d'Accueil 3878, Hôpital de la Cavale Blanche, CHRU, Brest, France.,Centre d'Investigation Clinique INSERM 1412, University of Brest, Brest, France
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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