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Bouget J, Balusson F, Roy PM, Viglino D, Pavageau L, Lacut K, Oger E. Management of epistaxis associated with oral antithrombotic drugs in emergency department and impact on prescription thereafter. Clin Otolaryngol 2023; 48:457-464. [PMID: 36789614 DOI: 10.1111/coa.14040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 11/25/2022] [Accepted: 01/21/2023] [Indexed: 02/16/2023]
Abstract
OBJECTIVES To describe management, and to assess factors associated with antithrombotic prescription thereafter in patients who had epistaxis referred to emergency department (ED). DESIGN Prospective cohort study. From EDs, clinical, biological and hospital data were collected. The clinical database was linked to the French Health Insurance Database where we retrieved antithrombotic drug deliveries in a 3-month period before and after referral. SETTING Multicentric population-based cohort study within five well-defined areas. PARTICIPANTS We considered 306 patients referred for epistaxis with a stable oral antithrombotic regimen before referral. MAIN OUTCOME MEASURES We considered management, hospital outcome and case fatality. Antithrombotic prescription in a 3-month follow-up period was categorised into three classes: no change, class change, or discontinuation. During follow-up, hospitalisation for epistaxis or ischaemic events was searched. RESULTS Among 306 adult individuals (mean age: 76 years), 166 took oral anticoagulant and 140 an antiplatelet drug. Blood transfusion was needed in 13.7% of patients and anterior packing alone in 61%. Half of the patients were hospitalised; 301 were discharged alive. Considering antithrombotic prescription thereafter we observed no change in 219 patients (72.8%), class changes in 47 patients (15.6%) and discontinuation in 35 patients (11.6%). We identified four independent predictors for antithrombotic prescription: hospitalisation (vs. returning home, p = .05), age (p = .03), haemoglobin level (p = .03) and oral anticoagulant (vs. antiplatelet agent, p < .001). During the 3 months following discharge, 2 thrombotic and 15 bleeding events were identified. CONCLUSIONS Epistaxis referred to emergency department had an impact on subsequent antithrombotic prescription. CLINICAL TRIAL REGISTRATION Clinical Trials.gov identifier: NCT02886533.
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Affiliation(s)
- Jacques Bouget
- Univ Rennes, CHU Rennes, EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Rennes, France.,Emergency Department, Rennes University Hospital, Rennes, France
| | - Frédéric Balusson
- Univ Rennes, CHU Rennes, EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Rennes, France
| | - Pierre-Marie Roy
- Emergency Department, Centre Hospitalier Universitaire, Institut MITOVASC, Université d'Angers, Angers, France.,F-CRIN INNOVTE, Paris, France
| | - Damien Viglino
- Emergency Department, Grenoble-Alpes University Hospital, Grenoble, France
| | - Laure Pavageau
- Emergency Department, University hospital, Nantes, France
| | - Karine Lacut
- CIC 1412, Université de Bretagne Loire, Université de Brest, INSERM CIC 1412, CHRU de Brest, Brest, France
| | - Emmanuel Oger
- Univ Rennes, CHU Rennes, EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Rennes, France
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Bouget J, Huet MC, Roy PM, Viglino D, Lacut K, Pavageau L, Oger E. Acute, major muscular hematoma associated with antithrombotic agents: A multicenter real-world cohort. Thromb Res 2020; 199:54-58. [PMID: 33429124 DOI: 10.1016/j.thromres.2020.12.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 12/17/2020] [Accepted: 12/18/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is little data on major muscular hematomas and the little there is has mainly focused on patients exposed to oral anticoagulants. OBJECTIVE To describe the clinical characteristics, management and outcomes of patients admitted to emergency department (ED) for major muscular hematoma associated with an antithrombotic agent, and to identify predictors of in-hospital mortality. PATIENTS AND METHODS Over a three-year period, all consecutive cases of adult patients admitted to the ED of 5 tertiary care hospitals for major muscular hematoma while exposed to an antithrombotic agent were prospectively collected and medically validated. Clinical and biological data, therapeutic management of the bleeding event, and in-hospital mortality were collected from the medical records and compared across five groups of hematoma locations. Potential confounders were taken in account using a multivariate binomial regression model. RESULTS Three hundred and seventy-five patients were included (mean age = 81.4 years): 271 were exposed to vitamin K antagonists, 58 to parenteral anticoagulants (heparin, LMWH, fondaparinux), 33 to antiplatelets, and 13 to direct oral anticoagulants. The muscular hematomas were located in the lower limbs (n = 198), the rectus sheath (n = 71), the iliopsoas (n = 45), the upper limbs (n = 33), or elsewhere (n = 28). Reversal therapy was prescribed for 48.5% of patients, red cell transfusions for 63.6%, surgery for 12.3% and embolization for 3.5%. For 84% of patients, hospitalization was required, with a median length of stay of 10 days. Overall, in-hospital mortality was 8.5%. Reversal therapy, the need for intensive care and mortality were significantly more frequent among patients with iliopsoas hematomas. The independent predictors of in-hospital mortality were: decrease in mean arterial pressure (RR = 1.84), decrease in hemoglobin level (RR = 1.37) and the iliopsoas location (RR = 3.06). CONCLUSION Frail elderly patients with major muscular hematomas linked to antithrombotic agents risk substantial morbidity and in-hospital mortality. The iliopsoas location was the most life-threatening bleeding site. Close observation of this population is warranted to ensure better outcomes.
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Affiliation(s)
- Jacques Bouget
- Univ Rennes, CHU Rennes, EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, F 35043 Rennes, France
| | | | - Pierre-Marie Roy
- Emergency Department, Centre Hospitalier Universitaire, Institut MITOVASC, Université d'Angers, Angers, France; F-CRIN INNOVTE, France
| | - Damien Viglino
- Emergency Department, Grenoble-Alpes University Hospital, F 38043 Grenoble, France
| | - Karine Lacut
- CIC 1412, Université de Bretagne Loire, Université de Brest, INSERM CIC 1412, CHRU de Brest, F 29200 Brest, France
| | - Laure Pavageau
- Emergency Department, University hospital, F 44093 Nantes, France
| | - Emmanuel Oger
- Univ Rennes, CHU Rennes, EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, F 35043 Rennes, France.
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Bouget J, Balusson F, Viglino D, Roy PM, Lacut K, Pavageau L, Oger E. Major bleeding risk and mortality associated with antiplatelet drugs in real-world clinical practice. A prospective cohort study. PLoS One 2020; 15:e0237022. [PMID: 32764775 PMCID: PMC7413418 DOI: 10.1371/journal.pone.0237022] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 07/18/2020] [Indexed: 12/20/2022] Open
Abstract
Background Major bleedings other than gastrointestinal (GI) and intracranial (ICH) and mortality rates associated with antiplatelet drugs in real-world clinical practice are unknown. The objective was to estimate major bleeding risk and mortality among new users of antiplatelet drugs in real-world clinical practice. Methods and findings A population-based prospective cohort using the French national health data system (SNIIRAM), identified 69,911 adults living within five well-defined geographical areas, who were new users of antiplatelet drugs in 2013–2015 and who had not received any antithrombotics in 2012. Among them, 63,600 started a monotherapy and 6,311 a dual regimen. Clinical data for all adults referred for bleeding was collected from all emergency departments within these areas, and medically validated. Databases were linked using common key variables. The main outcome measure was time to major bleeding (GI, ICH and other bleedings). Secondary outcomes were death, and event-free survival (EFS). Hazard ratios (HR) were derived from adjusted Cox proportional hazard models. We used Inverse Propensity of Treatment Weighting as a stratified sensitivity analysis according to the antiplatelet monotherapy indication: primary prevention without cardiovascular (CV) risk factors, with CV risk factors, and secondary prevention. We observed 250 (0.36%) major haemorrhages, 81 ICH, 106 GI and 63 other types of bleeding. Incidences were twice as high in dual therapy as in monotherapy. Compared to low-dose aspirin (≤ 100 mg daily), high-dose (> 100 up to 325 mg daily) was associated with an increased risk of ICH (HR = 1.80, 95%CI 1.10 to 2.95). EFS was improved by high-dose compared to low-dose aspirin (1.41, 1.04 to 1.90 and 1.32, 1.03 to 1.68) and clopidogrel (1.30, 0.73 to 2.3 and 1.7, 1.24 to 2.34) respectively in primary prevention with and without CV risk factors. Conclusion The incidence of major bleeding and mortality was low. In monotherapy, low-dose aspirin was the safest therapeutic option whatever the indication. Trial registration NCT02886533.
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Affiliation(s)
- Jacques Bouget
- EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Univ Rennes, CHU Rennes, Rennes, France
| | - Frédéric Balusson
- EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Univ Rennes, CHU Rennes, Rennes, France
| | - Damien Viglino
- Emergency Department, Grenoble-Alpes University Hospital, Grenoble, France
| | - Pierre-Marie Roy
- Emergency Department, Centre Hospitalier Universitaire, Institut MITOVASC, Université d'Angers, Angers, France.,F-CRIN INNOVTE, France
| | - Karine Lacut
- CIC 1412, Université de Bretagne Loire, Université de Brest, INSERM CIC 1412, CHRU de Brest, Brest, France
| | - Laure Pavageau
- Emergency Department, University Hospital, Nantes, France
| | - Emmanuel Oger
- EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Univ Rennes, CHU Rennes, Rennes, France
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Bouget J, Balusson F, Maignan M, Pavageau L, Roy PM, Lacut K, Scailteux LM, Nowak E, Oger E. Major bleeding risk associated with oral anticoagulant in real clinical practice. A multicentre 3-year period population-based prospective cohort study. Br J Clin Pharmacol 2020; 86:2519-2529. [PMID: 32415705 DOI: 10.1111/bcp.14362] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 04/21/2020] [Accepted: 05/01/2020] [Indexed: 12/11/2022] Open
Abstract
AIMS The objective was to compare major bleeding risk of direct oral anticoagulants (DOACs; per type and dose) with vitamin K antagonists (VKAs), irrespective of indication, using real-world data. METHODS A population-based prospective cohort study, using the French national health data system (SNIIRAM), identified 47 469 adults living within 5 well-defined geographical areas, who were new users of oral anticoagulants in the period 2013-2015: 20 205 VKA users, 19 579 rivaroxaban users, 4225 dabigatran users and 3460 apixaban users. From all emergency departments within these areas, clinical data for all adults referred for bleeding was collected and medically validated. The databases were linked for common key variables. The main outcome measure was major bleeding: intracranial haemorrhage, major gastrointestinal bleeding and other major bleeding events. Hazard ratios were derived from adjusted Cox proportional hazard models. We used propensity score weighting as a sensitivity analysis, with separate analyses according to indications (atrial fibrillation or venous thromboembolism). RESULTS Compared to VKAs, high and low-dose DOACs were associated with a reduced risk of intracranial haemorrhage (adjusted hazard ratio 0.55, 95% confidence interval 0.37-0.82 and 0.54, 0.26-1.12 respectively), and a reduced risk of other major bleeding events (0.41, 0.29-0.58 and 0.41, 0.22-0.79 respectively), irrespective of duration and indication. Neither DOAC dose evidenced any significant difference from VKAs in terms of risk of major gastrointestinal bleeding. CONCLUSION There is a clear benefit of using DOACs with regard to intracranial haemorrhage. The study provides new insight into major gastrointestinal and other major bleeding events.
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Affiliation(s)
- Jacques Bouget
- Univ Rennes, CHU Rennes, EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Rennes, France
| | - Frédéric Balusson
- Univ Rennes, CHU Rennes, EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Rennes, France
| | - Maxime Maignan
- Emergency Department, University Hospital, Grenoble, France
| | - Laure Pavageau
- Emergency Department, University hospital, Nantes, France
| | | | - Karine Lacut
- CIC 1412, Université de Bretagne Loire, Université de Brest, INSERM, CHRU de Brest, Brest, France
| | - Lucie-Marie Scailteux
- Univ Rennes, CHU Rennes, EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Rennes, France
| | - Emmanuel Nowak
- CIC 1412, Université de Bretagne Loire, Université de Brest, INSERM, CHRU de Brest, Brest, France
| | - Emmanuel Oger
- Univ Rennes, CHU Rennes, EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Rennes, France
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Bouget J, Balusson F, Scailteux LM, Maignan M, Roy PM, L'her E, Pavageau L, Nowak E. Major bleeding with antithrombotic agents: a 2012-2015 study using the French nationwide Health Insurance database linked to emergency department records within five areas - rationale and design of SACHA study. Fundam Clin Pharmacol 2019; 33:443-462. [PMID: 30537335 DOI: 10.1111/fcp.12444] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 11/27/2018] [Accepted: 12/06/2018] [Indexed: 12/29/2022]
Abstract
Bleeding represents the most recognized and feared complications of antithrombotic drugs including oral anticoagulants. Previous studies showed inconsistent results on the safety profile. Among explanations, bleeding definition could vary and classification bias exists related to the lack of medical evaluation. To quantify the risk of major haemorrhagic event and event-free survival associated with antithrombotic drugs (vitamin K antagonist [VKA], non-VKA anticoagulant [NOAC], antiplatelet agent, parenteral anticoagulant) in 2012-2015, we linked the French nationwide Health Insurance database (SNIIRAM) with a local 'emergency database' (clinical and biological data collected in clinical records). In the VKA-NOAC comparison, a Cox regression analysis will be used to estimate the hazard ratio of major haemorrhagic event adjusted on gender, modified HAS-BLED score and comorbidities. A distinction on the type of major haemorrhagic event (intracranial, gastrointestinal and other haemorrhagic events) was made. We present here the study protocol and the database linkage results. Using six linkage keys, among 3 837 557 hospital visits identified in SNIIRAM, 5264 have been matched with a major haemorrhagic event identified in the 'emergency database', thus clinically confirmed. The 1090 unmatched haemorrhagic events could be explained by the fact that patients were not extracted in the SNIIRAM database (patients living in accommodation establishment with internal use of pharmacy, military people with specific insurance…). We showed the value of SNIIRAM enrichment with a clinical database, a necessary step to categorize haemorrhagic events by a clinically relevant definition and medical validation; it will allow to estimate more accuracy each type of haemorrhagic event.
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Affiliation(s)
- Jacques Bouget
- Univ Rennes, REPERES [Pharmacoepidemiology and Heath Services Research] - EA 7449, Univ Rennes, Rennes, F-35000, France.,Emergency Department, University hospital, Rennes, F-35033, France
| | - Frédéric Balusson
- Univ Rennes, REPERES [Pharmacoepidemiology and Heath Services Research] - EA 7449, Univ Rennes, Rennes, F-35000, France
| | - Lucie-Marie Scailteux
- Univ Rennes, REPERES [Pharmacoepidemiology and Heath Services Research] - EA 7449, Univ Rennes, Rennes, F-35000, France.,Pharmacovigilance, Pharmacoepidemiology and drug information center, Rennes, F-35033, France
| | - Maxime Maignan
- Emergency Department, University Hospital, Grenoble, F-38043, France
| | - Pierre-Marie Roy
- Emergency Department, University hospital, Angers, F-49033, France
| | - Erwan L'her
- Emergency Department, University hospital, Brest, F-29609, France
| | - Laure Pavageau
- Emergency Department, University hospital, Nantes, F-44093, France
| | - Emmanuel Nowak
- CHU de Brest, Brest, F-29200, France.,Inserm CIC 1412, IFR 148, Université de Brest, Brest, F-29200, France
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