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Conti A, Renzi N, Bini G, Covelli A, Mazzucchelli M, Bigazzi IC, Lencioni AM, Bertolini L, Giusti L, Pennati P, Cipriano A, Ghiadoni L. P4636Major gastrointestinal haemorrhage of patients with ongoing anticoagulants presented to the emergency department of a community hospital: four-year survey. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.1018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objective
To look for outcomes of patients (pts) with major gastrointestinal haemorrhage (mGIH) and ongoing anticoagulants out of four-year survey of community hospital with catchment area 197,722 inhabitants, of whom 15,267 with Warfarin (W) and 10,397 with direct oral anticoagulants (DOACs). DOACs were available for prescription in the catchment area since 4 years (dabigatran and rivaroxaban), 3 years (apixaban), and 2 years (edoxaban).
Methods
Haemorrhage (n=1,919) were submitted to propensity score matching for major bleeding; mGIH were enrolled and stratified according to ongoing W or DOACs. Primary endpoint was one-month death.
Results
Out of 476 mGIH, 73 pts received anticoagulants; 22 DOACs and 51 W; p=0.0006. Of note mGIH on W accounted for 2.7% (51/1,919) per year of pts, and 0.08% (51/15,267) of the catchment area. Conversely, mGIH on DOACs accounted as follows: dabigatran (n=10/476) 0.53%, rivaroxaban (n=6/476) 0.32%, apixaban (n=5/476) 0.35%, and edoxaban (n=1/476) 0.11% per year of pts; p=0.117. Rate of mGIH and DOACs versus (vs) rate of mGIH and W as follows: less than (−) 5 fold (2.7x100/0.53) of dabigatran vs W, p=0.004; −8 fold (2.7x100/0.32) of rivaroxaban vs W, p=0.0002; −7 fold (2.7x100/0.35) of apixaban vs W; p=0.ehz745.10188, and −25 fold (2.7x100/0.11) of edoxaban vs W; p=0.ehz745.101801. However no difference versus the catchment area per year (0.723): 0.07% (10/3,373) dabigatran, 0.04% (6/4,046) rivaroxaban, 0.08% (5/2,141) apixaban, 0.06% (1/839) edoxaban.
Overall, one-month death accounted for 10/476 (2.1%). Of note 236 mGI were from the upper tract and 240 from the lower tract. Among upper tract, 10 pts received DOACs (4 dabigatran, 4 rivaroxaban, 2 apixaban, and 0 edoxaban) and 21 received W. One-month death was 0/10 DOACs versus 1/21 W, p=0.483. Among lower tract, 12 pts received DOACs (6 dabigatran, 2 rivaroxaban, 3 apixaban, and 1 edoxaban) and 30 pts received W; one-month death was 0 for every groop. Anticoagulant reversal treatment was given to 6/22 (27%) pts with DOACs versus 18/51 (35%) with W, p=0.014; transfusion to 6/22 (27%) versus 11/51 (22%), respectively, p=0.306; admission 19/22 (86%) versus 42/51 (82%), respectively, p=0.004. Sensitivity/specificity ratio of variables and biomarkers for aggressive pharmacological approach were obtained by area under ROC curve (AUC) >0.50. PTT value >37 sec (AUC 0.57) showed sensitivity 15%, specificity 90%; INR value >1.4 (0.50), sens 15%, spec 80%. In addition, warfarin (0.49) sens 15%, spec 80%; age ≥75 years (0.48) sen 60%, spec 40%.
Gastrointestinal bleeding: flow-chart.
Conclusion
Out of four-year survey, pts with ongoing DOACs were less likely to have mGIH when compared to W.
Patients with W were more likely to receive reversal tratment; pts with DOACs were more likely to undergo admission. Short-term mortality of pts with W was higher than DOACs. Aggressive pharmacological approach should be driven by PTT, INR, ongoing warfarin, and older age.
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Affiliation(s)
- A Conti
- North-West District Tuscany HealthCare, Apuane General Hospital, Emergency Department, Massa-Carrara, Italy
| | - N Renzi
- North-West District Tuscany HealthCare, Apuane General Hospital, Emergency Department, Massa-Carrara, Italy
| | - G Bini
- North-West District Tuscany HealthCare, Apuane General Hospital, Emergency Department, Massa-Carrara, Italy
| | - A Covelli
- North-West District Tuscany HealthCare, Apuane General Hospital, Emergency Department, Massa-Carrara, Italy
| | - M Mazzucchelli
- North-West District Tuscany HealthCare, Apuane General Hospital, Emergency Department, Massa-Carrara, Italy
| | - I C Bigazzi
- North-West District Tuscany HealthCare, Apuane General Hospital, Emergency Department, Massa-Carrara, Italy
| | - A M Lencioni
- North-West District Tuscany HealthCare, Apuane General Hospital, Emergency Department, Massa-Carrara, Italy
| | - L Bertolini
- North-West District Tuscany HealthCare, Apuane General Hospital, Emergency Department, Massa-Carrara, Italy
| | - L Giusti
- University of Genoa, Top Master School of Nursing, Genoa, Italy
| | - P Pennati
- North-West District Tuscany HealthCare, Cisanello General Hospital and University of Pisa, Emergency Department, Pisa, Italy
| | - A Cipriano
- North-West District Tuscany HealthCare, Cisanello General Hospital and University of Pisa, Emergency Department, Pisa, Italy
| | - L Ghiadoni
- North-West District Tuscany HealthCare, Cisanello General Hospital and University of Pisa, Emergency Department, Pisa, Italy
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Landini G, Cordopatri F, Scarti L, Spolveri S, Pennati P, Rosselli A. [Dissection of the epiaortic vessels: an emergency pathology as the cause of focal cerebral ischemia. The evaluation of a case load of 7 patients]. Ann Ital Med Int 1996; 11:12-6. [PMID: 8645524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Dissection of the epiaortic vessels is an emerging cause of focal cerebral ischemia, especially in young patients. Non-invasive diagnostic devices (ultrasound, nuclear magnetic resonance) have greatly improved the ability to suspect and identify it. We report our clinical experience with 5 patients affected by carotid artery dissection and 2 patients affected by vertebral artery dissection. Vessel dissection generally occurred spontaneously; it was preceded by head or cervical trauma in 2 cases. Arterial hypertension was commonly associated, and headache was always present together with other focal neurological signs. Clinical suspicion was confirmed by ultrasound duplex scanning: although never conclusive, it always showed typical Doppler patterns. Nuclear magnetic resonance has become an acknowledged means of definitive diagnosis although angiography remains the gold standard. In any case, diagnosis requires clinical suspicion and the accurate correlation of clinical data and instrumental results. Therapy consisted in anticoagulant and antiplatelet drugs. The clinical course of our patients was favorable in all cases, and no recurrences were recorded.
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Affiliation(s)
- G Landini
- Unità Operativa di Medicina Interna II, Ospedale S. Maria Annuziata di Antella, FI
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Brizzi E, De' Faveri Tron M, Todescan GC, Caiazzo A, Pennati P, Piccione R. [Characteristics of articular caps of the elbow in relation to flex-extension movement]. Boll Soc Ital Biol Sper 1984; 60:707-12. [PMID: 6732943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Considering the factors limiting flexo-extension movements of the elbow, particular importance has been given to the possible existing contact between its articular ends in the final stage of the movement. However, this factor has different importance according to the angle formed by the ulnar and humeral diaphysis with their respective epiphysis. Some authors assert that humeral and ulnar articular ends do not come into any contact during the first stage of the sigmoid cavity movement on the trochlea, according to their opinion, in fact, an angle of 45 degrees should exist between the prolongation of the humeral diaphysis axis and the lower epiphysis and the great ulnar sigmoid cavity should be oriented forward and high forming an axis that is inclined of 45 degrees the horizontal plane. In order to verify this affirmation, we have measured the width of these angles in 50 soaked humeri and 50 ulnas. The same angle has been measured in 50 radiograms of partially flexed laterally projected elbows. The mean observed values have been of about 34 degrees for the distal epiphysis-diaphysis angle in humeri and of about 25 degrees for the inclination angle of the orientation axis of the great ulnar sigmoid cavity. The results show that - when humeral epiphysis-diaphysis angle is larger or eventually equal to the ulnar one - it is sufficient that the considered angles are less than 45 degrees to get a correct and complete flexo-extension movement.
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