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Olie RH, Winckers K, Rocca B, Ten Cate H. Oral Anticoagulants Beyond Warfarin. Annu Rev Pharmacol Toxicol 2024; 64:551-575. [PMID: 37758192 DOI: 10.1146/annurev-pharmtox-032823-122811] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Direct oral anticoagulants (DOACs) have largely replaced vitamin K antagonists, mostly warfarin, for the main indications for oral anticoagulation, prevention and treatment of venous thromboembolism, and prevention of embolic stroke in atrial fibrillation. While DOACs offer practical, fixed-dose anticoagulation in many patients, specific restrictions or contraindications may apply. DOACs are not sufficiently effective in high-thrombotic risk conditions such as antiphospholipid syndrome and mechanical heart valves. Patients with cancer-associated thrombosis may benefit from DOACs, but the bleeding risk, particularly in those with gastrointestinal or urogenital tumors, must be carefully weighed. In patients with frailty, excess body weight, and/or moderate-to-severe chronic kidney disease, DOACs must be cautiously administered and may require laboratory monitoring. Reversal agents have been developed and approved for life-threatening bleeding. In addition, the clinical testing of potentially safer anticoagulants such as factor XI(a) inhibitors is important to further optimize anticoagulant therapy in an increasingly elderly and frail population worldwide.
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Affiliation(s)
- Renske H Olie
- Departments of Internal Medicine (Section of Vascular Medicine) and Biochemistry, Thrombosis Expertise Center, and CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands;
| | - Kristien Winckers
- Departments of Internal Medicine (Section of Vascular Medicine) and Biochemistry, Thrombosis Expertise Center, and CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands;
| | - Bianca Rocca
- Section of Pharmacology, Catholic University School of Medicine, Rome, Italy
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
| | - Hugo Ten Cate
- Departments of Internal Medicine (Section of Vascular Medicine) and Biochemistry, Thrombosis Expertise Center, and CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands;
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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Heuts S, Ceulemans A, Kuiper GJAJM, Schreiber JU, van Varik BJ, Olie RH, Ten Cate H, Maessen JG, Milojevic M, Maesen B. Optimal management of cardiac surgery patients using direct oral anticoagulants: recommendations for clinical practice. Eur J Cardiothorac Surg 2023; 64:ezad340. [PMID: 37812245 PMCID: PMC10585358 DOI: 10.1093/ejcts/ezad340] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 09/26/2023] [Accepted: 10/06/2023] [Indexed: 10/10/2023] Open
Abstract
OBJECTIVES Literature is scarce on the management of patients using direct oral anticoagulants (DOACs) undergoing elective, urgent and emergency surgery. Therefore, we summarize the current evidence and provide literature-based recommendations for the management of patients on DOACs in the perioperative phase. METHODS A general literature review was conducted on the pharmacology of DOACs and for recommendations on the management of cardiac surgical patients on DOACs. Additionally, we performed a systematic review for studies on the use of direct DOAC reversal agents in the emergency cardiac surgical setting. RESULTS When surgery is elective, the DOAC cessation strategy is relatively straightforward and should be adapted to the renal function. The same approach applies to urgent cases, but additional DOAC activity drug level monitoring tests may be useful. In emergency cases, idarucizumab can be safely administered to patients on dabigatran in any of the perioperative phases. However, andexanet alfa, which is not registered for perioperative use, should not be administered in the preoperative phase to reverse the effect of factor Xa inhibitors, as it may induce temporary heparin resistance. Finally, the administration of (activated) prothrombin complex concentrate may be considered in all patients on DOACs, and such concentrates are generally readily available. CONCLUSIONS DOACs offer several advantages over vitamin K antagonists, but care must be taken in patients undergoing cardiac surgery. Although elective and urgent cases can be managed relatively straightforwardly, the management of emergency cases requires particular attention.
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Affiliation(s)
- Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre+, Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Angelique Ceulemans
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
- Department of Neurology, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Gerhardus J A J M Kuiper
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
- Department of Anaesthesiology and Pain Treatment, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Jan U Schreiber
- Department of Anaesthesiology and Pain Treatment, Maastricht University Medical Centre+, Maastricht, Netherlands
| | | | - Renske H Olie
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
- Thrombosis Expertise Centre, Maastricht University Medical Centre+, Maastricht, Netherlands
- Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Hugo Ten Cate
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
- Thrombosis Expertise Centre, Maastricht University Medical Centre+, Maastricht, Netherlands
- Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre+, Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Bart Maesen
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre+, Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
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Schultinge L, Hulshof AM, van Neerven D, Mulder MMG, Sels JWEM, Hulsewe HPMG, Kuiper GJAJM, Olie RH, Ten Cate H, van der Horst ICC, van Bussel BCT, Henskens YMC. Applications of rotational thromboelastometry in heparin monitoring in critical COVID-19 disease: Observations in the Maastricht Intensive Care COVID cohort. Thromb Update 2023; 12:100140. [PMID: 38620129 PMCID: PMC10245457 DOI: 10.1016/j.tru.2023.100140] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 05/16/2023] [Accepted: 06/06/2023] [Indexed: 04/17/2024] Open
Abstract
Background Critically ill COVID-19 patients are at risk for venous thromboembolism (VTE). Therefore, they receive thromboprophylaxis and, when appropriate, therapeutic unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH). To monitor heparins in COVID-19 disease, whole-blood rotational thromboelastometry (ROTEM) may be a promising alternative to the aPTT and anti-Xa assays. Objective To evaluate the ROTEM INTEM/HEPTEM ratios in mechanically ventilated COVID-19 patients treated with UFH and therapeutic LMWH. Material and methods A subcohort of mechanically ventilated COVID-19 patients of the prospective Maastricht Intensive Care Covid (MaastrICCht) cohort was studied. Anti-Xa, aPTT, and ROTEM measurements following treatment with UFH or therapeutic dose of LMWH (nadroparin) were evaluated using uni- and multivariable linear regression analysis and receiver operating characteristics. Results A total of 98 patients were included, of which 82 were treated with UFH and 16 with therapeutic LMWH. ROTEM-measured INTEM/HEPTEM CT ratio was higher in patients using UFH (1.4 [1.3-1.4]) compared to patients treated with LMWH (1.0 [1.0-1.1], p < 0.001). Both the aPTT and anti-Xa were associated with the CT ratio. However, the β-regression coefficient (95%CI) was significantly higher in patients on UFH (0.31 (0.001-0.62)) compared to therapeutic LMWH (0.09 (0.05-0.13)) for comparison with the anti-Xa assay. Furthermore, ROC analysis demonstrated an area under the curve for detecting UFH of 0.936(0.849-1.00), 0.851(0.702-1.000), and 0.645(0.465-0.826) for the CT ratio, aPTT, and anti-Xa, respectively. Conclusion The ROTEM INTEM/HEPTEM CT ratio appears a promising tool to guide anticoagulant therapy in ICU patients with COVID-19 disease, but associations with clinical endpoints are currently lacking.
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Affiliation(s)
- Lejan Schultinge
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Department of Intensive Care Medicine, Laurentius Hospital Roermond, the Netherlands
| | - Anne-Marije Hulshof
- Central Diagnostic Laboratory, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University+, Maastricht, the Netherlands
| | - Danihel van Neerven
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Department of Anaesthesiology and Pain Treatment Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Mark M G Mulder
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Department of Anaesthesiology and Pain Treatment Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Jan-Willem E M Sels
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University+, Maastricht, the Netherlands
| | - Hendrina P M G Hulsewe
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Gerardus J A J M Kuiper
- Department of Anaesthesiology and Pain Treatment Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Renske H Olie
- Cardiovascular Research Institute Maastricht, Maastricht University+, Maastricht, the Netherlands
- Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Thrombosis Expert Centre Maastricht, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Hugo Ten Cate
- Cardiovascular Research Institute Maastricht, Maastricht University+, Maastricht, the Netherlands
- Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Thrombosis Expert Centre Maastricht, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University+, Maastricht, the Netherlands
| | - Bas C T van Bussel
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University+, Maastricht, the Netherlands
- Care and Public Health Research Institute, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Yvonne M C Henskens
- Central Diagnostic Laboratory, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University+, Maastricht, the Netherlands
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Bor WL, de Veer AJW, Olie RH, Rikken SA, Chan Pin Yin DR, Herrman JPR, Vrolix M, Meuwissen M, Vandendriessche T, van Mieghem C, Magro M, Bennaghmouch N, Hermanides R, Adriaenssens T, Dewilde WJ, ten Berg JM. Dual versus triple antithrombotic therapy after percutaneous coronary intervention: the prospective multicentre WOEST 2 Study. EUROINTERVENTION 2022; 18:e303-e313. [PMID: 35370126 PMCID: PMC9980408 DOI: 10.4244/eij-d-21-00703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 11/23/2022]
Abstract
BACKGROUND For patients on oral anticoagulants (OAC) undergoing percutaneous coronary intervention (PCI), European guidelines have recently changed their recommendations to dual antithrombotic therapy (DAT; P2Y12 inhibitor and OAC) without aspirin. AIMS The prospective WOEST 2 registry was designed to obtain contemporary real-world data on antithrombotic regimens and related outcomes after PCI in patients with an indication for OAC. METHODS In this analysis, we compare DAT (P2Y12 inhibitor and OAC) to triple antithrombotic therapy (TAT; aspirin, P2Y12 inhibitor, and OAC) on thrombotic and bleeding outcomes after one year. Clinically relevant bleeding was defined as Bleeding Academic Research Consortium classification (BARC) grade 2, 3, or 5; major bleeding as BARC grade 3 or 5. Major adverse cardiac and cerebrovascular events (MACCE) was defined as a composite of all-cause mortality, myocardial infarction, stent thrombosis, ischaemic stroke, and transient ischaemic attack. RESULTS A total of 1,075 patients were included between 2014 and 2021. Patients used OAC for atrial fibrillation (93.6%) or mechanical heart valve prosthesis (4.7%). Non-vitamin K oral anticoagulants (NOAC) were prescribed in 53.1% and vitamin K antagonists in 46.9% of patients. At discharge, 60.9% received DAT, and 39.1% TAT. DAT was associated with less clinically relevant and similar major bleeding (16.8% vs 23.4%; p<0.01 and 7.6% vs 7.7%, not significant), compared to TAT. The difference in MACCE between the two groups was not statistically significant (12.4% vs 9.7%; p=0.17). Multivariable adjustment and propensity score matching confirmed these results. CONCLUSIONS Dual antithrombotic therapy is associated with a substantially lower risk of clinically relevant bleeding without a statistically significant penalty in ischaemic events.
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Affiliation(s)
- Willem Lambertus Bor
- Department of Cardiology, St Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, the Netherlands
| | | | - Renske H. Olie
- Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Sem A.O.F. Rikken
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands,Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | | | - Mathias Vrolix
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | | | | | - Carlos van Mieghem
- Cardiovascular Research Center Aalst, OLV Clinic, Aalst, Belgium,Department of Cardiology, AZ Groeninge, Kortrijk, Belgium
| | - Michael Magro
- Department of Cardiology, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - Naoual Bennaghmouch
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Rick Hermanides
- Department of Cardiology, Isala Hospital, Zwolle, the Netherlands
| | - Tom Adriaenssens
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
| | | | - Jurriën Maria ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands,Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands
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5
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Hulshof AM, Olie RH, Vries MJA, Verhezen PWM, van der Meijden PEJ, ten Cate H, Henskens YMC. Rotational Thromboelastometry in High-Risk Patients on Dual Antithrombotic Therapy After Percutaneous Coronary Intervention. Front Cardiovasc Med 2021; 8:788137. [PMID: 35004899 PMCID: PMC8727359 DOI: 10.3389/fcvm.2021.788137] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 12/06/2021] [Indexed: 11/23/2022] Open
Abstract
Aims: Patients using antithrombotic drugs after percutaneous coronary intervention (PCI) are at risk for bleeding and recurrent ischemia. We aimed to explore routine and tissue plasminogen activated (tPA) ROTEM results in a post-PCI population on dual antithrombotic treatment. Methods and Results: In this prospective cohort, 440 patients treated with double antithrombotic therapy after recent PCI and with ≥3 risk factors for either ischemic or bleeding complications were included and compared with a control group (n = 95) consisting of perioperative patients not using antithrombotic medication. Laboratory assessment, including (tPA) ROTEM, was performed one month post-PCI and bleeding/ischemic complications were collected over a five-month follow-up. Patients were stratified by antithrombotic regimen consisting of a P2Y12 inhibitor with either aspirin (dual antiplatelet therapy; DAPT, n = 323), a vitamin K antagonist (VKA, n = 69) or a direct oral anticoagulant (DOAC, n = 48). All post-PCI patients had elevated ROTEM clot stiffness values, but only the DAPT group additionally presented with a decreased fibrinolytic potential as measured with tPA ROTEM. Patients receiving anticoagulants had prolonged clotting times (CT) when compared to the control and DAPT group; EXTEM and FIBTEM CT could best discriminate between patients (not) using anticoagulants (AUC > 0.97). Furthermore, EXTEM CT was significantly prolonged in DAPT patients with bleeding complications during follow-up (68 [62–70] vs. 62 [57–68], p = 0.030). Conclusion: ROTEM CT has high potential for identifying anticoagulants and tPA ROTEM could detect a diminished fibrinolytic potential in patients using DAPT. Furthermore, the ability of EXTEM CT to identify patients at risk for bleeding may be promising and warrants further research.
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Affiliation(s)
- Anne-Marije Hulshof
- Central Diagnostic Laboratory, Maastricht University Medical Center+, Maastricht, Netherlands
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
- *Correspondence: Anne-Marije Hulshof
| | - Renske H. Olie
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
- Department of Internal Medicine, Maastricht University, Maastricht, Netherlands
- Thrombosis Expert Centre Maastricht, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Minka J. A. Vries
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Paul W. M. Verhezen
- Central Diagnostic Laboratory, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Paola E. J. van der Meijden
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Hugo ten Cate
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
- Department of Internal Medicine, Maastricht University, Maastricht, Netherlands
- Thrombosis Expert Centre Maastricht, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Yvonne M. C. Henskens
- Central Diagnostic Laboratory, Maastricht University Medical Center+, Maastricht, Netherlands
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
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Olie RH, van der Meijden PEJ, Vries MJA, Veenstra L, van 't Hof AWJ, Ten Berg JM, Henskens YMC, Ten Cate H. Antithrombotic therapy in high-risk patients after percutaneous coronary intervention; study design, cohort profile and incidence of adverse events. Neth Heart J 2021; 29:525-535. [PMID: 34468944 PMCID: PMC8455732 DOI: 10.1007/s12471-021-01606-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2021] [Indexed: 12/25/2022] Open
Abstract
Background Patients with multiple clinical risk factors are a complex group in whom both bleeding and recurrent ischaemic events often occur during treatment with dual/triple antithrombotic therapy after percutaneous coronary intervention. Decisions on optimal antithrombotic treatment in these patients are challenging and not supported by clear guideline recommendations. A prospective observational cohort study was set up to evaluate patient-related factors, platelet reactivity, genetics, and a broad spectrum of biomarkers in predicting adverse events in these high-risk patients. Aim of the current paper is to present the study design, with a detailed description of the cohort as a whole, and evaluation of bleeding and ischaemic outcomes during follow-up, thereby facilitating future research questions focusing on specific data provided by the cohort. Methods We included patients with ≥ 3 predefined risk factors who were treated with dual/triple antithrombotic therapy following PCI. We performed a wide range of haemostatic tests and collected all ischaemic and bleeding events during 6–12 months follow-up. Results We included 524 high-risk patients who underwent PCI within the previous 1–2 months. All patients used a P2Y12 inhibitor (clopidogrel n = 388, prasugrel n = 61, ticagrelor n = 75) in combination with aspirin (n = 397) and/or anticoagulants (n = 160). Bleeding events were reported by 254 patients (48.5%), necessitating intervention or hospital admission in 92 patients (17.5%). Major adverse cardiovascular events (myocardial infarction, stroke, death) occurred in 69 patients (13.2%). Conclusion The high risk for both bleeding and ischaemic events in this cohort of patients with multiple clinical risk factors illustrates the challenges that the cardiologist faces to make a balanced decision on the optimal treatment strategy. This cohort will serve to answer several future research questions about the optimal management of these patients on dual/triple antithrombotic therapy, and the possible value of a wide range of laboratory tests to guide these decisions. Supplementary Information The online version of this article (10.1007/s12471-021-01606-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- R H Olie
- Thrombosis Expertise Centre, Heart and Vascular Centre, Department of Internal Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.
| | - P E J van der Meijden
- Thrombosis Expertise Centre, Heart and Vascular Centre, Department of Internal Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - M J A Vries
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - L Veenstra
- Department of Cardiology, MUMC+, Maastricht, The Netherlands
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - A W J van 't Hof
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Cardiology, MUMC+, Maastricht, The Netherlands
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - J M Ten Berg
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Y M C Henskens
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Central Diagnostic Laboratory, MUMC+, Maastricht, The Netherlands
| | - H Ten Cate
- Thrombosis Expertise Centre, Heart and Vascular Centre, Department of Internal Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
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7
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Hulshof A, Braeken DCW, Ghossein‐Doha C, van Santen S, Sels JEM, Kuiper GJAJM, van der Horst ICC, ten Cate H, van Bussel BCT, Olie RH, Henskens YMC. Hemostasis and fibrinolysis in COVID-19 survivors 6 months after intensive care unit discharge. Res Pract Thromb Haemost 2021; 5:e12579. [PMID: 34595368 PMCID: PMC8463660 DOI: 10.1002/rth2.12579] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/08/2021] [Accepted: 07/15/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The prothrombotic phenotype has been extensively described in patients with acute coronavirus disease 2019 (COVID-19). However, potential long-term hemostatic abnormalities are unknown. OBJECTIVE To evaluate the changes in routine hemostasis laboratory parameters and tissue-type plasminogen activator (tPA) rotational thromboelastometry (ROTEM) 6 months after COVID-19 intensive care unit (ICU) discharge in patients with and without venous thromboembolism (VTE) during admission. METHODS Patients with COVID-19 of the Maastricht Intensive Care COVID cohort with tPA ROTEM measurement at ICU and 6-month follow-up were included. TPA ROTEM is a whole blood viscoelastic assay that illustrates both clot development and fibrinolysis due to simultaneous addition of tissue factor and tPA. Analyzed ROTEM parameters include clotting time, maximum clot firmness (MCF), lysis onset time (LOT), and lysis time (LT). RESULTS Twenty-two patients with COVID-19 were included and showed extensive hemostatic abnormalities before ICU discharge. TPA ROTEM MCF (75 mm [interquartile range, 68-78]-59 mm [49-63]; P ≤ .001), LOT (3690 seconds [2963-4418]-1786 seconds [1465-2650]; P ≤ .001), and LT (7200 seconds [6144-7200]-3138 seconds [2591-4389]; P ≤ .001) normalized 6 months after ICU discharge. Of note, eight and four patients still had elevated fibrinogen and D-dimer concentrations at follow-up, respectively. In general, no difference in median hemostasis parameters at 6-month follow-up was observed between patients with (n=14) and without (n=8) VTE, although fibrinogen appeared to be lower in the VTE group (VTE-, 4.3 g/L [3.7-4.7] vs VTE+, 3.4 g/L [3.2-4.2]; P = .05). CONCLUSIONS Six months after COVID-19 ICU discharge, no persisting hypercoagulable or hypofibrinolytic profile was detected by tPA ROTEM. Nevertheless, increased D-dimer and fibrinogen concentrations persist up to 6 months in some patients, warranting further exploration of the role of hemostasis in long-term morbidity after hospital discharge.
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Affiliation(s)
- Anne‐Marije Hulshof
- Central Diagnostic LaboratoryMaastricht University Medical Centre+Maastrichtthe Netherlands
- Cardiovascular Research Institute Maastricht (CARIM)Maastricht UniversityMaastrichtthe Netherlands
| | - Dionne C. W. Braeken
- Thrombosis Expertise Centre MaastrichtMaastricht University Medical Centre+Maastrichtthe Netherlands
| | - Chahinda Ghossein‐Doha
- Department of CardiologyMaastricht University Medical Centre+Maastrichtthe Netherlands
- Department of Intensive Care MedicineMaastricht University Medical Centre+Maastrichtthe Netherlands
| | - Susanne van Santen
- Department of Intensive Care MedicineMaastricht University Medical Centre+Maastrichtthe Netherlands
| | - Jan‐Willem E. M. Sels
- Department of Intensive Care MedicineMaastricht University Medical Centre+Maastrichtthe Netherlands
| | | | - Iwan C. C. van der Horst
- Cardiovascular Research Institute Maastricht (CARIM)Maastricht UniversityMaastrichtthe Netherlands
- Department of Intensive Care MedicineMaastricht University Medical Centre+Maastrichtthe Netherlands
| | - Hugo ten Cate
- Cardiovascular Research Institute Maastricht (CARIM)Maastricht UniversityMaastrichtthe Netherlands
- Thrombosis Expertise Centre MaastrichtMaastricht University Medical Centre+Maastrichtthe Netherlands
- Department of Internal MedicineSection Vascular MedicineMaastricht University Medical Centre+Maastrichtthe Netherlands
| | - Bas C. T. van Bussel
- Department of Intensive Care MedicineMaastricht University Medical Centre+Maastrichtthe Netherlands
- Care and Public Health Research Institute (CAPHRI)Maastricht UniversityMaastrichtthe Netherlands
| | - Renske H. Olie
- Cardiovascular Research Institute Maastricht (CARIM)Maastricht UniversityMaastrichtthe Netherlands
- Thrombosis Expertise Centre MaastrichtMaastricht University Medical Centre+Maastrichtthe Netherlands
- Department of Internal MedicineSection Vascular MedicineMaastricht University Medical Centre+Maastrichtthe Netherlands
| | - Yvonne M. C. Henskens
- Central Diagnostic LaboratoryMaastricht University Medical Centre+Maastrichtthe Netherlands
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8
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de Breet CPDM, Zwaveling S, Vries MJA, van Oerle RG, Henskens YMC, Van't Hof AWJ, van der Meijden PEJ, Veenstra L, Ten Cate H, Olie RH. Thrombin Generation as a Method to Identify the Risk of Bleeding in High Clinical-Risk Patients Using Dual Antiplatelet Therapy. Front Cardiovasc Med 2021; 8:679934. [PMID: 34179143 PMCID: PMC8224526 DOI: 10.3389/fcvm.2021.679934] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 05/04/2021] [Indexed: 01/29/2023] Open
Abstract
Background: Patients using dual antiplatelet therapy after percutaneous coronary intervention are at risk for bleeding. It is currently unknown whether thrombin generation can be used to identify patients receiving dual antiplatelet therapy with increased bleeding risk. Objectives: To investigate whether thrombin generation measurement in plasma provides additional insight into the assessment of bleeding risk for high clinical-risk patients using dual antiplatelet therapy. Methods: Coagulation factors and thrombin generation in platelet-poor plasma were measured in 93 high clinical-risk frail patients using dual antiplatelet therapy after percutaneous coronary intervention. During 12-month follow-up, clinically relevant bleedings were reported. Thrombin generation at 1 and 6 months after percutaneous coronary intervention was compared between patients with and without bleeding events. Results: One month after percutaneous coronary intervention, the parameters of thrombin generation, endogenous thrombin potential, peak height, and velocity index were significantly lower in patients with bleeding in the following months compared to patients without bleeding. At 6 months follow-up, endogenous thrombin potential, peak height, and velocity index were still (significantly) decreased in the bleeding group as compared to non-bleeders. Thrombin generation in the patients' plasma was strongly dependent on factor II, V, and VIII activity and fibrinogen. Conclusion: High clinical-risk patients using dual antiplatelet therapy with clinically relevant bleeding during follow-up show reduced and delayed thrombin generation in platelet-poor plasma, possibly due to variation in coagulation factors. Thus, impaired thrombin-generating potential may be a "second hit" on top of dual antiplatelet therapy, increasing the bleeding risk in high clinical-risk patients. Thrombin generation has the potential to improve the identification of patients using dual antiplatelet therapy at increased risk of bleeding.
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Affiliation(s)
- C P D M de Breet
- Department of Internal Medicine, Maastricht Universitair Medisch Centrum+, Maastricht, Netherlands.,Department of Internal Medicine, Zuyderland Medisch Centrum, Heerlen, Netherlands
| | - S Zwaveling
- Department of Biochemistry-CARIM, Maastricht University, Maastricht, Netherlands.,Groene Hart Ziekenhuis, Gouda, Netherlands
| | - M J A Vries
- Department of Internal Medicine, Jeroen Bosch Ziekenhuis, 's-Hertogenbosch, Netherlands
| | - R G van Oerle
- Department of Biochemistry-CARIM, Maastricht University, Maastricht, Netherlands
| | - Y M C Henskens
- Department of Biochemistry-CARIM, Maastricht University, Maastricht, Netherlands
| | - A W J Van't Hof
- Department of Cardiology, Zuyderland Medisch Centrum, Heerlen, Netherlands.,Department of Cardiology, Maastricht Universitair Medisch Centrum+, Maastricht, Netherlands
| | | | - L Veenstra
- Department of Cardiology, Zuyderland Medisch Centrum, Heerlen, Netherlands
| | - H Ten Cate
- Department of Internal Medicine, Maastricht Universitair Medisch Centrum+, Maastricht, Netherlands.,Department of Biochemistry-CARIM, Maastricht University, Maastricht, Netherlands
| | - R H Olie
- Department of Internal Medicine, Maastricht Universitair Medisch Centrum+, Maastricht, Netherlands.,Department of Biochemistry-CARIM, Maastricht University, Maastricht, Netherlands
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9
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Mulder MMG, Brandts LI, Brüggemann RAG, Koelmann M, Streng AS, Olie RH, Gietema HA, Spronk HMH, van der Horst ICC, Sels JWEM, Wildberger JE, van Kuijk SMJ, Schnabel RM, Ten Cate H, Henskens YMC, van Bussel BCT. Serial markers of coagulation and inflammation and the occurrence of clinical pulmonary thromboembolism in mechanically ventilated patients with SARS-CoV-2 infection; the prospective Maastricht intensive care COVID cohort. Thromb J 2021; 19:35. [PMID: 34059058 PMCID: PMC8165953 DOI: 10.1186/s12959-021-00286-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 05/07/2021] [Indexed: 12/13/2022] Open
Abstract
Background The incidence of pulmonary thromboembolism is high in SARS-CoV-2 patients admitted to the Intensive Care. Elevated biomarkers of coagulation (fibrinogen and D-dimer) and inflammation (c-reactive protein (CRP) and ferritin) are associated with poor outcome in SARS-CoV-2. Whether the time-course of fibrinogen, D-dimer, CRP and ferritin is associated with the occurrence of pulmonary thromboembolism in SARS-CoV-2 patients is unknown. We hypothesise that patients on mechanical ventilation with SARS-CoV-2 infection and clinical pulmonary thromboembolism have lower concentrations of fibrinogen and higher D-dimer, CRP, and ferritin concentrations over time compared to patients without a clinical pulmonary thromboembolism. Methods In a prospective study, fibrinogen, D-dimer, CRP and ferritin were measured daily. Clinical suspected pulmonary thromboembolism was either confirmed or excluded based on computed tomography pulmonary angiography (CTPA) or by transthoracic ultrasound (TTU) (i.e., right-sided cardiac thrombus). In addition, patients who received therapy with recombinant tissue plasminogen activator were included when clinical instability in suspected pulmonary thromboembolism did not allow CTPA. Serial data were analysed using a mixed-effects linear regression model, and models were adjusted for known risk factors (age, sex, APACHE-II score, body mass index), biomarkers of coagulation and inflammation, and anticoagulants. Results Thirty-one patients were considered to suffer from pulmonary thromboembolism ((positive CTPA (n = 27), TTU positive (n = 1), therapy with recombinant tissue plasminogen activator (n = 3)), and eight patients with negative CTPA were included. After adjustment for known risk factors and anticoagulants, patients with, compared to those without, clinical pulmonary thromboembolism had lower average fibrinogen concentration of − 0.9 g/L (95% CI: − 1.6 – − 0.1) and lower average ferritin concentration of − 1045 μg/L (95% CI: − 1983 – − 106) over time. D-dimer and CRP average concentration did not significantly differ, 561 μg/L (− 6212–7334) and 27 mg/L (− 32–86) respectively. Ferritin lost statistical significance, both in sensitivity analysis and after adjustment for fibrinogen and D-dimer. Conclusion Lower average concentrations of fibrinogen over time were associated with the presence of clinical pulmonary thromboembolism in patients at the Intensive Care, whereas D-dimer, CRP and ferritin were not. Lower concentrations over time may indicate the consumption of fibrinogen related to thrombus formation in the pulmonary vessels. Supplementary Information The online version contains supplementary material available at 10.1186/s12959-021-00286-7.
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Affiliation(s)
- Mark M G Mulder
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.
| | - LIoyd Brandts
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Renée A G Brüggemann
- Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Marcel Koelmann
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Alexander S Streng
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Renske H Olie
- Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,Thrombosis Expert Centre Maastricht and Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Hester A Gietema
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,GROW School of Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Henri M H Spronk
- Thrombosis Expert Centre Maastricht and Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Jan-Willem E M Sels
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,Department of Cardiology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Joachim E Wildberger
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Ronny M Schnabel
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Hugo Ten Cate
- Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,Thrombosis Expert Centre Maastricht and Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Yvonne M C Henskens
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Maastricht University Medical Centre+, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Bas C T van Bussel
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,Care and Public Health Research Institute, Maastricht University Medical Centre+, Maastricht, The Netherlands
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10
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Hulshof AM, Brüggemann RAG, Mulder MMG, van de Berg TW, Sels JWEM, Olie RH, Spaetgens B, Streng AS, Verhezen P, van der Horst ICC, Ten Cate H, Spronk HMH, van Bussel BCT, Henskens YMC. Serial EXTEM, FIBTEM, and tPA Rotational Thromboelastometry Observations in the Maastricht Intensive Care COVID Cohort-Persistence of Hypercoagulability and Hypofibrinolysis Despite Anticoagulation. Front Cardiovasc Med 2021; 8:654174. [PMID: 33981736 PMCID: PMC8107372 DOI: 10.3389/fcvm.2021.654174] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/05/2021] [Indexed: 01/14/2023] Open
Abstract
Background: Coronavirus Disease 2019 (COVID-19) patients often present with thromboembolic events. In COVID-19 patients, routine hemostatic assays cannot correctly identify patients at risk for thromboembolic events. Viscoelastic testing with rotational thromboelastometry (ROTEM) might improve the characterization of COVID-19-associated coagulopathy. Objective: To unravel underlying coagulopathy and fibrinolysis over time as measured by serial assessment heparin-independent (FIBTEM and EXTEM) and fibrinolysis illustrating (tissue plasminogen activator; tPA) ROTEM assays. Patients/Methods: Between April 23 and June 12, consecutive adult patients enrolled within the Maastricht Intensive Care COVID (MaastrICCht) cohort were included, and a comprehensive set of clinical, physiological, pharmaceutical, and laboratory variables were collected daily. Twice per week, EXTEM, FIBTEM, and tPA ROTEM were performed. Clotting time (CT), clot formation time (CFT), maximum clot firmness (MCF), lysis onset time (LOT), and lysis time (LT) were determined to assess clot development and breakdown and were compared to routine hemostatic assays. Results: In 36 patients, 96 EXTEM/FIBTEM and 87 tPA ROTEM tests were performed during a 6-week follow-up. CT prolongation was present in 54% of EXTEM measurements, which were not matched by prothrombin time (PT) in 37%. Respectively, 81 and 99% of all EXTEM and FIBTEM MCF values were above the reference range, and median MCF remained elevated during follow-up. The ROTEM fibrinolysis parameters remained prolonged with median LOT consequently >49 min and unmeasurable LT in 56% of measurements, suggesting a severe hypofibrinolytic phenotype. Conclusion: ROTEM tests in COVID-19 ICU patients show hypercoagulability and severe hypofibrinolysis persisting over at least 6 weeks.
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Affiliation(s)
- Anne-Marije Hulshof
- Central Diagnostic Laboratory, Maastricht University Medical Centre+, Maastricht, Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Renée A G Brüggemann
- Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Mark M G Mulder
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Tom W van de Berg
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Jan-Willem E M Sels
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Renske H Olie
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands.,Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands.,Thrombosis Expert Centre Maastricht, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Bart Spaetgens
- Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Alexander S Streng
- Central Diagnostic Laboratory, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Paul Verhezen
- Central Diagnostic Laboratory, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Iwan C C van der Horst
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands.,Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Hugo Ten Cate
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands.,Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands.,Thrombosis Expert Centre Maastricht, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Henri M H Spronk
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Bas C T van Bussel
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands.,Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands
| | - Yvonne M C Henskens
- Central Diagnostic Laboratory, Maastricht University Medical Centre+, Maastricht, Netherlands
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11
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Bavalia R, Abdoellakhan R, Beenen LF, Brekelmans MPA, Olie RH, Ten Cate H, Huisman MV, Kruip M, Middeldorp S, Meijer K, Hutten BA, Coppens M. Outcome of intracranial bleeding managed with prothrombin complex concentrate in patients on direct factor Xa inhibitors or vitamin K antagonists. Thromb Res 2020; 196:404-409. [PMID: 33011638 DOI: 10.1016/j.thromres.2020.09.028] [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] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/10/2020] [Accepted: 09/18/2020] [Indexed: 11/16/2022]
Abstract
Intracranial hemorrhage (ICH) is the most feared complication of anticoagulation with a high mortality and morbidity. Before registration of a specific reversal agent for factor Xa inhibitors (FXa-I), international guidelines recommended prothrombin complex concentrate (PCC), which also is the specific reversal agent for vitamin K antagonists (VKA). In two contemporary cohorts, we compared clinical outcomes between patients with FXa-I and VKA related ICH treated with PCC between 2014 and 2018. Primary outcome was effective hemostasis after 24 h, according to the International Society of Thrombosis and Hemostasis definition. Safety outcomes were defined as venous and arterial thromboembolic complications and death within 30 days. Thirty-six patients with FXa-I-ICH and 39 patients with VKA-ICH were available for analysis. Baseline characteristics were comparable between both groups, except for time from start of symptoms to presentation at the hospital. In the FXa-I-ICH cohort, 24 (73%) patients achieved effective hemostasis compared to 23 (62%) patients in the VKA-ICH cohort (crude odds ratio [OR] 1.62 [95%CI 0.59-4.48], adjusted OR 1.45 [95%CI 0.44-4.83]). Eight (24%) patients with FXa-I-ICH deceased compared to 17 (45%) patients with VKA-ICH (crude OR 0.38 [95%CI 0.14-1.24], adjusted OR 0.41 [95%CI 0.12-1.24]). In this observational cohort study, the outcome of ICH managed with PCC was similar in patients with FXa-I-ICH and in patients with VKA-ICH.
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Affiliation(s)
- Roisin Bavalia
- Amsterdam UMC, University of Amsterdam, Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Rahat Abdoellakhan
- University Medical Center Groningen, University of Groningen, Department of Hematology, Groningen, the Netherlands
| | - Ludo F Beenen
- Amsterdam UMC, University of Amsterdam, Department of Radiology and Nuclear Medicine, Amsterdam, the Netherlands
| | - M P A Brekelmans
- Utrecht Medical Center, Department of Internal Medicine, Utrecht, the Netherlands
| | - Renske H Olie
- Maastricht University Medical Center+, Department of Internal Medicine, Maastricht, the Netherlands
| | - Hugo Ten Cate
- Maastricht University Medical Center+, Department of Internal Medicine, Maastricht, the Netherlands
| | - Menno V Huisman
- Leiden University Medical Center, Department of Vascular Medicine, Leiden, the Netherlands
| | - Marieke Kruip
- Erasmus University Medical Center, Department of Hematology, Rotterdam, the Netherlands
| | - Saskia Middeldorp
- Amsterdam UMC, University of Amsterdam, Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Karina Meijer
- University Medical Center Groningen, University of Groningen, Department of Hematology, Groningen, the Netherlands
| | - Barbara A Hutten
- Amsterdam UMC, University of Amsterdam, Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Michiel Coppens
- Amsterdam UMC, University of Amsterdam, Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands.
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12
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Streng AS, Delnoij TS, Mulder MM, Sels JWE, Wetzels RJ, Verhezen PW, Olie RH, Kooman JP, van Kuijk SM, Brandts L, ten Cate H, Lorusso R, van der Horst IC, van Bussel BC, Henskens YM. Monitoring of Unfractionated Heparin in Severe COVID-19: An Observational Study of Patients on CRRT and ECMO. TH Open 2020; 4:e365-e375. [PMID: 33235946 PMCID: PMC7676995 DOI: 10.1055/s-0040-1719083] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 09/25/2020] [Indexed: 01/08/2023] Open
Abstract
Objective Severe cases of coronavirus disease 2019 (COVID-19) can require continuous renal replacement therapy (CRRT) and/or extracorporeal membrane oxygenation (ECMO). Unfractionated heparin (UFH) to prevent circuit clotting is mandatory but monitoring is complicated by (pseudo)-heparin resistance. In this observational study, we compared two different activated partial thromboplastin time (aPTT) assays and a chromogenic anti-Xa assay in COVID-19 patients on CRRT or ECMO in relation to their UFH dosages and acute phase reactants. Materials and Methods The aPTT (optical [aPTT-CS] and/or mechanical [aPTT-STA] clot detection methods were used), anti-Xa, factor VIII (FVIII), antithrombin III (ATIII), and fibrinogen were measured in 342 samples from 7 COVID-19 patients on CRRT or ECMO during their UFH treatment. Dosage of UFH was primarily based on the aPTT-CS with a heparin therapeutic range (HTR) of 50-80s. Associations between different variables were made using linear regression and Bland-Altman analysis. Results Dosage of UFH was above 35,000IU/24 hours in all patients. aPTT-CS and aPTT-STA were predominantly within the HTR. Anti-Xa was predominantly above the HTR (0.3-0.7 IU/mL) and ATIII concentration was >70% for all patients; mean FVIII and fibrinogen were 606% and 7.5 g/L, respectively. aPTT-CS correlated with aPTT-STA ( r 2 = 0.68) with a bias of 39.3%. Correlation between aPTT and anti-Xa was better for aPTT-CS (0.78 ≤ r 2 ≤ 0.94) than for aPTT-STA (0.34 ≤ r 2 ≤ 0.81). There was no general correlation between the aPTT-CS and ATIII, FVIII, fibrinogen, thrombocytes, C-reactive protein, or ferritin. Conclusion All included COVID-19 patients on CRRT or ECMO conformed to the definition of heparin resistance. A patient-specific association was found between aPTT and anti-Xa. This association could not be explained by FVIII or fibrinogen.
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Affiliation(s)
- Alexander S. Streng
- Central Diagnostic Laboratory, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Thijs S.R. Delnoij
- Intensive Care Unit, Maastricht University Medical Centre, Maastricht, the Netherlands
- Cardiovascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Mark M.G. Mulder
- Intensive Care Unit, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Jan Willem E.M. Sels
- Intensive Care Unit, Maastricht University Medical Centre, Maastricht, the Netherlands
- Cardiovascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Rick J.H. Wetzels
- Central Diagnostic Laboratory, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Paul W.M. Verhezen
- Central Diagnostic Laboratory, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Renske H. Olie
- Department of Vascular Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Jeroen P. Kooman
- Department of Clinical Nephrology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Sander M.J. van Kuijk
- Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, the Netherlands
- Care and Public Health Research Institute, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Lloyd Brandts
- Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Hugo ten Cate
- Department of Vascular Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Roberto Lorusso
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands
| | | | - Bas C.T. van Bussel
- Intensive Care Unit, Maastricht University Medical Centre, Maastricht, the Netherlands
- Care and Public Health Research Institute, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Yvonne M.C. Henskens
- Central Diagnostic Laboratory, Maastricht University Medical Centre, Maastricht, the Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
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13
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Bavalia R, Abdoellakhan R, Brinkman HJM, Brekelmans MPA, Hamulyák EN, Zuurveld M, Hutten BA, Westerweel PE, Olie RH, ten Cate H, Kruip M, Middeldorp S, Meijer K, Coppens M. Emergencies on direct oral anticoagulants: Management, outcomes, and laboratory effects of prothrombin complex concentrate. Res Pract Thromb Haemost 2020; 4:569-581. [PMID: 32548555 PMCID: PMC7292661 DOI: 10.1002/rth2.12336] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 02/04/2020] [Accepted: 02/25/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND In the initial absence of specific reversal agents for factor Xa inhibitors (FXa-Is), prothrombin complex concentrate (PCC) as a hemostatic agent has been recommended by guidelines. Since 2017, idarucizumab has been registered for dabigatran reversal. Still, data on the clinical outcome of direct oral anticoagulant (DOAC)-related emergencies (major bleeding or urgent interventions) is scarce. In addition, it is unknown to what extent PCC restores thrombin generation in FXa-I-related emergencies. Our aim was to describe management and clinical outcomes of DOAC-related emergencies and to assess the laboratory effect of PCC in patients with FXa-I emergencies. METHODS In this prospective cohort study in 5 Dutch hospitals, patients presenting with DOAC-related emergencies were eligible. The primary outcome was effective hemostasis according to the ISTH definition. Safety outcomes were 30-day mortality and thromboembolic rate. In patients treated with PCC, additional blood samples were taken to assess the effect on thrombin generation. RESULTS We included 101 patients with major bleeding (FXa-I, 76; dabigatran, 25) and 21 patients requiring an urgent intervention (FXa-I, 16; dabigatran, 5). Of patients with major bleeding, 67% were treated with PCC or idarucizumab. Effective hemostasis, 30-day mortality, and thromboembolism rate were 67%, 22%, and 1%, respectively. In a subset of bleeding patients on FXa-I managed with PCC, thrombin generation increased, with 96% immediately after PCC administration. In patients requiring an urgent intervention, effective hemostasis, 30-day mortality, and thromboembolic rate were 95%, 14%, and 5%. CONCLUSIONS Effective hemostasis was achieved in the majority of patients presenting with DOAC-related emergencies;, thromboembolic complications were rare, and mortality was quite high.
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Affiliation(s)
- Roisin Bavalia
- Department of Vascular MedicineAmsterdam Cardiovascular SciencesAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Rahat Abdoellakhan
- Department of HematologyUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Herm Jan M. Brinkman
- Department of Molecular and Cellular HemostasisSanquin ResearchAmsterdamThe Netherlands
| | - Marjolein P. A. Brekelmans
- Department of Vascular MedicineAmsterdam Cardiovascular SciencesAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Eva N. Hamulyák
- Department of Vascular MedicineAmsterdam Cardiovascular SciencesAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Marleen Zuurveld
- Department of Molecular and Cellular HemostasisSanquin ResearchAmsterdamThe Netherlands
| | - Barbara A. Hutten
- Department of Clinical Epidemiology, Biostatistics and BioinformaticsAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Peter E. Westerweel
- Department of Internal MedicineAlbert Schweitzer HospitalDordrechtThe Netherlands
| | - Renske H. Olie
- Department of Internal MedicineMaastricht University Medical Center+MaastrichtThe Netherlands
| | - Hugo ten Cate
- Department of Internal MedicineMaastricht University Medical Center+MaastrichtThe Netherlands
| | - Marieke Kruip
- Department of HematologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Saskia Middeldorp
- Department of Vascular MedicineAmsterdam Cardiovascular SciencesAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Karina Meijer
- Department of HematologyUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Michiel Coppens
- Department of Vascular MedicineAmsterdam Cardiovascular SciencesAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
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d'Alessandro E, Becker C, Bergmeier W, Bode C, Bourne JH, Brown H, Buller HR, Ten Cate-Hoek AJ, Ten Cate V, van Cauteren YJM, Cheung YFH, Cleuren A, Coenen D, Crijns HJGM, de Simone I, Dolleman SC, Klein CE, Fernandez DI, Granneman L, van T Hof A, Henke P, Henskens YMC, Huang J, Jennings LK, Jooss N, Karel M, van den Kerkhof D, Klok FA, Kremers B, Lämmle B, Leader A, Lundstrom A, Mackman N, Mannucci PM, Maqsood Z, van der Meijden PEJ, van Moorsel M, Moran LA, Morser J, van Mourik M, Navarro S, Neagoe RAI, Olie RH, van Paridon P, Posma J, Provenzale I, Reitsma PH, Scaf B, Schurgers L, Seelig J, Siegbahn A, Siegerink B, Soehnlein O, Soriano EM, Sowa MA, Spronk HMH, Storey RF, Tantiwong C, Veninga A, Wang X, Watson SP, Weitz J, Zeerleder SS, Ten Cate H. Thrombo-Inflammation in Cardiovascular Disease: An Expert Consensus Document from the Third Maastricht Consensus Conference on Thrombosis. Thromb Haemost 2020; 120:538-564. [PMID: 32289858 DOI: 10.1055/s-0040-1708035] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Thrombo-inflammation describes the complex interplay between blood coagulation and inflammation that plays a critical role in cardiovascular diseases. The third Maastricht Consensus Conference on Thrombosis assembled basic, translational, and clinical scientists to discuss the origin and potential consequences of thrombo-inflammation in the etiology, diagnostics, and management of patients with cardiovascular disease, including myocardial infarction, stroke, and peripheral artery disease. This article presents a state-of-the-art reflection of expert opinions and consensus recommendations regarding the following topics: (1) challenges of the endothelial cell barrier; (2) circulating cells and thrombo-inflammation, focused on platelets, neutrophils, and neutrophil extracellular traps; (3) procoagulant mechanisms; (4) arterial vascular changes in atherogenesis; attenuating atherosclerosis and ischemia/reperfusion injury; (5) management of patients with arterial vascular disease; and (6) pathogenesis of venous thrombosis and late consequences of venous thromboembolism.
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Affiliation(s)
- Elisa d'Alessandro
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Biochemistry and Internal Medicine and Thrombosis Expert Center, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Christian Becker
- Department of Dermatology, University Medical Center, Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Wolfgang Bergmeier
- Department of Biochemistry and Biophysics, McAllister Heart Institute, University of North Carolina, Chapel Hill, United States
| | - Christoph Bode
- Department of Cardiology and Angiology I, Medical Center - University of Freiburg, University Heart Center Freiburg, Bad Krozingen, Germany
| | - Joshua H Bourne
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Helena Brown
- Rudolf-Virchov-Zentrum, DFG Forschungszentrum fur Experimentelle Biomedizin, Wurzburg, Germany
| | - Harry R Buller
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Arina J Ten Cate-Hoek
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Biochemistry and Internal Medicine and Thrombosis Expert Center, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Vincent Ten Cate
- Clinical Epidemiology and Systems Medicine, Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Yvonne J M van Cauteren
- Department of Cardiology, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Yam F H Cheung
- Leibniz-Institut für Analytische Wissenschaften - ISAS, Dortmund, Germany
| | - Audrey Cleuren
- Life Sciences Institute, University of Michigan, Ann Arbor, Michigan, United States
| | - Danielle Coenen
- Department of Biochemistry, Maastricht University and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Harry J G M Crijns
- Department of Cardiology, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Ilaria de Simone
- Department of Biochemistry, Maastricht University and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Sophie C Dolleman
- Department of Internal Medicine (Nephrology) and the Einthoven Laboratory for Experimental Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Christine Espinola Klein
- Center of Cardiology/Cardiology I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Delia I Fernandez
- Department of Biochemistry, Maastricht University and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Lianne Granneman
- Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Arnoud van T Hof
- Department of Cardiology, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Peter Henke
- Michigan Medicine Vascular Surgery Clinic, Cardiovascular Center, Ann Arbor, Michigan, United States
| | - Yvonne M C Henskens
- Central Diagnostic Laboratory, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Jingnan Huang
- Department of Biochemistry, Maastricht University and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Lisa K Jennings
- CirQuest Labs, LLC and the University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Natalie Jooss
- Department of Biochemistry, Maastricht University and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Mieke Karel
- Department of Biochemistry, Maastricht University and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Danique van den Kerkhof
- Department of Biochemistry, Maastricht University and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Frederik A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Bram Kremers
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Biochemistry and Internal Medicine and Thrombosis Expert Center, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Bernhard Lämmle
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Haemostasis Research Unit, University College London, London, United Kingdom
| | - Avi Leader
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Biochemistry and Internal Medicine and Thrombosis Expert Center, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands.,Department of Hematology, Rabin Medical Center, Petah Tikva, Israel
| | - Annika Lundstrom
- Division of Internal Medicine, Department of Clinical Sciences, Karolinska Institute, Danderyd Hospital, Stockholm, Sweden
| | - Nigel Mackman
- Department of Medicine, UNC McAllister Heart Institute, University of North Carolina, Chapel Hill, North Carolina, United States
| | - Pier M Mannucci
- Scientific Direction, IRCCS Ca' Granda Maggiore Policlinico Hospital Foundation, Milano, Italy
| | - Zahra Maqsood
- Rudolf-Virchov-Zentrum, DFG Forschungszentrum fur Experimentelle Biomedizin, Wurzburg, Germany
| | - Paola E J van der Meijden
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Biochemistry and Internal Medicine and Thrombosis Expert Center, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands.,Department of Biochemistry, Maastricht University and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Marc van Moorsel
- Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Luis A Moran
- CiMUS, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - John Morser
- Division of Hematology, Stanford University School of Medicine and Palo Alto Veterans Administration Health Care System, California, United States
| | - Manouk van Mourik
- Department of Cardiology, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Stefano Navarro
- Rudolf-Virchov-Zentrum, DFG Forschungszentrum fur Experimentelle Biomedizin, Wurzburg, Germany
| | - Raluca A I Neagoe
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Renske H Olie
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Biochemistry and Internal Medicine and Thrombosis Expert Center, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Pauline van Paridon
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Biochemistry and Internal Medicine and Thrombosis Expert Center, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Jens Posma
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Biochemistry and Internal Medicine and Thrombosis Expert Center, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Isabella Provenzale
- Department of Biochemistry, Maastricht University and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Pieter H Reitsma
- Department of Internal Medicine (Nephrology) and the Einthoven Laboratory for Experimental Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Billy Scaf
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Biochemistry and Internal Medicine and Thrombosis Expert Center, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Leon Schurgers
- Department of Biochemistry, Maastricht University and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Jaap Seelig
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Biochemistry and Internal Medicine and Thrombosis Expert Center, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands.,Department of Cardiology, Rijnstate ziekenhuis, Arnhem, The Netherlands
| | - Agneta Siegbahn
- Department of Medical Sciences, Clinical Chemistry and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Bob Siegerink
- Center for Stroke research Berlin, Charité Universitätamedizin, Berlin, Germany
| | - Oliver Soehnlein
- Institute for Cardiovascular Prevention, Ludwig Maximilian University Munich, Munich, Germany
| | - Eva Maria Soriano
- Institute for Cardiovascular and Metabolic Research, School of Biological Sciences, University of Reading, Reading, United Kingdom
| | - Marcin A Sowa
- Institute for Cardiovascular and Metabolic Research, School of Biological Sciences, University of Reading, Reading, United Kingdom
| | - Henri M H Spronk
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Biochemistry and Internal Medicine and Thrombosis Expert Center, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Chukiat Tantiwong
- Department of Biochemistry, Maastricht University and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Alicia Veninga
- Department of Biochemistry, Maastricht University and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Xueqing Wang
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Steve P Watson
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Jeff Weitz
- Division of Hematology and Thromboembolism, Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Sacha S Zeerleder
- Department of Haematology and Central Haematology Laboratory, Inselspital, Bern University Hospital, University of Bern, and Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Hugo Ten Cate
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Biochemistry and Internal Medicine and Thrombosis Expert Center, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
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Olie RH, van der Meijden PEJ, Spronk HMH, Ten Cate H. Antithrombotic Therapy: Prevention and Treatment of Atherosclerosis and Atherothrombosis. Handb Exp Pharmacol 2020; 270:103-130. [PMID: 32776281 DOI: 10.1007/164_2020_357] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Atherosclerosis is a multifactorial vascular disease that develops in the course of a lifetime. Numerous risk factors for atherosclerosis have been identified, mostly inflicting pro-inflammatory effects. Vessel injury, such as occurring during erosion or rupture of atherosclerotic lesions triggers blood coagulation, in attempt to maintain hemostasis (protect against bleeding). However, thrombo-inflammatory mechanisms may drive blood coagulation such that thrombosis develops, the key process underlying myocardial infarction and ischemic stroke (not due to embolization from the heart). In the blood coagulation system, platelets and coagulation proteins are both essential elements. Hyperreactivity of blood coagulation aggravates atherosclerosis in preclinical models. Pharmacologic inhibition of blood coagulation, either with platelet inhibitors, or better documented with anticoagulants, or both, limits the risk of thrombosis and may potentially reverse atherosclerosis burden, although the latter evidence is still based on animal experimentation.Patients at risk of atherothrombotic complications should receive a single antiplatelet agent (acetylsalicylic acid, ASA, or clopidogrel); those who survived an atherothrombotic event will be prescribed temporary dual antiplatelet therapy (ASA plus a P2Y12 inhibitor) in case of myocardial infarction (6-12 months), or stroke (<6 weeks), followed by a single antiplatelet agent indefinitely. High risk for thrombosis patients (such as those with peripheral artery disease) benefit from a combination of an anticoagulant and ASA. The price of gained efficacy is always increased risk of (major) bleeding; while tailoring therapy to individual needs may limit the risks to some extent, new generations of agents that target less critical elements of hemostasis and coagulation mechanisms are needed to maintain efficacy while reducing bleeding risks.
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Affiliation(s)
- R H Olie
- Internal Medicine and CARIM School for Cardiovascular Research, Maastricht University Medical Center, Maastricht, The Netherlands.,Thrombosis Expertise Center, Heart+ Cardiovascular Center, and Department of Biochemistry, Maastricht University Medical Center, Maastricht, The Netherlands
| | - P E J van der Meijden
- Thrombosis Expertise Center, Heart+ Cardiovascular Center, and Department of Biochemistry, Maastricht University Medical Center, Maastricht, The Netherlands
| | - H M H Spronk
- Thrombosis Expertise Center, Heart+ Cardiovascular Center, and Department of Biochemistry, Maastricht University Medical Center, Maastricht, The Netherlands
| | - H Ten Cate
- Internal Medicine and CARIM School for Cardiovascular Research, Maastricht University Medical Center, Maastricht, The Netherlands. .,Thrombosis Expertise Center, Heart+ Cardiovascular Center, and Department of Biochemistry, Maastricht University Medical Center, Maastricht, The Netherlands.
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16
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Olie RH, van der Meijden PEJ, Spronk HMH, van Oerle R, Barvik S, Bonarjee VVS, Ten Cate H, Nilsen DWT. Effects of the PAR-1 Antagonist Vorapaxar on Platelet Activation and Coagulation Biomarkers in Patients with Stable Coronary Artery Disease. TH Open 2019; 3:e259-e262. [PMID: 31428739 PMCID: PMC6697509 DOI: 10.1055/s-0039-1695710] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 07/05/2019] [Indexed: 11/02/2022] Open
Affiliation(s)
- Renske H Olie
- Laboratory for Clinical Thrombosis and Hemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, The Netherlands.,Thrombosis Expertise Center, Maastricht University Medical Center+ (MUMC+ ), Maastricht, The Netherlands
| | - Paola E J van der Meijden
- Laboratory for Clinical Thrombosis and Hemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, The Netherlands.,Thrombosis Expertise Center, Maastricht University Medical Center+ (MUMC+ ), Maastricht, The Netherlands
| | - Henri M H Spronk
- Laboratory for Clinical Thrombosis and Hemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, The Netherlands
| | - Rene van Oerle
- Laboratory for Clinical Thrombosis and Hemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, The Netherlands
| | - Stale Barvik
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
| | | | - Hugo Ten Cate
- Laboratory for Clinical Thrombosis and Hemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, The Netherlands.,Thrombosis Expertise Center, Maastricht University Medical Center+ (MUMC+ ), Maastricht, The Netherlands
| | - Dennis W T Nilsen
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
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17
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Petersohn S, Ramaekers BLT, Olie RH, Ten Cate-Hoek AJ, Daemen JWHC, Ten Cate H, Joore MA. Comparison of three generic quality-of-life metrics in peripheral arterial disease patients undergoing conservative and invasive treatments. Qual Life Res 2019; 28:2257-2279. [PMID: 30929124 PMCID: PMC6620242 DOI: 10.1007/s11136-019-02166-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2019] [Indexed: 01/22/2023]
Abstract
PURPOSE To determine the effect of revascularisation for peripheral arterial disease (PAD) on QoL in the first and second year following diagnosis, to compare the effect depicted by Short Form Six Dimensions (SF-6D) and EuroQoL five Dimensions (EQ-5D) utilities, and Visual Analogue Scale (VAS) scores and to analyse heterogeneity in treatment response. METHODS Longitudinal data from 229 PAD patients were obtained in an observational study in southern Netherlands. Utility scores were calculated with the international (SF-6D) and Dutch (EQ-5D) tariffs. We analysed treatment effect at years 1 and 2 through propensity score-matched ANCOVAs. Thereby, we estimated the marginal means (EMMs) of revascularisation and conservative treatment, and identified covariates of revascularisation effect. RESULTS A year after diagnosis, 70 patients had been revascularised; the EMMs of revascularisation were 0.038, 0.077 and 0.019 for SF-6D, EQ-5D and VAS, respectively (always in this order). For conservative treatment these were - 0.017, 0.038 and 0.021. At 2-year follow-up, the EMMs of revascularisation were 0.015, 0.077 and 0.027, for conservative treatment these were - 0.020, 0.013 and - 0.004. Baseline QoL (and rest pain in year 2) were covariates of treatment effect. CONCLUSIONS We measured positive effects of revascularisation and conservative treatment on QoL a year after diagnosis, the effect of revascularisation was sustained over 2 years. The magnitude of effect varied between the metrics and was largest for the EQ-5D, which may be most suitable for QoL measurement in PAD patients. Baseline QoL influenced revascularisation effect, in clinical practice this may inform expected QoL gain in individual patients.
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Affiliation(s)
- Svenja Petersohn
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre +, Maastricht, The Netherlands.
- School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands.
| | - Bram L T Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre +, Maastricht, The Netherlands
- School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Renske H Olie
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Internal Medicine, Maastricht University Medical Centre +, Maastricht, The Netherlands
| | - Arina J Ten Cate-Hoek
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Internal Medicine, Maastricht University Medical Centre +, Maastricht, The Netherlands
| | - Jan-Willem H C Daemen
- Department of Vascular surgery, Maastricht University Medical Centre +, Maastricht, The Netherlands
| | - Hugo Ten Cate
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Internal Medicine, Maastricht University Medical Centre +, Maastricht, The Netherlands
| | - Manuela A Joore
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre +, Maastricht, The Netherlands
- School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
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Hensgens RRK, Olie RH, Henskens YMC, Wijnen PAHM. P5733Comparison of three different platelet function tests in patients on P2Y12 inhibitors in correlation to genetic background. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy566.p5733] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- R R K Hensgens
- Maastricht University Medical Centre (MUMC), Department of Internal Medicine and Department of Clinical Thrombosis and Haemostasis, Maastricht, Netherlands
| | - R H Olie
- Maastricht University Medical Centre (MUMC), Department of Internal Medicine and Department of Clinical Thrombosis and Haemostasis, Maastricht, Netherlands
| | - Y M C Henskens
- Maastricht University Medical Centre (MUMC), Clinical Chemistry, Maastricht, Netherlands
| | - P A H M Wijnen
- Maastricht University Medical Centre (MUMC), Research Technician, Maastricht, Netherlands
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Olie RH, Van Der Meijden PEJ, Spronk HMH, Van Oerle R, Barvik S, Bonarjee VVS, Ten Cate H, Nilsen DWT. 355Effects of the PAR-1 receptor antagonist vorapaxar on platelet activation and coagulation biomarkers in patients with stable coronary artery disease. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy564.355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- R H Olie
- Maastricht University Medical Centre (MUMC), Department of Internal Medicine and Laboratory for Clinical Thrombosis and Haemostasis, Maastricht, Netherlands
| | - P E J Van Der Meijden
- Cardiovascular Research Institute Maastricht (CARIM), Laboratory for Clinical Thrombosis and Haemostasis, Maastricht University, Maastricht, Netherlands
| | - H M H Spronk
- Cardiovascular Research Institute Maastricht (CARIM), Laboratory for Clinical Thrombosis and Haemostasis, Maastricht University, Maastricht, Netherlands
| | - R Van Oerle
- Cardiovascular Research Institute Maastricht (CARIM), Laboratory for Clinical Thrombosis and Haemostasis, Maastricht University, Maastricht, Netherlands
| | - S Barvik
- Stavanger University Hospital, Department of Cardiology, Stavanger, Norway
| | - V V S Bonarjee
- Stavanger University Hospital, Department of Cardiology, Stavanger, Norway
| | - H Ten Cate
- Maastricht University Medical Centre (MUMC), Department of Internal Medicine and Laboratory for Clinical Thrombosis and Haemostasis, Maastricht, Netherlands
| | - D W T Nilsen
- Stavanger University Hospital, Department of Cardiology, Stavanger, Norway
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Olie RH, van der Meijden PE, ten Cate H. The coagulation system in atherothrombosis: Implications for new therapeutic strategies. Res Pract Thromb Haemost 2018; 2:188-198. [PMID: 30046721 PMCID: PMC6055505 DOI: 10.1002/rth2.12080] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 01/05/2018] [Indexed: 12/13/2022] Open
Abstract
Clinical manifestations of atherosclerotic disease include coronary artery disease (CAD), peripheral artery disease (PAD), and stroke. Although the role of platelets is well established, evidence is now accumulating on the contribution of coagulation proteins to the processes of atherosclerosis and atherothrombosis. Coagulation proteins not only play a role in fibrin formation and platelet activation, but also mediate various biological and pathophysiologic processes through activation of protease-activated-receptors (PARs). Thus far, secondary prevention in patients with CAD/PAD has been the domain of antiplatelet therapy, however, residual atherothrombotic risks remain substantial. Therefore, combining antiplatelet and anticoagulant therapy has gained more attention. Recently, net clinical benefit of combining aspirin with low-dose rivaroxaban in patients with stable atherosclerotic disease has been demonstrated. In this review, based on the State of the Art lecture "Clotting factors and atherothrombosis" presented at the ISTH Congress 2017, we highlight the role of coagulation proteins in the pathophysiology of atherothrombosis, and specifically focus on therapeutic strategies to decrease atherothrombotic events by optimization of vascular protection.
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Affiliation(s)
- Renske H. Olie
- Department of Internal MedicineMaastricht University Medical Center+ (MUMC+)MaastrichtThe Netherlands
- Thrombosis Expertise CenterMUMC+MaastrichtThe Netherlands
- Laboratory for Clinical Thrombosis and HemostasisMaastricht UniversityMaastrichtThe Netherlands
| | - Paola E.J. van der Meijden
- Thrombosis Expertise CenterMUMC+MaastrichtThe Netherlands
- Laboratory for Clinical Thrombosis and HemostasisMaastricht UniversityMaastrichtThe Netherlands
| | - Hugo ten Cate
- Department of Internal MedicineMaastricht University Medical Center+ (MUMC+)MaastrichtThe Netherlands
- Thrombosis Expertise CenterMUMC+MaastrichtThe Netherlands
- Laboratory for Clinical Thrombosis and HemostasisMaastricht UniversityMaastrichtThe Netherlands
- Center for Thrombosis and HaemostasisGutenberg UniversityMainzGermany
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21
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Spronk HMH, Padro T, Siland JE, Prochaska JH, Winters J, van der Wal AC, Posthuma JJ, Lowe G, d'Alessandro E, Wenzel P, Coenen DM, Reitsma PH, Ruf W, van Gorp RH, Koenen RR, Vajen T, Alshaikh NA, Wolberg AS, Macrae FL, Asquith N, Heemskerk J, Heinzmann A, Moorlag M, Mackman N, van der Meijden P, Meijers JCM, Heestermans M, Renné T, Dólleman S, Chayouâ W, Ariëns RAS, Baaten CC, Nagy M, Kuliopulos A, Posma JJ, Harrison P, Vries MJ, Crijns HJGM, Dudink EAMP, Buller HR, Henskens YMC, Själander A, Zwaveling S, Erküner O, Eikelboom JW, Gulpen A, Peeters FECM, Douxfils J, Olie RH, Baglin T, Leader A, Schotten U, Scaf B, van Beusekom HMM, Mosnier LO, van der Vorm L, Declerck P, Visser M, Dippel DWJ, Strijbis VJ, Pertiwi K, Ten Cate-Hoek AJ, Ten Cate H. Atherothrombosis and Thromboembolism: Position Paper from the Second Maastricht Consensus Conference on Thrombosis. Thromb Haemost 2018; 118:229-250. [PMID: 29378352 DOI: 10.1160/th17-07-0492] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Atherothrombosis is a leading cause of cardiovascular mortality and long-term morbidity. Platelets and coagulation proteases, interacting with circulating cells and in different vascular beds, modify several complex pathologies including atherosclerosis. In the second Maastricht Consensus Conference on Thrombosis, this theme was addressed by diverse scientists from bench to bedside. All presentations were discussed with audience members and the results of these discussions were incorporated in the final document that presents a state-of-the-art reflection of expert opinions and consensus recommendations regarding the following five topics: 1. Risk factors, biomarkers and plaque instability: In atherothrombosis research, more focus on the contribution of specific risk factors like ectopic fat needs to be considered; definitions of atherothrombosis are important distinguishing different phases of disease, including plaque (in)stability; proteomic and metabolomics data are to be added to genetic information. 2. Circulating cells including platelets and atherothrombosis: Mechanisms of leukocyte and macrophage plasticity, migration, and transformation in murine atherosclerosis need to be considered; disease mechanism-based biomarkers need to be identified; experimental systems are needed that incorporate whole-blood flow to understand how red blood cells influence thrombus formation and stability; knowledge on platelet heterogeneity and priming conditions needs to be translated toward the in vivo situation. 3. Coagulation proteases, fibrin(ogen) and thrombus formation: The role of factor (F) XI in thrombosis including the lower margins of this factor related to safe and effective antithrombotic therapy needs to be established; FXI is a key regulator in linking platelets, thrombin generation, and inflammatory mechanisms in a renin-angiotensin dependent manner; however, the impact on thrombin-dependent PAR signaling needs further study; the fundamental mechanisms in FXIII biology and biochemistry and its impact on thrombus biophysical characteristics need to be explored; the interactions of red cells and fibrin formation and its consequences for thrombus formation and lysis need to be addressed. Platelet-fibrin interactions are pivotal determinants of clot formation and stability with potential therapeutic consequences. 4. Preventive and acute treatment of atherothrombosis and arterial embolism; novel ways and tailoring? The role of protease-activated receptor (PAR)-4 vis à vis PAR-1 as target for antithrombotic therapy merits study; ongoing trials on platelet function test-based antiplatelet therapy adjustment support development of practically feasible tests; risk scores for patients with atrial fibrillation need refinement, taking new biomarkers including coagulation into account; risk scores that consider organ system differences in bleeding may have added value; all forms of oral anticoagulant treatment require better organization, including education and emergency access; laboratory testing still needs rapidly available sensitive tests with short turnaround time. 5. Pleiotropy of coagulation proteases, thrombus resolution and ischaemia-reperfusion: Biobanks specifically for thrombus storage and analysis are needed; further studies on novel modified activated protein C-based agents are required including its cytoprotective properties; new avenues for optimizing treatment of patients with ischaemic stroke are needed, also including novel agents that modify fibrinolytic activity (aimed at plasminogen activator inhibitor-1 and thrombin activatable fibrinolysis inhibitor.
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Affiliation(s)
- H M H Spronk
- Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - T Padro
- Cardiovascular Research Center (ICCC), Hospital Sant Pau, Barcelona, Spain
| | - J E Siland
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - J H Prochaska
- Center for Cardiology/Center for Thrombosis and Hemostasis/DZHK, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - J Winters
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - A C van der Wal
- Department of Pathology, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - J J Posthuma
- Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - G Lowe
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland
| | - E d'Alessandro
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.,Department of Pathology, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - P Wenzel
- Department of Cardiology, Universitätsmedizin Mainz, Mainz, Germany
| | - D M Coenen
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - P H Reitsma
- Einthoven Laboratory, Leiden University Medical Center, Leiden, The Netherlands
| | - W Ruf
- Center for Cardiology/Center for Thrombosis and Hemostasis/DZHK, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - R H van Gorp
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - R R Koenen
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - T Vajen
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - N A Alshaikh
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - A S Wolberg
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina, United States
| | - F L Macrae
- Thrombosis and Tissue Repair Group, Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine, School of Medicine, University of Leeds, Leeds, UK
| | - N Asquith
- Thrombosis and Tissue Repair Group, Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine, School of Medicine, University of Leeds, Leeds, UK
| | - J Heemskerk
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - A Heinzmann
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - M Moorlag
- Synapse, Maastricht, The Netherlands
| | - N Mackman
- Department of Medicine, UNC McAllister Heart Institute, University of North Carolina, Chapel Hill, North Carolina, United States
| | - P van der Meijden
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - J C M Meijers
- Department of Plasma Proteins, Sanquin, Amsterdam, The Netherlands
| | - M Heestermans
- Einthoven Laboratory, Leiden University Medical Center, Leiden, The Netherlands
| | - T Renné
- Department of Molecular Medicine and Surgery, Karolinska Institutet and University Hospital, Stockholm, Sweden.,Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - S Dólleman
- Department of Nephrology, Leiden University Medical Centre, Leiden, The Netherlands
| | - W Chayouâ
- Synapse, Maastricht, The Netherlands
| | - R A S Ariëns
- Thrombosis and Tissue Repair Group, Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine, School of Medicine, University of Leeds, Leeds, UK
| | - C C Baaten
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - M Nagy
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - A Kuliopulos
- Tufts University School of Graduate Biomedical Sciences, Biochemistry/Developmental, Molecular and Chemical Biology, Tufts University School of Medicine, Boston, Massachusetts
| | - J J Posma
- Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - P Harrison
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - M J Vries
- Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - H J G M Crijns
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - E A M P Dudink
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - H R Buller
- Department of Vascular Medicine, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - Y M C Henskens
- Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - A Själander
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - S Zwaveling
- Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands.,Synapse, Maastricht, The Netherlands
| | - O Erküner
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - J W Eikelboom
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - A Gulpen
- Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - F E C M Peeters
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - J Douxfils
- Department of Pharmacy, Thrombosis and Hemostasis Center, Faculty of Medicine, Namur University, Namur, Belgium
| | - R H Olie
- Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - T Baglin
- Department of Haematology, Addenbrookes Hospital Cambridge, Cambridge, United Kingdom
| | - A Leader
- Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands.,Davidoff Cancer Center, Rabin Medical Center, Institute of Hematology, Sackler Faculty of Medicine, Tel Aviv University, Petah Tikva, Tel Aviv, Israel
| | - U Schotten
- Center for Cardiology/Center for Thrombosis and Hemostasis/DZHK, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - B Scaf
- Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - H M M van Beusekom
- Department of Experimental Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - L O Mosnier
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, United States
| | | | - P Declerck
- Department of Pharmaceutical and Pharmacological Sciences, University of Leuven, Leuven, Belgium
| | | | - D W J Dippel
- Department of Neurology, Erasmus MC, Rotterdam, The Netherlands
| | | | - K Pertiwi
- Department of Cardiovascular Pathology, University of Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
| | - A J Ten Cate-Hoek
- Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - H Ten Cate
- Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
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22
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Olie RH, Meertens NEL, Henskens YMC, Ten Cate H. Empirically Reduced Dosages of Tinzaparin in Patients with Moderate-to-Severe Renal Insufficiency Lead to Inadequate Anti-Xa Levels. Nephron Clin Pract 2017; 137:113-123. [PMID: 28662505 DOI: 10.1159/000477474] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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: 01/04/2017] [Accepted: 05/07/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Due to the higher molecular weight of tinzaparin, the low molecular weight heparin (LMWH) is less dependent on renal excretion than other LMWH preparations. However, several international guidelines recommend the same preemptive dosage reduction for all therapeutic dose LMWHs prescribed in renal insufficient patients, to ensure that there is no accumulation of anticoagulant activity and increased risk of bleeding. This study is aimed at assessing whether a preemptive dosage reduction of tinzaparin in all renal insufficient patients (comprising 25% reduction in patients with Modification of Diet in Renal Disease - estimated glomerular filtration rate (MDRD-eGFR) 30-60 mL/min/1.73 m2 and 50% reduction in patients with MDRD-eGFR <30 mL/min/1.73 m2) leads to adequate anti-Xa levels. METHODS We selected the anti-Xa levels of in-hospital patients (≥18 years) with moderate-to-severe renal insufficiency (MDRD-eGFR <60 mL/min/1.73 m2), on therapeutic dosages of tinzaparin. Anti-Xa levels were measured using a chromogenic assay. RESULTS Preemptive dosage reduction resulted in a median anti-Xa activity of 0.50 IU/mL (interquartile range [IQR] 0.38-0.60). In 92.3% of patients the anti-Xa level was below the target anti-Xa level of >0.85 IU/mL for therapeutic indications. Unadjusted dosages led to a median anti-Xa activity of 0.74 IU/mL (IQR 0.56-0.92). The preemptive dosage reduction was significantly associated with anti-Xa activity below therapeutic range (p = 0.007). No difference in anti-Xa activity was observed between patients with moderate (0.71 IU/mL, IQR 0.61-0.95) versus severe (0.65 IU/mL, IQR 0.41-1.06) renal insufficiency in whom an unadjusted dose had been administered (p = 0.77). None of the anti-Xa levels were above the upper margin of the presumed therapeutic range of 2.0 IU/mL. CONCLUSION In renal insufficient patients, the preemptive dosage reduction of tinzaparin leads to inadequate anti-Xa levels.
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Affiliation(s)
- Renske H Olie
- Department of Internal Medicine, Maastricht University Medical Center+ (MUMC+), Maastricht, The Netherlands
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23
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Vries MJ, Bouman HJ, Olie RH, Veenstra LF, Zwaveling S, Verhezen PW, ten Cate-Hoek AJ, ten Cate H, Henskens YM, van der Meijden PE. Determinants of agreement between proposed therapeutic windows of platelet function tests in vulnerable patients. Eur Heart J Cardiovasc Pharmacother 2016; 3:11-17. [DOI: 10.1093/ehjcvp/pvw026] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 09/05/2016] [Accepted: 09/06/2016] [Indexed: 12/18/2022]
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