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Sundermann M, Clendon O, McNeill R, Doogue M, Chin PKL. Optimising interruptive clinical decision support alerts for antithrombotic duplicate prescribing in hospital. Int J Med Inform 2024; 186:105418. [PMID: 38518676 DOI: 10.1016/j.ijmedinf.2024.105418] [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] [Received: 11/28/2023] [Revised: 03/05/2024] [Accepted: 03/17/2024] [Indexed: 03/24/2024]
Abstract
INTRODUCTION Duplicate prescribing clinical decision support alerts can prevent important prescribing errors but are frequently the cause of much alert fatigue. Stat dose prescriptions are a known reason for overriding these alerts. This study aimed to evaluate the effect of excluding stat dose prescriptions from duplicate prescribing alerts for antithrombotic medicines on alert burden, prescriber adherence, and prescribing. MATERIALS AND METHODS A before (January 1st, 2017 to August 31st, 2022) and after (October 5th, 2022 to September 30th, 2023) study was undertaken of antithrombotic duplicate prescribing alerts and prescribing following a change in alert settings. Alert and prescribing data for antithrombotic medicines were joined, processed, and analysed to compare alert rates, adherence, and prescribing. Alert burden was assessed as alerts per 100 prescriptions. Adherence was measured at the point of the alert as whether the prescriber accepted the alert and following the alert as whether a relevant prescription was ceased within an hour. Co-prescribing of antithrombotic stat dose prescriptions was assessed pre- and post-alert reconfiguration. RESULTS Reconfiguration of the alerts reduced the alert rate by 29 % (p < 0.001). The proportion of alerts associated with cessation of antithrombotic duplication significantly increased (32.8 % to 44.5 %, p < 0.001). Adherence at the point of the alert increased 1.2 % (4.8 % to 6.0 %, p = 0.012) and 11.5 % (29.4 % to 40.9 %, p < 0.001) within one hour of the alert. When ceased after the alert over 80 % of duplicate prescriptions were ceased within 2 min of overriding. Antithrombotic stat dose co-prescribing was unchanged for 4 out of 5 antithrombotic duplication alert rules. CONCLUSION By reconfiguring our antithrombotic duplicate prescribing alerts, we reduced alert burden and increased alert adherence. Many prescribers ceased duplicate prescribing within 2 min of alert override highlighting the importance of incorporating post-alert measures in accurately determining prescriber alert adherence.
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Affiliation(s)
- Milan Sundermann
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Olivia Clendon
- Department of Clinical Pharmacology, Te Whatu Ora Health New Zealand - Waitaha Canterbury, New Zealand
| | - Richard McNeill
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Matthew Doogue
- Department of Medicine, University of Otago, Christchurch, New Zealand; Department of Clinical Pharmacology, Te Whatu Ora Health New Zealand - Waitaha Canterbury, New Zealand
| | - Paul K L Chin
- Department of Medicine, University of Otago, Christchurch, New Zealand; Department of Clinical Pharmacology, Te Whatu Ora Health New Zealand - Waitaha Canterbury, New Zealand.
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Shyu M, Liu A, Srikureja A, Gregorian A, Srisuwananukorn A, Tremblay D, Naymagon L. Equivalent thrombotic risk with Warfarin, Dabigatran, or Enoxaparin after failure of initial direct oral anticoagulation (DOAC) therapy. J Thromb Thrombolysis 2024:10.1007/s11239-024-02978-z. [PMID: 38643437 DOI: 10.1007/s11239-024-02978-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/02/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND The direct oral anticoagulants (DOACs) are now commonly regarded as first line anticoagulants in most cases of venous thromboembolism (VTE). However, the optimal choice of subsequent anticoagulant in instances of first line DOAC failure is unclear. OBJECTIVES To describe and compare outcomes with second line anticoagulants used after DOAC failure. METHODS Patients seen at an urban hospital system for an episode of acute VTE initially treated with either apixaban or rivaroxaban who experienced a subsequent recurrent thrombosis while on anticoagulation (1st recurrent thrombosis) were included. RESULTS In total, 166 patients after apixaban or rivaroxaban failure were included. Following DOAC failure (1st recurrent thrombosis), the subsequent anticoagulant was warfarin in 60 patients (36%), dabigatran in 42 patients (25%), and enoxaparin in 64 patients (39%). Enoxaparin was preferentially prescribed in patients with a malignancy-associated etiology for 1st recurrent thrombosis (p < 0.01). The median follow-up time in our cohort was 16 months. There was no difference in 2nd recurrent thrombosis-free survival (p = 0.72) or risk for major bleeding event (p = 0.30) among patients treated with dabigatran, warfarin, or enoxaparin. CONCLUSIONS In this retrospective analysis of patients failing first line DOAC therapy, rates of 2nd recurrent thrombosis and bleeding did not differ among subsequently chosen anticoagulants. Our study provides evidence that the optimal 2nd anticoagulant is not clear, and the choice of 2nd anticoagulant should continue to balance patient preference, cost, and provider experience.
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Affiliation(s)
- Margaret Shyu
- Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- Division of Oncology, Stanford University School of Medicine, 300 Pasteur Drive MC 5151, Stanford, CA, USA.
| | - Angela Liu
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Anya Srikureja
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alison Gregorian
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Andrew Srisuwananukorn
- Division of Hematology, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Douglas Tremblay
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Leonard Naymagon
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
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3
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Samuelson Bannow BT. Management of Abnormal Uterine Bleeding on Anticoagulation: The Patient-Clinician Perspective. J Thromb Haemost 2024:S1538-7836(24)00216-2. [PMID: 38642705 DOI: 10.1016/j.jtha.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 03/21/2024] [Accepted: 04/04/2024] [Indexed: 04/22/2024]
Abstract
Bleeding is a well-recognized side effect of anticoagulant therapy, which is used to treat venous thromboembolism (VTE) in individuals of all ages, including those of female sex, who commonly experience VTE as a complication of hormonal therapies and/or pregnancy. Heavy menstrual bleeding (HMB) is also extremely common in reproductive aged individuals of female sex. Despite these overlapping situations, relatively little attention has been paid to the impact of anticoagulant-associated HMB on treatment strategies and the patient experience. In this review, we summarize incidence and complications of HMB in anticoagulated individuals as well as management strategies for HMB in this population. We also address the patient experience, including the impact of HMB on quality of life and the impact of discontinuing hormonal therapies at the time of VTE diagnosis and anticoagulant initiation. We conclude by highlighting specific gaps related to the patient experience of anticoagulant-associated HMB in both the research and clinical settings.
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McGrady ME, Ignjatovic V, Jones S, Bruce A, Goldenberg NA, Rizzi M, Thornburg CD, Todd KE, Luchtman-Jones L. Evaluation, analysis, and reporting of medication adherence for clinical trials of anticoagulants in children: Guidance from the ISTH SSC Subcommittee on Pediatric and Neonatal Thrombosis and Hemostasis. J Thromb Haemost 2024:S1538-7836(24)00217-4. [PMID: 38642706 DOI: 10.1016/j.jtha.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/02/2024] [Accepted: 04/03/2024] [Indexed: 04/22/2024]
Abstract
In response to growing recognition that non-adherence prevents children, adolescents, and young adults from achieving the therapeutic benefits of anticoagulant medication, the ISTH SSC Subcommittee on Pediatric and Neonatal Thrombosis and Hemostasis convened a working party on medication adherence. The primary aim of this manuscript was to synthesize recommendations from the larger adherence science literature to provide guidance regarding the classification, collection, and interpretation of anticoagulation adherence data. The secondary aim of this manuscript was to evaluate the degree to which trials published from 2013 to 2023 adhered to these guidance recommendations. As less than half of all trials reported on adherence and none included all recommended elements, the proposed ISTH SSC guidance has the potential to enhance the rigor and reproducibility of pediatric anticoagulant research.
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Affiliation(s)
- Meghan E McGrady
- Center for Adherence and Self-Management, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Patient and Family Wellness Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Vera Ignjatovic
- Haematology, Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Paediatrics, The University of Melbourne, Parkville, VIC, Australia
| | - Sophie Jones
- Haematology, Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Clinical Haematology, The Royal Children's Hospital, Melbourne, Australia; Department of Nursing, The University of Melbourne, Parkville, VIC, Australia
| | - Aisha Bruce
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Neil A Goldenberg
- Johns Hopkins All Children's Institute for Clinical and Translational Research, St. Petersburg, FL, USA; Departments of Pediatrics and Medicine, Divisions of Hematology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mattia Rizzi
- Hematology/Oncology Unit, Division of Pediatrics, Lausanne University Hospital, Lausanne, Switzerland
| | - Courtney D Thornburg
- Division of Pediatric Hematology/Oncology, Rady Children's Hospital San Diego, San Diego, CA, USA; Department of Pediatrics, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Kevin E Todd
- Department of Pediatric Hematology/Oncology, Children's Hospital of the King's Daughters, Norfolk, VA, USA
| | - Lori Luchtman-Jones
- Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Stuby J, Haschke M, Tritschler T, Aujesky D. Oral anticoagulant therapy in older adults. Thromb Res 2024; 238:1-10. [PMID: 38636204 DOI: 10.1016/j.thromres.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 03/06/2024] [Accepted: 04/11/2024] [Indexed: 04/20/2024]
Abstract
Patients aged ≥65 years not only account for the majority of patients with atrial fibrillation (AF) and venous thromboembolism (VTE), they are also at a higher risk of morbidity, mortality, and undertreatment than younger patients. Several age-related physiological changes with effects on drug pharmacokinetics/-dynamics and blood vessel fragility as well as the higher prevalence of geriatric conditions such as frailty, multimorbidity, polypharmacy, fall risk, dementia, and malnutrition make older persons more vulnerable to disease- and anticoagulation-related complications. Moreover, because older patients with AF/VTE are underrepresented in oral anticoagulation (OAC) trials, evidence on OAC in older adults with AF/VTE is mainly based on subgroup analyses from clinical trials and observational studies. A growing body of such limited evidence suggests that direct oral anticoagulants (DOACs) may be superior in terms of efficacy and safety compared to vitamin K antagonists in older persons with AF/VTE and that specific DOACs may have a differing risk-benefit profile. In this narrative review, we summarize the evidence on epidemiology of AF/VTE, impact of age-related physiological changes, efficacy/safety of OAC, specifically considering individuals with common geriatric conditions, and review OAC guideline recommendations for older adults with AF/VTE. We also propose a research agenda to improve the evidence basis on OAC older individuals with AF/VTE, including the conduct of advanced age-specific and pragmatic studies using less restrictive eligibility criteria and patient-reported health outcomes, in order to compare the effectiveness and safety of different DOACs, and investigate lower-dose regimens and optimal OAC durations in older patients.
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Affiliation(s)
- J Stuby
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - M Haschke
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland; Clinical Pharmacology & Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - T Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - D Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
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Numao Y, Takahashi S, Nakao YM, Tajima E, Noma S, Endo A, Honye J, Tsukada Y. Sex Differences in Bleeding Risk Associated With Antithrombotic Therapy Following Percutaneous Coronary Intervention. Circ Rep 2024; 6:99-109. [PMID: 38606417 PMCID: PMC11004037 DOI: 10.1253/circrep.cr-24-0015] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 02/21/2024] [Indexed: 04/13/2024] Open
Abstract
Background: Antithrombotic therapy is crucial for secondary prevention of cardiovascular disease (CVD), but women with CVD may face increased bleeding complications post-percutaneous coronary intervention (PCI) under antithrombotic therapy. However, women are often underrepresented in clinical trials in this field, so evidence for sex-specific recommendations is lacking. Methods and Results: A search on PubMed was conducted for English-language articles addressing bleeding complications and antithrombotic therapy in women. Despite women potentially showing higher baseline platelet responsiveness than men, the clinical implications remain unclear. Concerning antiplatelet therapy post-PCI, although women have an elevated bleeding risk in the acute phase, no sex differences were observed in the chronic phase. However, women require specific considerations for factors such as age, renal function, and weight when determining the dose and duration of antiplatelet therapy. Regarding anticoagulation post-PCI, direct oral anticoagulants may pose a lower bleeding risk in women compared with warfarin. Concerning triple antithrombotic therapy (TAT) post-PCI for patients with atrial fibrillation, there is a lack of evidence on whether sex differences should be considered in the duration and regimen of TAT. Conclusions: Recent findings on sex differences in post-PCI bleeding complications did not provide enough evidence to recommend specific therapies for women. Further studies are needed to address this gap and recommend optimal antithrombotic therapy post-PCI for women.
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Affiliation(s)
- Yoshimi Numao
- Department of Cardiology, Itabashi Chuo Medical Center Tokyo Japan
| | - Saeko Takahashi
- Department of Cardiology, Shonan Oiso Hospital Kanagawa Japan
| | - Yoko M Nakao
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University Kyoto Japan
| | - Emi Tajima
- Department of Cardiology, Tokyo General Hospital Tokyo Japan
| | - Satsuki Noma
- Department of Cardiovascular Medicine, Nippon Medical School Tokyo Japan
| | - Ayaka Endo
- Department of Cardiology, Tokyo Saiseikai Central Hospital Tokyo Japan
| | - Junko Honye
- Cardiovascular Center, Kikuna Memorial Hospital Kanagawa Japan
| | - Yayoi Tsukada
- Department of General Medicine and Health Science, Nippon Medical School Tokyo Japan
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Ryu B, Mochizuki T, Shima S, Sato S, Inoue T, Kawamata T, Niimi Y. Perioperative Management of Spinal Arteriovenous Malformation Embolization: Delayed Venous Thrombosis and Implications for Severe Back Pain. Clin Neuroradiol 2024:10.1007/s00062-024-01403-5. [PMID: 38592446 DOI: 10.1007/s00062-024-01403-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/01/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND AND PURPOSE The prognosis of untreated spinal arteriovenous malformations (SAVMs) is poor. Embolization plays an important role in the management of intramedullary SAVMs. Delayed aggravation due to spinal venous thrombosis following successful embolization has been reported; however, perioperative management strategies to prevent thrombosis have not been explored. We present our single-center experience of SAVM embolization and perioperative management, including anticoagulation. MATERIAL AND METHODS We retrospectively evaluated 18 patients with SAVMs who underwent transarterial embolization. Perioperative anticoagulation therapy was administered to selected patients. We compared the characteristics of the patients, including perioperative management procedures, between those with and without postoperative worsening following embolization. RESULTS Acute postoperative worsening within 1 week occurred in 4 (22.2%) patients. Of these, immediate worsening was observed in one patient as a procedure-related complication. Delayed worsening after 24 h was observed in 3 patients, caused by delayed venous thrombosis with severe back pain. Rescue anticoagulation for delayed worsening improved symptoms in two patients. A comparison between patients with and without acute postoperative worsening revealed significant differences in age (median 46.5 vs. 26.5 years, p = 0.009) and the presence of postoperative back pain (75.0% vs. 0%, p = 0.005); however, there was no significant difference in use of selective anticoagulation (p = 0.274). CONCLUSION The results of this study suggest that SAVM embolization can cause acute worsening due to postoperative venous thrombosis with severe back pain, which may be reversed by anticoagulation therapy. Back pain is an important finding that suggests venous thrombosis, and anticoagulation should be urgently administered.
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Affiliation(s)
- Bikei Ryu
- Department of Neuroendovascular Therapy, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, 104-8560, Tokyo, Japan.
- Department of Neurosurgery, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, 104-8560, Tokyo, Japan.
- Department of Neurosurgery, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, 162-8666, Tokyo, Japan.
| | - Tatsuki Mochizuki
- Department of Neurosurgery, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, 104-8560, Tokyo, Japan
| | - Shogo Shima
- Department of Neurosurgery, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, 104-8560, Tokyo, Japan
| | - Shinsuke Sato
- Department of Neuroendovascular Therapy, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, 104-8560, Tokyo, Japan
- Department of Neurosurgery, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, 104-8560, Tokyo, Japan
- Department of Neurosurgery, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, 162-8666, Tokyo, Japan
| | - Tatsuya Inoue
- Department of Neurosurgery, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, 104-8560, Tokyo, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, 162-8666, Tokyo, Japan
| | - Yasunari Niimi
- Department of Neuroendovascular Therapy, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, 104-8560, Tokyo, Japan
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Vanderstuyft E, Hias J, Hellemans L, Van Aelst L, Tournoy J, Van der Linden LR. Appropriateness of antithrombotics in geriatric inpatients with atrial fibrillation: a retrospective, cross-sectional study. Eur J Hosp Pharm 2024:ejhpharm-2023-004033. [PMID: 38580430 DOI: 10.1136/ejhpharm-2023-004033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 03/19/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Atrial fibrillation occurs in nearly half of geriatric inpatients and is a major cause of morbidity and mortality. Suboptimal anticoagulation use is an important concern in this population. This study aimed to evaluate the appropriateness of antithrombotic therapies in this patient cohort. METHODS A retrospective analysis was conducted on the geriatric wards of a teaching hospital in Belgium, on a background of clinical pharmacy services. The first 90 atrial fibrillation patients from 2020 to 2022 were included if they received an oral anticoagulant. We assessed utilisation and appropriateness of antithrombotics at discharge, examined reasons for guideline deviations, and explored factors associated with underdosing. Temporal associations for appropriateness and type of anticoagulant (vitamin K antagonist (VKA) vs direct oral anticoagulant (DOAC)) were assessed. RESULTS The mean age of patients was 86.5 (±5.3) years and the median CHA2DS2-VASc score was 5 (interquartile range (IQR) 4-6). At discharge, 256 (94.8%) patients used a DOAC; nine (3.3%) used a VKA; one (0.4%) a DOAC-antiplatelet combination, and in four patients (1.5%) all antithrombotics were discontinued. The majority (64.4%) of patients received reduced DOAC doses with apixaban prescribed in 40.7%. In 39 (14.4%) patients, antithrombotic use was considered inappropriate, mostly without a rationale (23/39). Year 2022 (odds ratio (OR) 0.104; 95% confidence interval (CI), 0.012-0.878) was the sole determinant for underdosing. No significant differences were found with respect to appropriateness (p=0.533) or anticoagulant class (p=0.479) over time. CONCLUSION Most geriatric inpatients received a justified reduced DOAC dose. A significant proportion was managed inappropriately with underdosing (= unjustified reduced dose) being most common. Frequently no rationale was provided for deviating from trial-tested doses.
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Affiliation(s)
- Esther Vanderstuyft
- Pharmacy Department, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Julie Hias
- Pharmacy Department, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Laura Hellemans
- Pharmacy Department, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven Biomedical Sciences Group, Leuven, Belgium
| | - Lucas Van Aelst
- Department of Cardiovascular Sciences, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
- Department of Cardiology, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Jos Tournoy
- Department of Geriatric Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
- Department of Chronic Diseases, Metabolism and Ageing, Katholieke Universiteit Leuven, Leuven, Flanders, Belgium
| | - Lorenz Roger Van der Linden
- Pharmacy Department, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, Katholieke Universiteit Leuven, Leuven, Flanders, Belgium
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Kang X, Hong S, Tan C, Di W, Zhang N. Successful management of VTE with essential thrombocythemia and cavernous transformation of the portal vein in early pregnancy: a case report. BMC Womens Health 2024; 24:211. [PMID: 38566064 PMCID: PMC10985859 DOI: 10.1186/s12905-024-03051-w] [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] [Received: 12/16/2023] [Accepted: 03/25/2024] [Indexed: 04/04/2024] Open
Abstract
Due to the thrombohemorrhagic potential of essential thrombocythemia, pregnancy complicated by essential thrombocythemia should be recognized as a risk factor for obstetric complications. Here, we report the case of a patient with essential thrombocythemia with two significantly different pregnancy outcomes. Her first pregnancy (at 30 years of age) ended with an uneventful term delivery. However, the patient progressed to cavernous transformation of the portal vein in the period between her two pregnancies and subsequently experienced deep venous thrombosis during the first trimester of her second pregnancy (at 36 years of age). The patient's platelet count during pregnancy was within the normal range, so she ignored previous instances of essential thrombocytosis (at 26 years of age). The patient's main symptom was unrelieved pain in her leg. After that, she was successfully treated with anticoagulant throughout her entire pregnancy, resulting in a term vaginal delivery. This case highlights the importance of assessing pregnant patients with essential thrombocythemia according to their risk stratification. Specifically, risk assessments for potential pregnancy complications should take into account advanced maternal age and a previous history of thrombosis. Patients with essential thrombocythemia should be encouraged to participate in preconception counseling for risk assessment and to initiate prophylactic anticoagulation as soon as possible.
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Affiliation(s)
- Xin Kang
- Department of Obstetrics and Gynecology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
- Shanghai Key Laboratory of Gynecologic Oncology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Shibin Hong
- Department of Obstetrics and Gynecology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
- Shanghai Key Laboratory of Gynecologic Oncology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Chengxi Tan
- Department of Ophthalmology, University of California, San Francisco, 1550 4th Street, San Francisco, CA, 94143-2811, USA
| | - Wen Di
- Department of Obstetrics and Gynecology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.
- Shanghai Key Laboratory of Gynecologic Oncology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.
| | - Ning Zhang
- Department of Obstetrics and Gynecology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.
- Shanghai Key Laboratory of Gynecologic Oncology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.
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Perego M, Calloni M, Taino A, Cogliati C, Gidaro A. Letter in response to a recent article by Zhang et al. []. Thromb Res 2024; 236:85-87. [PMID: 38402646 DOI: 10.1016/j.thromres.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/31/2023] [Accepted: 02/05/2024] [Indexed: 02/27/2024]
Affiliation(s)
- Martina Perego
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy.
| | - Maria Calloni
- Internal Medicine, L. Sacco Hospital, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Alba Taino
- Internal Medicine, L. Sacco Hospital, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Chiara Cogliati
- Internal Medicine, L. Sacco Hospital, ASST Fatebenefratelli-Sacco, Milan, Italy; Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Antonio Gidaro
- Internal Medicine, L. Sacco Hospital, ASST Fatebenefratelli-Sacco, Milan, Italy
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11
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Cohen O, Kenet G, Levy-Mendelovich S, Tzoran I, Brenner B, De Ancos C, López-Miguel P, Varona JF, Catella J, Monreal M. Outcomes of venous thromboembolism in patients with inherited thrombophilia treated with direct oral anticoagulants: insights from the RIETE registry. J Thromb Thrombolysis 2024; 57:710-720. [PMID: 38491267 DOI: 10.1007/s11239-024-02957-4] [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] [Accepted: 02/06/2024] [Indexed: 03/18/2024]
Abstract
While direct oral anticoagulants (DOACs) are frequently used to treat venous thromboembolism (VTE), the outcomes of patients with inherited thrombophilia (IT) receiving DOACs for VTE remain understudied. We used data from the international RIETE registry to compare the rates of VTE recurrences, major bleeding, and mortality during anticoagulant treatment in VTE patients with and without IT, grouped by the use of DOACs or standard anticoagulant therapy. Among 103,818 enrolled patients, 21,089 (20.3%) were tested for IT, of whom 8422 (39.9%) tested positive: Protein C deficiency 294, Protein S deficiency 726, Antithrombin deficiency 240, Factor V Leiden 2248, Prothrombin gene mutation 1434, combined IT 3480. Overall, 14,189 RIETE patients (6.2% with IT) received DOACs, and 89,629 standard anticoagulation (8.4% with IT), mostly with heparins followed by vitamin K antagonists. Proportions of patients receiving DOACs did not differ between IT-positive and IT-negative patients. Rates of VTE recurrence on anticoagulant treatment were highest in patients with AT deficiency (P < 0.01). Rates of on-treatment major bleeding and all-cause mortality were lowest among patients with Factor V Leiden (FVL) or PT G20210A mutations, compared with patients who tested negative. Patients with IT who received DOACs had lower rates of major bleeding than those receiving standard anticoagulation. Excluding FVL and Protein S deficiency, patients with IT had lower rates of VTE recurrence with DOACs than with standard anticoagulation. DOACs are equally safe and effective in VTE patients with IT, with lower bleeding rates than those on standard anticoagulation.
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Affiliation(s)
- Omri Cohen
- National Hemophilia Center & Institute of Thrombosis & Hemostasis, Sheba Medical Center, Tel Hashomer, Derech Sheba 2, 52621, Ramat Gan, Israel.
- Amalia Biron Research Institute of Thrombosis and Hemostasis, School of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Department of Medicine and Surgery, University of Insubria, Varese, Italy.
| | - Gili Kenet
- National Hemophilia Center & Institute of Thrombosis & Hemostasis, Sheba Medical Center, Tel Hashomer, Derech Sheba 2, 52621, Ramat Gan, Israel
- Amalia Biron Research Institute of Thrombosis and Hemostasis, School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sarina Levy-Mendelovich
- National Hemophilia Center & Institute of Thrombosis & Hemostasis, Sheba Medical Center, Tel Hashomer, Derech Sheba 2, 52621, Ramat Gan, Israel
- Amalia Biron Research Institute of Thrombosis and Hemostasis, School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Inna Tzoran
- Department of Hematology and Bone Marrow Transplantation, Rambam Healthcare Campus, Haifa, Israel
| | - Benjamin Brenner
- Department of Hematology and Bone Marrow Transplantation, Rambam Healthcare Campus, Haifa, Israel
| | - Cristina De Ancos
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Patricia López-Miguel
- Department of Pneumonology, Hospital General Universitario de Albacete, Albacete, Spain
| | - José F Varona
- Department of Internal Medicine, Hospital Universitario HM Montepríncipe, HM Hospitales, Boadilla del Monte, Madrid, Spain
| | - Judith Catella
- Department of Internal Medicine, Hôpital Édouard Herriot, Lyon, France
| | - Manuel Monreal
- Faculty of Health Sciences, Universidad Católica San Antonio de Murcia (UCAM), El Centro de Investigación Biomédica en Red Enfermedades Respiratorias (CIBERS), Madrid, Spain
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Comín Colet J, Sicras Mainar A, Salazar-Mendiguchía J, Isabel del Campo Alonso M, Echeto A, Vilanova Larena D, Delgado Sánchez O. Influence of the COVID-19 pandemic on patients receiving oral anticoagulants for the treatment of non-valvular atrial fibrillation. Int J Cardiol Heart Vasc 2024; 51:101358. [PMID: 38371309 PMCID: PMC10869899 DOI: 10.1016/j.ijcha.2024.101358] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/23/2024] [Accepted: 02/04/2024] [Indexed: 02/20/2024]
Abstract
Background Frequent monitoring of patients declined during the COVID-19 pandemic, harming patients with chronic diseases who critically needed correct monitoring. We evaluated the impact of the COVID-19 pandemic in patients with non-valvular atrial fibrillation (NVAF) receiving treatment with vitamin K antagonists (VKA) or non-vitamin K antagonist oral anticoagulants (NOAC) in clinical practice in Spain. Methods This observational, retrospective study analyzed prevalent patients treated with NOAC/VKA on 14/03/2019 (pre-COVID-19 period) and 14/03/2020 (COVID-19 period), who were followed up to 12 months. The study also considered incident patients who started treatment with NOAC/VKA between 15/03/2019 and 13/03/2020 (pre-COVID-19 period) and from 15/03/2020 to 13/03/2021 (COVID-19 period). Demographic characteristics, comorbidities, effectiveness, treatment patterns, and healthcare resource utilization were considered. Results Prevalent patients amounted to 12,336 and 13,342 patients, whereas 1,612 and 1,602 incident patients were included in the pre-COVID-19 and COVID-19 periods, respectively. Prevalent patients treated with VKA had more strokes, thromboembolism, and major bleeding compared to those receiving NOAC, particularly during the COVID-19 period. NOAC patients had a 12 % lower risk of death than those on treatment with VKA (Hazard ratio = 0.88 [95 % CI: 0.81 - 0.95], p = 0.033). In addition, VKA patients were less persistent after 12 months than NOAC patients (pre-COVID-19 period: 52.1 % vs. 78.9 %, p < 0.001; COVID-19 period: 49.2 % vs. 80.3 %, p < 0.001), and required more healthcare visits and hospitalizations than those on treatment with NOAC. Conclusion Compared to VKA, NOAC seems to have reduced the incidence of severe events and the use of healthcare resources for NVAF, particularly during the pandemic.
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Affiliation(s)
- Josep Comín Colet
- Cardiology Department, Hospital Universitario de Bellvitge (IDIBELL) and CIBERCV, 08907 Hospitalet del Llobregat, Spain
| | | | | | | | - Ainara Echeto
- Bristol Myers Squibb, Madrid, Spain, 28050 Madrid, Spain
| | - David Vilanova Larena
- Real World Evidence and Outcomes Research, Bristol Myers Squibb, 28050 Madrid, Spain
| | - Olga Delgado Sánchez
- Pharmacy Department, Hospital Universitario Son Espases, IdISBa, 07120 Palma de Mallorca, Spain
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Alshihab S, Mohamed Ibrahim MI, Hadi MA, Syed A, Arabi A, Al-Qahtani A, Almujalli H, Rafie I, Al-Kuwari MG, Kandy M, Al-Zaidan M. Evaluation of warfarin management in primary health care centers in Qatar: A retrospective cross-sectional analysis of the national dataset. Curr Probl Cardiol 2024; 49:102427. [PMID: 38301919 DOI: 10.1016/j.cpcardiol.2024.102427] [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] [Received: 01/23/2024] [Accepted: 01/29/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Warfarin management is associated with severe complications, highlighting the critical need to evaluate the quality of its administration. OBJECTIVES To evaluate the quality of warfarin management for patients managed in primary healthcare centers by measuring the percentage of Time in Therapeutic Range (TTR) and the proportion of extreme out-of-range international normalized ratio (INR) values. METHODS This is a cross-sectional study. Data was extracted from a national dataset retrieved from the largest primary healthcare provider in Qatar. TTR was calculated using the traditional method. Inferential and descriptive analyses were performed as appropriate. RESULTS Four hundred ninety-four patients met the inclusion criteria. The mean (SD) TTR was 45.3 % (17.5). This was significantly lower than the recommended cutoff value (P<0.001). Extreme out-of-range INR accounted for 24.7 % of total INR readings. CONCLUSIONS The management of patients taking warfarin in Qatar is inadequate. More effective strategies are warranted to ensure safe and effective therapy.
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Affiliation(s)
- Safaa Alshihab
- Clinical Pharmacy and Practice Department, College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | | | - Muhammad Abdul Hadi
- Clinical Pharmacy and Practice Department, College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Abdullah Syed
- Primary Health Care Corporation, Clinical Pharmacy and Practice Department, College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Abdulrahman Arabi
- Heart Hospital, Hamad Medical Corporation, Clinical Pharmacy and Practice Department, College of Pharmacy, QU Health, Qatar, Doha, Qatar
| | - Awad Al-Qahtani
- Heart Hospital, Hamad Medical Corporation, Clinical Pharmacy and Practice Department, College of Pharmacy, QU Health, Qatar, Doha, Qatar
| | - Hanan Almujalli
- Primary Health Care Corporation, Clinical Pharmacy and Practice Department, College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Ihsan Rafie
- Heart Hospital, Hamad Medical Corporation, Clinical Pharmacy and Practice Department, College of Pharmacy, QU Health, Qatar, Doha, Qatar
| | - Mohamed Gaith Al-Kuwari
- Primary Health Care Corporation, Clinical Pharmacy and Practice Department, College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Mujeeb Kandy
- Primary Health Care Corporation, Clinical Pharmacy and Practice Department, College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Manal Al-Zaidan
- Primary Health Care Corporation, Clinical Pharmacy and Practice Department, College of Pharmacy, QU Health, Qatar University, Doha, Qatar.
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Momic J, Yassin N, Kim MY, Walser E, Smith S, Ball I, Moffat B, Parry N, Vogt K. Antiplatelets versus anticoagulants in the treatment of blunt cerebrovascular injury (BCVI) - A systematic review and meta-analysis. Injury 2024; 55:111485. [PMID: 38452701 DOI: 10.1016/j.injury.2024.111485] [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: 01/18/2024] [Revised: 02/20/2024] [Accepted: 02/25/2024] [Indexed: 03/09/2024]
Abstract
INTRODUCTION Blunt cerebrovascular injury (BCVI) occurs in 1-3% of blunt traumas and is associated with stroke, disability, and mortality if unrecognized and untreated. Early detection and treatment are imperative to reduce the risk of stroke, however, there is significant variation amongst centers and trauma care providers in the specific medical management strategy used. This study compares antiplatelets vs. anticoagulants to determine BCVI-related stroke risk and bleeding complications to better understand the efficacy and safety of various treatment strategies. METHODS A systematic review of MEDLINE, Embase, and Cochrane CENTRAL databases was conducted with the assistance of a medical librarian. The search was supplemented with manual review of the literature. Included studies reported treatment-stratified risk of stroke following BCVI. All studies were screened independently by two reviewers, and data was extracted in duplicate. Meta-analysis was conducted using pooled estimates of odds ratios (OR) with a random-effects model using Mantel-Haenszel methods. RESULTS A total of 3315 studies screened yielded 39 studies for inclusion, evaluating 6552 patients (range 8 - 920 per study) with a total of 7643 BCVI. Stroke rates ranged from 0% to 32.8%. Amongst studies included in the meta-analysis, there were a total of 405 strokes, with 144 (35.5%) occurring on therapy, for a total stroke rate of 4.5 %. Meta-analysis showed that stroke rate after BCVI was lower for patients treated with antiplatelets vs. anticoagulants (OR 0.57; 95% CI 0.33-0.96, p = 0.04); when evaluating only the 9 studies specifically comparing ASA to heparin, the stroke rate was similar between groups (OR 0.43; 95% CI 0.15-1.20, p = 0.11). Eleven studies evaluated bleeding complications and demonstrated lower risk of bleeding with antiplatelets vs. anticoagulants (OR 0.29; 95% CI 0.13-0.63, p = 0.002); 5 studies evaluating risk of bleeding complications with ASA vs. heparin showed lower rates of bleeding complications with ASA (OR 0.16; 95% CI 0.04-0.58, p = 0.005). CONCLUSIONS Treatment of patients with BCVI with antiplatelets is associated with lower risks of stroke and bleeding complications compared to treatment with anticoagulants. Use of ASA vs. heparin specifically was not associated with differences in stroke risk, however, patients treated with ASA had fewer bleeding complications. Based on this evidence, antiplatelets should be the preferred treatment strategy for patients with BCVI.
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Affiliation(s)
- Jovana Momic
- Division of General Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada.
| | - Nouf Yassin
- Division of General Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada
| | - Mella Y Kim
- Schulich School of Medicine and Dentistry, University of Western Ontario, 1151 Richmond St., London, ON, N6A 3K7, Canada
| | - Eric Walser
- Division of General Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada
| | - Shane Smith
- Division of General Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada; Division of Vascular Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada
| | - Ian Ball
- Department of Medicine, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada
| | - Bradley Moffat
- Division of General Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada
| | - Neil Parry
- Division of General Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada
| | - Kelly Vogt
- Division of General Surgery, London Health Sciences Center, 800 Commissioner's Rd. East, London, ON, N6A 5W9, Canada
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15
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Dix C, McFadyen JD, Tran HA. Exploring the effects of Factor Xa inhibitors on thrombin generation in people with haemophilia. Thromb Res 2024; 237:148-153. [PMID: 38603817 DOI: 10.1016/j.thromres.2024.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 02/29/2024] [Accepted: 03/28/2024] [Indexed: 04/13/2024]
Abstract
Optimal management of cardiovascular disease (CVD) in people with haemophilia (PWH) is a growing issue, given the continuing improvement in life expectancy among PWH. The evolving treatment paradigms targeting higher trough levels and the advent of non-factor replacement therapies (NFRT) means much of the 'protection' PWH were thought to have against CVD may be lost. There is a paucity of evidence regarding the safety of using anticoagulants in PWH. We designed a study assessing the thrombin generation (TG) of PWH of different severities and treatments, compared to non-haemophilia patients receiving a Factor Xa (FXa) inhibitor (apixaban or rivaroxaban), healthy controls, and assessing TG parameters of adding FXa inhibitor to the plasma of PWH receiving emicizumab prophylaxis. In total, 40 patients were included. TG was initiated with 5pM tissue factor (TF) using the calibrated automated thrombinoscope. Compared to those with mild haemophilia, patients receiving a FXa inhibitor had higher endogenous thrombin potential (ETP) (1278.42 vs 1831.36) and velocity index (40.71 vs 112.56), but both had a similar peak height (154.0 vs 262.63) and time to peak (both 5.83). People with severe haemophilia receiving emicizumab had significantly improved TG parameters compared to those not receiving emicizumab - ETP 1678.11 vs 809.96 and peak height 233.8 vs 92.05; however, when FXa inhibitor was added their TG parameters deteriorated to the severe haemophilia range (ETP 1179.60 and peak height 103.05). TG may provide additional useful information regarding the use of anticoagulants in PWH.
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Affiliation(s)
- Caroline Dix
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - James D McFadyen
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Victoria, Australia; Atherothrombosis and Vascular Biology Laboratory, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, Victoria, Australia; Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Huyen A Tran
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Victoria, Australia; Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia.
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Suda S, Iguchi Y, Yagita Y, Kanzawa T, Okubo S, Fujimoto S, Kono Y, Kimura K. High brain natriuretic peptide level is associated with severe stroke in patients taking oral anticoagulants: A sub-analysis of the PASTA registry study. J Neurol Sci 2024; 458:122935. [PMID: 38368640 DOI: 10.1016/j.jns.2024.122935] [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] [Received: 12/07/2023] [Revised: 02/02/2024] [Accepted: 02/13/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND Brain natriuretic peptides (BNP) are an important diagnostic and prognostic marker in patients with heart failure. However, the relationship between BNP levels and stroke severity in patients with atrial fibrillation (AF) remains unelucidated. In this study, we aimed to investigate the association between stroke severity at admission and BNP levels. METHODS In this prospective observational study, we used data from 513 patients with AF and acute ischemic stroke treated with oral anticoagulants (OAC) registered in the Multicenter Prospective Analysis of Stroke Patients Taking Oral Anticoagulants study. The patients were divided into two groups: high-BNP (≥200 pg/mL) and low-BNP level (<200 pg/mL) groups. We compared the clinical characteristics between the two groups and determined the effect of BNP levels on stroke severity on admission. RESULTS Among the 513 enrolled patients, 248 (females, n = 30; median age, 82 years) and 265 (females, n = 76; median age, 71 years) were assigned to the high- and low-BNP level groups, respectively. The high-BNP level group had a higher proportion of patients with severe stroke (National Institutes of Health Stroke Scale score, ≥10) on admission (49.2% vs. 32.8%, p = 0.002) and major vessel occlusion (57.5% vs. 39.2%, p < 0.0001) than that had by the low-BNP level group. Multivariate analysis showed that high BNP level was independently associated with severe stroke on admission (odds ratio 1.07, 95% confidence interval 1.00-1.15; p = 0.0478). CONCLUSIONS High BNP level compared with low BNP level was associated with severe stroke and major vessel occlusion, even before OAC treatment.
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Affiliation(s)
- Satoshi Suda
- Department of Neurology, Nippon Medical School, Tokyo, Japan; Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Saitama, Japan.
| | - Yasuyuki Iguchi
- Department of Neurology, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshiki Yagita
- Department of Stroke Medicine, Kawasaki Medical School, Okayama, Japan
| | - Takao Kanzawa
- Department of Stroke Medicine, Institute of Brain and Blood Vessels, Mihara Memorial Hospital, Gunma, Japan; Institute of HM network, Gunyukai Isesaki Clinic, Gunma, Japan
| | - Seiji Okubo
- Department of Cerebrovascular Medicine, NTT Medical Center Tokyo, Tokyo, Japan
| | - Shigeru Fujimoto
- Division of Neurology, Department of Medicine, Jichi Medical University Hospital, Tochigi, Japan
| | - Yu Kono
- Department of Neurology, Fuji City General Hospital, Shizuoka, Japan
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
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Chatani R, Yamashita Y, Morimoto T, Muraoka N, Shioyama W, Shibata T, Nishimoto Y, Ogihara Y, Doi K, Oi M, Shiga T, Sueta D, Kim K, Tanabe Y, Koitabashi N, Takada T, Ikeda S, Nakagawa H, Mitsuhashi T, Shoji M, Sakamoto J, Hisatake S, Ogino Y, Fujita M, Nakanishi N, Dohke T, Hiramori S, Nawada R, Kaneda K, Mushiake K, Yamamoto H, Kadota K, Ono K, Kimura T. Home Treatment for Active Cancer Patients With Low-Risk Pulmonary Embolism - A Predetermined Companion Report From the ONCO PE Trial. Circ J 2024:CJ-24-0004. [PMID: 38462535 DOI: 10.1253/circj.cj-24-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
BACKGROUND Patients with appropriately selected low-risk pulmonary embolism (PE) can be treated at home, although it has been controversial whether applies to patients with cancer, who are considered not to be at low risk.Methods and Results: The current predetermined companion report from the ONCO PE trial evaluated the 3-month clinical outcomes of patients with home treatment and those with in-hospital treatment. The ONCO PE trial was a multicenter, randomized clinical trial among 32 institutions in Japan investigating the optimal duration of rivaroxaban treatment in cancer-associated PE patients with a score of 1 using the simplified version of the Pulmonary Embolism Severity Index (sPESI). Among 178 study patients, there were 66 (37%) in the home treatment group and 112 (63%) in the in-hospital treatment group. The primary endpoint of a composite of PE-related death, recurrent venous thromboembolism (VTE) and major bleeding occurred in 3 patients (4.6% [0.0-9.6%]) in the home treatment group and in 2 patients (1.8% [0.0-4.3%]) in the in-hospital treatment group. In the home treatment group, there were no cases of PE-related death or recurrent VTE, but major bleeding occurred in 3 patients (4.6% [0.0-9.6%]), and 2 patients (3.0% [0.0-7.2%]) required hospitalization due to bleeding events. CONCLUSIONS Active cancer patients with PE of sPESI score=1 could be potential candidates for home treatment.
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Affiliation(s)
- Ryuki Chatani
- Department of Cardiovascular Medicine, Kurashiki Central Hospital
| | - Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Nao Muraoka
- Division of Cardiology, Shizuoka Cancer Center
| | - Wataru Shioyama
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | - Tatsuhiro Shibata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine
| | | | - Yoshito Ogihara
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | - Kosuke Doi
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Maki Oi
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | - Taro Shiga
- Department of Onco-Cardiology/Cardiovascular Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research
| | - Daisuke Sueta
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Kitae Kim
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Yasuhiro Tanabe
- Department of Cardiology, St. Marianna University School of Medicine
| | - Norimichi Koitabashi
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine
| | - Takuma Takada
- Department of Cardiology, Tokyo Women's Medical University
| | - Satoshi Ikeda
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences
| | | | | | - Masaaki Shoji
- Department of Cardiovascular Medicine, National Cancer Center Hospital
| | | | - Shinji Hisatake
- Division of Cardiovascular Medicine, Toho University Omori Medical Center
| | - Yutaka Ogino
- Department of Cardiology, Yokohama City University
| | - Masashi Fujita
- Department of Onco-Cardiology, Osaka International Cancer Institute
| | - Naohiko Nakanishi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | | | | | - Ryuzo Nawada
- Department of Cardiology, Shizuoka City Shizuoka Hospital
| | - Kazuhisa Kaneda
- Department of Cardiovascular Medicine, Mitsubishi Kyoto Hospital
| | | | - Hiromi Yamamoto
- Department of Cardiovascular Medicine, Kurashiki Central Hospital
| | - Kazushige Kadota
- Department of Cardiovascular Medicine, Kurashiki Central Hospital
| | - Koh Ono
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
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18
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Buchtele N, Levy JH. Between a rock and a hard place: anticoagulation management for ECMO. Med Klin Intensivmed Notfmed 2024:10.1007/s00063-024-01116-0. [PMID: 38457000 DOI: 10.1007/s00063-024-01116-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/01/2024] [Indexed: 03/09/2024]
Abstract
Anticoagulation is an essential component of optimal extracorporeal membrane oxygenation (ECMO) management. Unfractionated heparin is still the anticoagulant of choice in most centers due to longstanding familiarity with the agent. Disadvantages include alterations in drug responses due to its capability to bind multiple heparin-binding proteins that compete with antithrombin and the potential for heparin-induced thrombocytopenia. In such cases, direct thrombin inhibitors are the treatment of choice but pose difficulties in monitoring due to the limited experience and target ranges for non-aPTT-guided management (aPTT: activated partial thromboplastin time). The current trend toward low-dose anticoagulation, especially for venovenous ECMO, is supported by data associating bleeding complications with mortality but not thromboembolic events, which include circuit thrombosis. However, only prospective data will provide appropriate answers to how to individualize anticoagulation, transfusions, and bleeding management which is currently only supported by expert opinion. Empiric therapy for ECMO patients based on laboratory coagulation alone should always be critically questioned. In summary, only collaboration and future studies of coagulation management during ECMO will help us to make this life-saving therapy that has become part of daily life of the intensivist even safer and more effective. Until then, a fundamental understanding of coagulation and bleeding management, as well as pearls and pitfalls of monitoring, is essential to optimize anticoagulation during ECMO. This article is freely available.
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Affiliation(s)
- Nina Buchtele
- Intensive Care Unit 13i2, Department of Medicine I, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, NC, USA
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Presume J, Ferreira J, Ribeiras R. Factor XI Inhibitors: A New Horizon in Anticoagulation Therapy. Cardiol Ther 2024; 13:1-16. [PMID: 38306010 PMCID: PMC10899133 DOI: 10.1007/s40119-024-00352-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 01/10/2024] [Indexed: 02/03/2024] Open
Abstract
Anticoagulation therapy has undergone significant evolution, marked by the emergence of direct oral anticoagulants with distinct advantages. Despite these advancements, challenges persist in managing residual thrombotic and bleeding risks, particularly among vulnerable populations. The pursuit of alternative drugs has honed in on factor XI/XIa inhibitors. This comprehensive review delves into several key aspects regarding this new target: (i) the role of factor XI in the coagulation cascade; (ii) the genetic evidence and pathophysiologic rationale supporting factor XI inhibition as a therapeutic target; (iii) an exploration of the various types of factor XI/XIa inhibitors currently under investigation; (iv) potential applications of these medications, spanning thromboprophylaxis after orthopedic surgery, stroke prevention in atrial fibrillation, secondary prevention after acute coronary syndrome, non-cardioembolic stroke, thromboprophylaxis after foreign material implantation, end-stage renal disease, and patients with cancer; and (v) an overview of ongoing studies, recent findings, and the future trajectory of research into these drugs.
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Affiliation(s)
- João Presume
- Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo Dos Santos, Carnaxide, 2790-134, Lisbon, Portugal
- Comprehensive Health Research Centre, NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Jorge Ferreira
- Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo Dos Santos, Carnaxide, 2790-134, Lisbon, Portugal
| | - Regina Ribeiras
- Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo Dos Santos, Carnaxide, 2790-134, Lisbon, Portugal.
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20
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Abdulrehman J, Harrigan A, Simard C, Tagalakis V, Shivakumar S. TRanEXamic acid to decrease Heavy Menstrual Bleeding in individuals anticoagulated for venous thromboembolism (T-REX HMB): Health care practitioner survey. Thromb Res 2024; 235:11-14. [PMID: 38262288 DOI: 10.1016/j.thromres.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 01/02/2024] [Accepted: 01/10/2024] [Indexed: 01/25/2024]
Affiliation(s)
- Jameel Abdulrehman
- Division of Hematology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada.
| | - Amye Harrigan
- Division of Hematology, Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Canada
| | - Camille Simard
- Department of Medicine and Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, Canada
| | - Vicky Tagalakis
- Department of Medicine and Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, Canada
| | - Sudeep Shivakumar
- Department of Medicine, Nova Scotia Health, Dalhousie University, Halifax, Canada
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21
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Salmasi S, Safari A, De Vera MA, Högg T, Lynd LD, Koehoorn M, Barry AR, Andrade JG, Deyell MW, Rush KL, Zhao Y, Loewen P. Adherence to direct or vitamin K antagonist oral anticoagulants in patients with atrial fibrillation: a long-term observational study. J Thromb Thrombolysis 2024; 57:437-444. [PMID: 38103148 PMCID: PMC10961264 DOI: 10.1007/s11239-023-02921-8] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/01/2023] [Indexed: 12/17/2023]
Abstract
Our objectives were to measure long-term adherence to oral anticoagulants (OACs) in patients with atrial fibrillation (AF) and to identify patient factors associated with adherence. Using linked, population-based administrative data from British Columbia, Canada, an incident cohort of adults prescribed OACs for AF was identified. We calculated the proportion of days covered (PDC) as a time-dependent covariate for each 90-day window from OAC initiation until the end of follow-up. Associations between patient attributes and adherence were assessed using generalized mixed effect linear regression models. 30,264 patients were included. Mean PDC was 0.69 (SD 0.28) over a median follow-up of 6.7 years. 54% of patients were non-adherent (PDC < 0.8). After controlling for confounders, factors positively associated with adherence were number of drug class switches, history of stroke or transient ischemic attack, history of vascular disease, time since initiation, and age. Age > 75 years at initiation, polypharmacy (among VKA users only), and receiving DOAC (vs. VKA) were negatively associated with adherence. PDC decreased over time for VKA users and increased for DOAC users. Over half of AF patients studied were, on average, nonadherent to OAC therapy and missed 32% of their doses. Several patient factors were associated with higher or lower adherence, and adherence to VKA declined during therapy while DOAC adherence increased slightly over time. To min im ize the risk stroke, adherence-supporting interventions are needed for all patients with AF, particularly those aged > 75 years, those with prior stroke or vascular disease, VKA users with polypharmacy, and DOAC recipients.
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Affiliation(s)
- Shahrzad Salmasi
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver Campus, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Abdollah Safari
- Department of Mathematics, Statistics, and Computer Science, University of Tehran, Tehran, Iran
- Department of Data Analytics, Statistics and Informatics, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Mary A De Vera
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver Campus, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care Research Institute, Vancouver, BC, Canada
| | - Tanja Högg
- Department of Statistics, University of British Columbia, Vancouver, BC, Canada
| | - Larry D Lynd
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver Campus, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care Research Institute, Vancouver, BC, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Mieke Koehoorn
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Arden R Barry
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver Campus, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Jason G Andrade
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- UBC Center for Cardiovascular Innovation, Vancouver, BC, Canada
| | - Marc W Deyell
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Kathy L Rush
- School of Nursing, Faculty of Health and Social Development, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Yinshan Zhao
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Peter Loewen
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver Campus, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada.
- UBC Center for Cardiovascular Innovation, Vancouver, BC, Canada.
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22
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Wang C, Shi C, Guo R, Wu T. Comparison of clinical outcomes among patients with isolated axial vs muscular calf vein thrombosis: A systematic review and meta-analysis. J Vasc Surg Venous Lymphat Disord 2024; 12:101727. [PMID: 38043681 DOI: 10.1016/j.jvsv.2023.101727] [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] [Received: 09/02/2023] [Revised: 10/14/2023] [Accepted: 11/05/2023] [Indexed: 12/05/2023]
Abstract
OBJECTIVE Thrombi in the axial calf veins have quite different anatomical and physiological characteristics from that in the muscular calf veins, but their treatment was usually addressed in the same manner. We performed a meta-analysis of randomized and cohort studies to compare clinical outcomes among patients with isolated axial vs muscular calf deep vein thrombosis (DVT). METHODS Recurrent venous thromboembolism (VTE) was selected as the primary outcome. Resolution, proximal propagation of calf DVT, pulmonary embolism (PE), major bleeds, and clinically relevant non-major bleeds were separately analyzed as secondary outcomes. Data were pooled and compared with risk ratio (RR) and 95% confidence interval (CI). RESULTS Thirteen studies, consisting of 4889 patients, met the inclusion criteria and were included for analysis. A greater rate of recurrent VTE (FE model: RR, 1.23; 95% CI, 1.00-1.53; I2 = 29%), resolution (FE model: RR, 1.32; 95% CI, 1.01-1.72; I2 = 31%), proximal propagation (FE model: RR, 1.63; 95% CI, 1.10-2.41; I2 = 40%), and PE (FE model: RR, 2.79; 95% CI, 1.31-5.95; I2 = 0%) in the axial group compared with the muscular group. There was no difference in the pooled estimates for major bleeds (FE model: RR, 1.09; 95% CI, 0.61-1.95; I2 = 0%), and clinically relevant non-major bleeds (FE model: RR, 1.80; 95% CI, 0.93-3.48) in the axial and muscular arms. CONCLUSIONS Patients with calf DVT limited to muscular veins might have a lower rate of recurrent VTE, resolution, proximal propagation, and PE vs those with axial calf vein involvement and exhibited similar safety outcomes.
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Affiliation(s)
- Chunjiang Wang
- Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Can Shi
- Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Ren Guo
- Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Tian Wu
- Third Xiangya Hospital, Central South University, Changsha, Hunan, China; Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, Hunan, China.
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23
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Marcelin C, Thouveny F, Goyault G, Del Giudice C, Loffroy R, Sapoval M, Douane F, Rodiere M, Crombé A, Le Bras Y. Ilio-femoral venous stenting for post-thrombotic syndrome in women of childbearing age: efficacy and impact of pregnancy-a multi-center study by the French Society of Cardiovascular Imaging. Eur Radiol 2024; 34:1567-1577. [PMID: 37653047 DOI: 10.1007/s00330-023-10188-z] [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] [Received: 05/05/2023] [Revised: 06/07/2023] [Accepted: 07/07/2023] [Indexed: 09/02/2023]
Abstract
OBJECTIVE We investigated the efficacy of iliofemoral venous stenting in women of childbearing age treated for post-thrombotic syndrome (PTS) and assessed the influence of pregnancy on stent occlusion. METHODS A retrospective analysis was conducted on women of childbearing age who underwent endovascular stenting for PTS due to chronic iliocava occlusion across 15 centers from 2009 to 2020. The study assessed pregnancy rates, primary patency rates, secondary patency rates, and clinical efficacy using the Villalta score for PTS severity and the Chronic Venous Disease Quality of Life Questionnaire - version 20 (CIVIQ-20), 6-12 months after the procedure. The impact of pregnancy on stent occlusion was analyzed using classical and multi-state survival analyses. Prophylactic low-molecular-weight heparin or fondaparinux was administered to patients during pregnancy until 6 weeks post-partum. RESULTS In total, 211 women with PTS underwent endovascular stenting, with a median age of 31 years (range: 16-42). Following recanalization, significant improvements were observed in the Villalta score (p < 0.0001) and the CIVIQ-20 score (p < 0.0001). Thirty-seven (17.6%) women became pregnant and 49 (23.2%) experienced stent occlusions. The 1-year and 5-year occlusion-free survival probabilities were 80.6% (95% confidence interval [CI]: 75.1-86.4%) and 66.6% (95% CI: 57.4-77.4%), respectively. There was no significant association between pregnancy and stent occlusion-free survival (hazard ratio = 1.00 [95% CI: 0.11-8.92], p = 0.9930). CONCLUSION Iliofemoral venous stenting in women of childbearing age was an effective treatment for post-thrombotic syndrome, and it did not increase the risk for stent occlusion during pregnancy when accompanied by appropriate anticoagulation. CLINICAL RELEVANCE STATEMENT This study demonstrates that pregnancy following iliofemoral venous stenting for post-thrombotic syndrome does not elevate the risk for stent occlusion. KEY POINTS • The severity of post-thrombotic syndrome and the quality of life, as measured using the Villalta score and Chronic Venous Disease Quality of Life Questionnaire - version 20, respectively, showed significant improvements 6-12 months after iliofemoral venous stenting. • The occurrence of pregnancy after recanalization in women of childbearing age did not lead to a significant increase in the risk for stent occlusion.
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Affiliation(s)
- Clément Marcelin
- Department of Diagnostic and Interventional Radiology, Hôpital Pellegrin, 2 Place Amélie Raba-Léon, 33000, Bordeaux, France.
- Bordeaux Institute of Oncology, BRIC U1312, INSERM, Université de Bordeaux, Bâtiment Bordeaux Biologie Santé, 2 Rue Dr Hoffmann Martinot, 33000, Bordeaux, France.
| | | | - Gilles Goyault
- Department of Vascular and Oncological Interventional Radiology, Institut Cardiovasculaire de Strasbourg (ICS), Clinique Rhena, Strasbourg, France
| | | | - Romaric Loffroy
- Department of Vascular Medicine and Interventional Radiology, François-Mitterrand University Hospital, Dijon, France
| | - Marc Sapoval
- Service d'imagerie Diagnostique Et Thérapeutique de L'adulte, HEGP, Paris, France
| | - Frederic Douane
- Department of Radiology, Nantes University Hospital, University of Medicine of Nantes, Nantes, France
| | - Mathieu Rodiere
- Department of Imaging and Interventional Radiology, Grenoble-Alpes University Hospital (CHUGA), Grenoble, France
| | - Amandine Crombé
- Department of Diagnostic and Interventional Radiology, Hôpital Pellegrin, 2 Place Amélie Raba-Léon, 33000, Bordeaux, France
- Models in Oncology (MONC) Team, UMR 5251 &, INRIA Bordeaux Sud-Ouest, CNRS, Bordeaux University, F-33400, Talence, France
| | - Yann Le Bras
- Department of Diagnostic and Interventional Radiology, Hôpital Pellegrin, 2 Place Amélie Raba-Léon, 33000, Bordeaux, France
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Kang SJ, Tae CH, Bang CS, Shin CM, Jeong YH, Choi M, Hwang JH, Saito Y, Chiu PWY, Rerknimitr R, Khor C, Khien VV, Choi KD, Shim KN, Song GA, Lee OY. International Digestive Endoscopy Network consensus on the management of antithrombotic agents in patients undergoing gastrointestinal endoscopy. Clin Endosc 2024; 57:141-157. [PMID: 38556472 PMCID: PMC10984749 DOI: 10.5946/ce.2024.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/04/2024] [Accepted: 02/09/2024] [Indexed: 04/02/2024] Open
Abstract
Antithrombotic agents, including antiplatelet agents and anticoagulants, are widely used in Korea because of the increasing incidence of cardiocerebrovascular disease and the aging population. The management of patients using antithrombotic agents during endoscopic procedures is an important clinical challenge. The clinical practice guidelines for this issue, developed by the Korean Society of Gastrointestinal Endoscopy, were published in 2020. However, new evidence on the use of dual antiplatelet therapy and direct anticoagulant management has emerged, and revised guidelines have been issued in the United States and Europe. Accordingly, the previous guidelines were revised. Cardiologists were part of the group that developed the guideline, and the recommendations went through a consensus-reaching process among international experts. This guideline presents 14 recommendations made based on the Grading of Recommendations, Assessment, Development, and Evaluation methodology and was reviewed by multidisciplinary experts. These guidelines provide useful information that can assist endoscopists in the management of patients receiving antithrombotic agents who require diagnostic and elective therapeutic endoscopy. It will be revised as necessary to cover changes in technology, evidence, or other aspects of clinical practice.
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Affiliation(s)
- Seung Joo Kang
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea
| | - Chung Hyun Tae
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Chang Seok Bang
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Cheol Min Shin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Young-Hoon Jeong
- CAU Thrombosis and Biomarker Center, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong; Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Miyoung Choi
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
| | - Joo Ha Hwang
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Philip Wai Yan Chiu
- Division of Upper GI and Metabolic Surgery, Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Christopher Khor
- Department of Gastroenterology and Hepatology, Singapore General Hospital and Duke-NUS Medical School, Singapore, Singapore
| | - Vu Van Khien
- Departments of GI Endoscopy, 108 Central Hospital, Hanoi, Vietnam
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Nam Shim
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Geun Am Song
- Department of Internal Medicine, Pusan National University Hospital, Pusan National University College of Medicine and Biomedical Research Institute, Busan, Korea
| | - Oh Young Lee
- Department of Internal Medicine, Hanyang University School of Medicine, Seoul, Korea
| | - The Korean Society of Gastrointestinal Endoscopy Task Force on Clinical Practice Guidelines
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- CAU Thrombosis and Biomarker Center, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong; Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Stanford, CA, USA
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
- Division of Upper GI and Metabolic Surgery, Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
- Division of Gastroenterology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand
- Department of Gastroenterology and Hepatology, Singapore General Hospital and Duke-NUS Medical School, Singapore, Singapore
- Departments of GI Endoscopy, 108 Central Hospital, Hanoi, Vietnam
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Internal Medicine, Pusan National University Hospital, Pusan National University College of Medicine and Biomedical Research Institute, Busan, Korea
- Department of Internal Medicine, Hanyang University School of Medicine, Seoul, Korea
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25
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Masseli F, Veseli A, Pfohl M, Hoch J, Treede H, Schiller W. Blood group AB is associated with reduced blood loss but also elevated cardiovascular mortality in aortocoronary bypass surgery. J Thromb Thrombolysis 2024; 57:512-519. [PMID: 38347373 PMCID: PMC10961287 DOI: 10.1007/s11239-023-02934-3] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2023] [Indexed: 03/26/2024]
Abstract
Patient blood group (BG) is predictive for von-Willebrand-factor (VWF) and Factor VIII variation. The clinical impact of this ABO-effect on blood loss, cardiovascular complications and outcome has been described for several patient cohorts. The aim of this study was to investigate the impact of patient BG on blood loss and outcome after coronary artery bypass surgery (CABG). Patient records, intraoperative data and perioperative transfusion records of 5713 patients receiving an on-pump CABG procedure between 05/2004 and 12/2018 were analyzed. A logistic regression model for death due to perioperative myocardial ischaemia (PMI) was developed from initially 24 variables by using an univariate and multivariate selection process. BG AB patients required less blood transfusions as compared to the other blood groups, especially in case of emergency operations. However, BG AB patients also had a higher mortality which was due to secondary cardiovascular complications. The impact of blood type on the rate of cardiovascular mortality was confirmed in the logistic regression model. BG AB patients have a worse outcome after CABG surgery due to an increased incidence of fatal cardiovascular complications. As perioperative myocardial ischemia due to graft occlusion appears to be the most likely explanation, stricter anticoagulation for BG AB patients should be discussed.
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Affiliation(s)
- Franz Masseli
- Department of Cardiac and Vascular Surgery, University Medical Center, Langenbeckstr. 1, 55131, Mainz, Germany.
| | - Arlinda Veseli
- Medical Faculty, University of Bonn, Sigmund-Freud-Straße 25, 53127, Bonn, Germany
| | - Marvin Pfohl
- Department of Cardiac and Vascular Surgery, University Medical Center, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Jochen Hoch
- Department for Experimental Hematology and Transfusion Medicine, University Clinic Bonn, Sigmund-Freud-Straße 25, 53127, Bonn, Germany
| | - Hendrik Treede
- Department of Cardiac and Vascular Surgery, University Medical Center, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Wolfgang Schiller
- Department of Cardiac and Vascular Surgery, University Medical Center, Langenbeckstr. 1, 55131, Mainz, Germany
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Gunka B, Mackenzie D, Hughes T, Sardo L, Bayadinova J, Siegal DM, Tseng EK, Doumouras AG, Mithoowani S. Pharmacokinetics of direct oral anticoagulants after bariatric surgery: A retrospective cohort study. Thromb Res 2024; 235:15-17. [PMID: 38266535 DOI: 10.1016/j.thromres.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 01/01/2024] [Accepted: 01/08/2024] [Indexed: 01/26/2024]
Affiliation(s)
- Barbara Gunka
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Laurie Sardo
- McMaster University, Hamilton, Ontario, Canada; St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | | | - Deborah M Siegal
- Department of Medicine, University of Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ontario, Canada
| | - Eric K Tseng
- Department of Medicine, University of Toronto, Canada; Division of Hematology/Oncology, St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
| | - Aristithes G Doumouras
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada; St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Siraj Mithoowani
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
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Yasaka M, Suzuki M, Kushimoto S, Kiyonaga A, Mangione A, Niwa Y, Terasaka N. Real-World Safety and Effectiveness of a 4-Factor Prothrombin Complex Concentrate in Japanese Patients Experiencing Major Bleeding: A Post-marketing Surveillance Study. Cardiol Ther 2024; 13:221-232. [PMID: 38319533 PMCID: PMC10899136 DOI: 10.1007/s40119-024-00357-6] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 01/18/2024] [Indexed: 02/07/2024] Open
Abstract
INTRODUCTION Limited data are available regarding the safety and effectiveness of 4-factor prothrombin complex concentrate (4F-PCC) in patients experiencing major hemorrhage or requiring expeditious surgical intervention, both globally and within Japan. METHODS We executed a prospective, observational post-marketing surveillance study of patients receiving 4F-PCC for the first time between September 19, 2017 and August 15, 2018 in Japan. Patients were subjected to a comprehensive follow-up for a duration of 4 weeks. RESULTS Of 1381 eligible patients, 1271 (92%) received a vitamin K antagonist. Among these, 58% were aged ≥ 75 years, 49% manifested atrial fibrillation, 17% presented with valvular heart disease, and 6% exhibited venous thromboembolism. The median (range) international normalized ratio was 2.67 (0.96-27.11) at baseline and 1.21 (0.45-6.61) at first measurement post-administration of 4F-PCC. The most common reason for 4F-PCC administration was intracranial hemorrhage (59.6%), followed by gastrointestinal bleeding (6.6%). Hemostatic effectiveness was achieved in 85.8% of patients. The incidences of adverse drug reactions (ADRs) and serious ADRs were 3.9% and 2.8%, respectively. Thromboembolic events (TEEs) occurred in 20 (1.5%) patients, with a mean onset of 10 days. The majority of TEEs were classified as nervous system disorders (55%). At the time of TEE, only 13% of patients resumed anticoagulant therapy. CONCLUSION The incidence of TEEs following treatment with 4F-PCC did not surpass those observed in phase 3 trials. No novel safety signals were identified. The safety and effectiveness of 4F-PCC in Japanese real-world practice were in harmony with the observations of prior studies.
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Affiliation(s)
- Masahiro Yasaka
- Cerebrovascular Medicine and Neurology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
- Cerebrovascular Medicine, Fukuoka Neurosurgical Hospital, Fukuoka, Japan
| | - Michiyasu Suzuki
- Department of Neurosurgery, Yamaguchi University Graduate School of Medicine, Manaka Hospital, Yamaguchi, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Ayako Kiyonaga
- Medical Affairs, CSL Behring K.K., 1-2-3 Kita-Aoyama Minato-Ku, Tokyo, 107-0061, Japan
| | | | - Yuki Niwa
- Medical Affairs, CSL Behring K.K., 1-2-3 Kita-Aoyama Minato-Ku, Tokyo, 107-0061, Japan
| | - Naoki Terasaka
- Medical Affairs, CSL Behring K.K., 1-2-3 Kita-Aoyama Minato-Ku, Tokyo, 107-0061, Japan.
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28
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Mangion K, Vella K, Gatt A, Vella AM, Borg M, Borg-Aquilina D, Douxfils J, Camilleri L, Riva N. A comparative in vitro study of the anticoagulant effect of branded versus generic rivaroxaban. Thromb Res 2024; 235:41-51. [PMID: 38295600 DOI: 10.1016/j.thromres.2024.01.017] [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] [Received: 04/01/2023] [Revised: 12/04/2023] [Accepted: 01/22/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND Several generic formulations of rivaroxaban were recently marketed to be used interchangeably with their branded equivalent. However, there have been no previously published studies that directly compared the in vitro anticoagulant effect of branded vs. generic rivaroxaban. The aim of this in vitro study was to compare the effects of three raw rivaroxaban materials, obtained from the branded (Xarelto®) and two generic (Rivarolto® and Rivaroxaban Sandoz®) rivaroxaban formulations on an array of coagulation assays. METHODS A pool of normal plasma was spiked with several concentrations of the three rivaroxaban (range 50-750 ng/ml). The concentrations were assessed with a rivaroxaban calibrated anti-Xa assay and confirmed by ultra-high-performance liquid chromatography-mass spectrometry coupled with tandem mass spectrometry (UHPLC-MS/MS). The following assays were performed: Prothrombin time (PT), activated Partial Thromboplastin time (aPTT), Diluted Russell's Viper Venom Test (dRVVT), Thrombin time (TT), Clauss Fibrinogen, Factor VII, VIII and IX assays, and thromboelastography. RESULTS The results obtained by the three rivaroxaban at similar concentrations were comparable. Increasing concentrations of the three rivaroxaban showed a strong positive correlation with the PT, aPTT and dRVVT assays (r > 0.95, p < 0.01 for all), and a strong negative correlation with the Factors assays (r < -0.95, p < 0.01 for all). TT and Clauss Fibrinogen were not affected by rivaroxaban. No significant difference was identified in the mean assays' results obtained by the three rivaroxaban. CONCLUSION This study showed that the branded and generic rivaroxaban exert an identical in vitro anticoagulant effect across a wide range of concentrations.
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Affiliation(s)
- Karl Mangion
- Department of Applied Biomedical Science, Faculty of Health Sciences, University of Malta, Msida, Malta.
| | - Kevin Vella
- Coagulation Laboratory, Department of Pathology, Mater Dei Hospital, Msida, Malta.
| | - Alex Gatt
- Coagulation Laboratory, Department of Pathology, Mater Dei Hospital, Msida, Malta; Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta.
| | - Amy Marie Vella
- Coagulation Laboratory, Department of Pathology, Mater Dei Hospital, Msida, Malta.
| | - Marica Borg
- Coagulation Laboratory, Department of Pathology, Mater Dei Hospital, Msida, Malta.
| | - Denise Borg-Aquilina
- National Blood Transfusion Service & Mater Dei Hospital Blood Bank, Msida, Malta.
| | - Jonathan Douxfils
- University of Namur, Faculty of Medicine, Department of Pharmacy, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Namur, Belgium; Qualiblood s.a., Qualiclinics, Namur, Belgium.
| | - Liberato Camilleri
- Department of Statistics & Operations Research, Faculty of Science, University of Malta, Msida, Malta.
| | - Nicoletta Riva
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta.
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Fisher AD, Fisher G. Danger, Danger, Gaston Labat! Does zero-shot artificial intelligence correlate with anticoagulation guidelines recommendations for neuraxial anesthesia? Reg Anesth Pain Med 2024:rapm-2024-105405. [PMID: 38418408 DOI: 10.1136/rapm-2024-105405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 02/19/2024] [Indexed: 03/01/2024]
Affiliation(s)
- Andrew D Fisher
- Department of Anesthesia & Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Gabrielle Fisher
- Department of Anesthesia & Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
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Sharobeam A, Lin L, Lam C, Garcia-Esperon C, Gawarikar Y, Patel R, Lee-Archer M, Wong A, Roizman M, Gilligan A, Lee A, Tan KM, Day S, Levi C, Davis SM, Parsons M, Yan B. Early anticoagulation in patients with stroke and atrial fibrillation is associated with fewer ischaemic lesions at 1 month: the ATTUNE study. Stroke Vasc Neurol 2024; 9:30-37. [PMID: 37247875 PMCID: PMC10956108 DOI: 10.1136/svn-2023-002357] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 05/05/2023] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND The optimal time to commence anticoagulation in patients with atrial fibrillation (AF) after ischaemic stroke or transient ischaemic attack (TIA) is unclear, with guidelines differing in recommendations. A limitation of previous studies is the focus on clinically overt stroke, rather than radiologically obvious diffusion-weighted imaging ischaemic lesions. We aimed to quantify silent ischaemic lesions and haemorrhages on MRI at 1 month in patients commenced on early (<4 days) vs late (≥4 days) anticoagulation. We hypothesised that there would be fewer ischaemic lesions and more haemorrhages in the early anticoagulant group at 1-month MRI. METHODS A prospective multicentre, observational cohort study was performed at 11 Australian stroke centres. Clinical and MRI data were collected at baseline and follow-up, with blinded imaging assessment performed by two authors. Timing of commencement of anticoagulation was at the discretion of the treating stroke physician. RESULTS We recruited 276 patients of whom 208 met the eligibility criteria. The average age was 74.2 years (SD±10.63), and 79 (38%) patients were female. Median National Institute of Health Stroke Scale score was 5 (IQR 1-12). Median baseline ischaemic lesion volume was 5 mL (IQR 2-17). There were a greater number of new ischaemic lesions on follow-up MRI in patients commenced on anticoagulation ≥4 days after index event (17% vs 8%, p=0.04), but no difference in haemorrhage rates (22% vs 32%, p=0.10). Baseline ischaemic lesion volume of ≤5 mL was less likely to have a new haemorrhage at 1 month (p=0.02). There was no difference in haemorrhage rates in patients with an initial ischaemic lesion volume of >5 mL, regardless of anticoagulation timing. CONCLUSION Commencing anticoagulation <4 days after stroke or TIA is associated with fewer ischaemic lesions at 1 month in AF patients. There is no increased rate of haemorrhage with early anticoagulation. These results suggest that early anticoagulation after mild-to-moderate acute ischaemic stroke associated with AF might be safe, but randomised controlled studies are needed to inform clinical practice.
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Affiliation(s)
- Angelos Sharobeam
- Melbourne Brain Centre at Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Longting Lin
- University of New South Wales South Western Sydney Clinical School, Liverpool, New South Wales, Australia
| | - Christina Lam
- Melbourne Brain Centre at Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Carlos Garcia-Esperon
- Department of Neurology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Yash Gawarikar
- Department of Neurology, Calvary Public Hospital, Canberra, Australian Capital Territory, Australia
| | - Ronak Patel
- Department of Neurology, Calvary Public Hospital, Canberra, Australian Capital Territory, Australia
| | - Matthew Lee-Archer
- Department of Neurology, Northern Hospital Epping, Epping, Victoria, Australia
| | - Andrew Wong
- Department of Neurology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- The University of Queensland School of Medicine, Herston, Queensland, Australia
| | - Michael Roizman
- Department of Neurology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- The University of Queensland School of Medicine, Herston, Queensland, Australia
| | - Amanda Gilligan
- Neurosciences Clinical Institute, Epworth Healthcare, Richmond, Virginia, Australia
- Department of Neurology, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia
| | - Andrew Lee
- Flinders University College of Medicine and Public Health, Adelaide, South Australia, Australia
| | - Kee Meng Tan
- Department of Neurology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Susan Day
- The University of Sydney Northern Clinical School, St Leonards, New South Wales, Australia
| | - Christopher Levi
- Department of Neurology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Stephen M Davis
- Melbourne Brain Centre at Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Mark Parsons
- University of New South Wales South Western Sydney Clinical School, Liverpool, New South Wales, Australia
- Department of Neurology and Neurophysiology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Bernard Yan
- Melbourne Brain Centre at Royal Melbourne Hospital, Parkville, Victoria, Australia
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Cha JM, Kim M, Jo HH, Seo WW, Rhee SY, Kim JH, Kim GH, Park J. Real-World Risk of Gastrointestinal Bleeding for Direct Oral Anticoagulants and Warfarin Users: A Distributed Network Analysis Using a Common Data Model. Gut Liver 2024:gnl230406. [PMID: 38384200 DOI: 10.5009/gnl230406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 12/08/2023] [Accepted: 12/21/2023] [Indexed: 02/23/2024] Open
Abstract
Background/Aims : Early studies on direct oral anticoagulants (DOACs) reported a higher risk of gastrointestinal bleeding (GIB) compared with warfarin; however, recent studies have reported a reduced risk. Therefore, this study was designed to evaluate the risk of GIB in users of DOAC and warfarin. Methods : Using a common data model, we investigated the comparative risk of GIB in subjects from eight hospitals who were newly prescribed DOACs or warfarin. We excluded subjects who had a prior history of GIB or had been prescribed both medications. After propensity score matching, we analyzed 3,347 matched pairs of new DOAC and new warfarin users. Results : The risk of GIB in new DOAC users was comparable to that in new warfarin users (hazard ratio [HR], 0.95; 95% confidence interval [CI], 0.65 to 1.40; p=0.808). New DOAC users had a similar risk of GIB to new warfarin users among older patients >65 years (HR, 1.00; 95% CI, 0.69 to 1.52; p=0.997) and in older patients >75 years (HR, 1.21; 95% CI, 0.68 to 2.10; p=0.509). In addition, the risk of GIB was not significantly different between two groups according to sex. We also found that the risk of GIB in DOAC users was 26% lower in edoxaban or apixaban subgroups compared to rivaroxaban or dabigatran subgroups (HR, 0.74; 95% CI, 0.69 to 1.00; p=0.049). Conclusions : In real-world practice, the risk of GIB in new DOAC users is comparable to that in new warfarin users. In DOAC users, the risk of GIB was lower in edoxaban or apixaban subgroups than rivaroxaban or dabigatran subgroups.
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Affiliation(s)
- Jae Myung Cha
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Myoungsuk Kim
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Hyeong Ho Jo
- Department of Internal Medicine, Daegu Catholic University Medical Center, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Won-Woo Seo
- Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Sang Youl Rhee
- Center for Digital Health, Kyung Hee University, Seoul, Korea
| | - Ji Hyun Kim
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Gwang Ha Kim
- Department of Internal Medicine, Pusan National University Hospital, Pusan National University School, Busan, Korea
| | - Junseok Park
- Department of Internal Medicine, Soonchunhyang University Hospital, Soonchunhyang University School of Medicine, Seoul, Korea
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Ntalouka MP, Brotis A, Karagianni MD, Arvaniti C, Mermiri M, Solou M, Stamoulis K, Bareka M, Fountas KN, Arnaoutoglou EM. Perioperative management of antithrombotics in elective intracranial procedures: systematic review, critical appraisal. Acta Neurochir (Wien) 2024; 166:97. [PMID: 38383680 DOI: 10.1007/s00701-024-05990-7] [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] [Received: 12/07/2023] [Accepted: 12/29/2023] [Indexed: 02/23/2024]
Abstract
PURPOSE Perioperative management of patients medicated with antithrombotics requiring elective intracranial procedures is challenging. We ought to (1) identify the clinical practice guidelines (CPGs) and recommendations (CPRs) on perioperative management of antithrombotic agents in elective intracranial surgery and (2) assess their methodological quality and reporting clarity. METHODS The study was conducted following the 2020 PRISMA guidelines for a systematic review and has been registered (PROSPERO, CRD42023415710). An electronic search was conducted using PubMed, Scopus, and Google Scholar. The search terms used were "adults," "antiplatelets," "anticoagulants," "guidelines," "recommendations," "english language," "cranial surgery," "brain surgery," "risk of bleeding," "risk of coagulation," and "perioperative management" in all possible combinations. The search period extended from 1964 to April 2023 and was limited to literature published in the English language. The eligible studies were evaluated by three blinded raters, by employing the Appraisal of Guidelines for Research & Evaluation II (AGREE-II) analysis tool. RESULTS A total of 14 sets of guidelines were evaluated. Two guidelines from the European Society of Anaesthesiology and one from the American College of Chest Physicians found to have the highest methodological quality and reporting clarity according to the AGREE-II tool. The interrater agreement was good with a mean Cohens Kappa of 0.70 (range, 46.5-94.4%) in the current analysis. CONCLUSION The perioperative management of antithrombotics in intracranial procedures may be challenging, complex, and demanding. Due to the lack of high quality data, uncertainty remains regarding the optimal practices to balance the risk of thromboembolism against that of bleeding.
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Affiliation(s)
- Maria P Ntalouka
- Department of Anaesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece.
| | - Alexandros Brotis
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Maria D Karagianni
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Christina Arvaniti
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Maria Mermiri
- Department of Anaesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Maria Solou
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Konstantinos Stamoulis
- Department of Anaesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Metaxia Bareka
- Department of Anaesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Konstantinos N Fountas
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
| | - Eleni M Arnaoutoglou
- Department of Anaesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece
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Davis S, Goodacre S, Horner D, Pandor A, Holland M, de Wit K, Hunt BJ, Griffin XL. Effectiveness and cost effectiveness of pharmacological thromboprophylaxis for medical inpatients: decision analysis modelling study. BMJ Med 2024; 3:e000408. [PMID: 38389721 PMCID: PMC10882286 DOI: 10.1136/bmjmed-2022-000408] [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] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 01/03/2024] [Indexed: 02/24/2024]
Abstract
Objective To determine the balance of costs, risks, and benefits for different thromboprophylaxis strategies for medical patients during hospital admission. Design Decision analysis modelling study. Setting NHS hospitals in England. Population Eligible adult medical inpatients, excluding patients in critical care and pregnant women. Interventions Pharmacological thromboprophylaxis (low molecular weight heparin) for all medical inpatients, thromboprophylaxis for none, and thromboprophylaxis given to higher risk inpatients according to risk assessment models (Padua, Caprini, IMPROVE, Intermountain, Kucher, Geneva, and Rothberg) previously validated in medical cohorts. Main outcome measures Lifetime costs and quality adjusted life years (QALYs). Costs were assessed from the perspective of the NHS and Personal Social Services in England. Other outcomes assessed were incidence and treatment of venous thromboembolism, major bleeds including intracranial haemorrhage, chronic thromboembolic complications, and overall survival. Results Offering thromboprophylaxis to all medical inpatients had a high probability (>99%) of being the most cost effective strategy (at a threshold of £20 000 (€23 440; $25 270) per QALY) in the probabilistic sensitivity analysis, when applying performance data from the Padua risk assessment model, which was typical of that observed across several risk assessment models in a medical inpatient cohort. Thromboprophylaxis for all medical inpatients was estimated to result in 0.0552 additional QALYs (95% credible interval 0.0209 to 0.1111) while generating cost savings of £28.44 (-£47 to £105) compared with thromboprophylaxis for none. No other risk assessment model was more cost effective than thromboprophylaxis for all medical inpatients when assessed in deterministic analysis. Risk based thromboprophylaxis was found to have a high (76.6%) probability of being the most cost effective strategy only when assuming a risk assessment model with very high sensitivity is available (sensitivity 99.9% and specificity 23.7% v base case sensitivity 49.3% and specificity 73.0%). Conclusions Offering pharmacological thromboprophylaxis to all eligible medical inpatients appears to be the most cost effective strategy. To be cost effective, any risk assessment model would need to have a very high sensitivity resulting in widespread thromboprophylaxis in all patients except those at the very lowest risk, who could potentially avoid prophylactic anticoagulation during their hospital stay.
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Affiliation(s)
- Sarah Davis
- Sheffield Centre for Health and Related Research, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- Sheffield Centre for Health and Related Research, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Daniel Horner
- Sheffield Centre for Health and Related Research, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
- Department of Emergency and Intensive Care Medicine, Northern Care Alliance Foundation Trust, Salford, UK
- Division of Immunology, Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
| | - Abdullah Pandor
- Sheffield Centre for Health and Related Research, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Mark Holland
- School of Clinical and Biomedical Sciences, Faculty of Health and Wellbeing, University of Bolton, Bolton, UK
| | - Kerstin de Wit
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
| | - Beverley J Hunt
- Department of Thrombosis & Haemostasis, Kings Healthcare Partners, London, UK
| | - Xavier Luke Griffin
- Barts Bone and Joint Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Alfahad A, Alhalabi R. Ultrasound (US)-guided percutaneous thrombin injection for stoma-site bleeding after PEG tube insertion: a case series and review of the literature. CVIR Endovasc 2024; 7:20. [PMID: 38376801 PMCID: PMC10879047 DOI: 10.1186/s42155-024-00432-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/01/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND Post-gastrostomy bleeding sequelae are acknowledged, with reported approaches focusing on conservative measures or surgical repair. Nonetheless, Percutaneous Thrombin Injections (PTI) role in PEG-site-related bleeding remains underexplored. PTI under ultrasound guidance is an advocated management strategy for stoma-site bleeding following gastrostomy in high-risk patients, particularly those on direct oral anticoagulants. CASE PRESENTATION This study presents three cases with multiple comorbidities who underwent PTI. Resulting in immediate resolution of bleeding, no systemic\local effect, and no reported complications or rebleeding after a 3-6-month follow-up. CONCLUSION The findings highlight the safety, direct complete resolution, and absence of sequelae associated with PTI, suggesting its potential as a promising technique in managing PEG stoma-related bleeding.
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Siepen BM, Forfang E, Branca M, Drop B, Mueller M, Goeldlin MB, Katan M, Michel P, Cereda C, Medlin F, Peters N, Renaud S, Niederhauser J, Carrera E, Kahles T, Kägi G, Bolognese M, Salmen S, Mono ML, Polymeris AA, Wegener S, Z'Graggen W, Kaesmacher J, Schaerer M, Rodic B, Kristoffersen ES, Larsen KT, Wyller TB, Volbers B, Meinel TR, Arnold M, Engelter ST, Bonati LH, Fischer U, Rønning OM, Seiffge DJ. Intracerebral haemorrhage in patients taking different types of oral anticoagulants: a pooled individual patient data analysis from two national stroke registries. Stroke Vasc Neurol 2024:svn-2023-002813. [PMID: 38336370 DOI: 10.1136/svn-2023-002813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 01/05/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND We investigated outcomes in patients with intracerebral haemorrhage (ICH) according to prior anticoagulation treatment with Vitamin K antagonists (VKAs), direct oral anticoagulants (DOACs) or no anticoagulation. METHODS This is an individual patient data study combining two prospective national stroke registries from Switzerland and Norway (2013-2019). We included all consecutive patients with ICH from both registries. The main outcomes were favourable functional outcome (modified Rankin Scale 0-2) and mortality at 3 months. RESULTS Among 11 349 patients with ICH (mean age 73.6 years; 47.6% women), 1491 (13.1%) were taking VKAs and 1205 (10.6%) DOACs (95.2% factor Xa inhibitors). The median percentage of patients on prior anticoagulation was 23.7 (IQR 22.6-25.1) with VKAs decreasing (from 18.3% to 7.6%) and DOACs increasing (from 3.0% to 18.0%) over time. Prior VKA therapy (n=209 (22.3%); adjusted ORs (aOR), 0.64; 95% CI, 0.49 to 0.84) and prior DOAC therapy (n=184 (25.7%); aOR, 0.64; 95% CI, 0.47 to 0.87) were independently associated with lower odds of favourable outcome compared with patients without anticoagulation (n=2037 (38.8%)). Prior VKA therapy (n=720 (49.4%); aOR, 1.71; 95% CI, 1.41 to 2.08) and prior DOAC therapy (n=460 (39.7%); aOR, 1.28; 95% CI, 1.02 to 1.60) were independently associated with higher odds of mortality compared with patients without anticoagulation (n=2512 (30.2%)). CONCLUSIONS The spectrum of anticoagulation-associated ICH changed over time. Compared with patients without prior anticoagulation, prior VKA treatment and prior DOAC treatment were independently associated with lower odds of favourable outcome and higher odds of mortality at 3 months. Specific reversal agents unavailable during the study period might improve outcomes of DOAC-associated ICH in the future.
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Affiliation(s)
- Bernhard M Siepen
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Elisabeth Forfang
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - Mattia Branca
- CTU Bern, Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Boudewijn Drop
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Madlaine Mueller
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Martina B Goeldlin
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mira Katan
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Patrik Michel
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Carlo Cereda
- Stroke Center EOC, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Friedrich Medlin
- Stroke Unit and Division of Neurology, HFR Fribourg-Cantonal Hospital, Fribourg, Switzerland
| | - Nils Peters
- Stroke Center Hirslanden, Klinik Hirslanden Zurich, Zurich, Switzerland
| | - Susanne Renaud
- Division of Neurology, Pourtalès Hospital, Neuchatel, Switzerland
| | | | - Emmanuel Carrera
- Stroke Research Group, Department of Clinical Neurosciences, Geneva University Hospital, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Timo Kahles
- Department of Neurology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Georg Kägi
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Neurology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Manuel Bolognese
- Neurology Department, Lucerne Cantonal Hospital (LUKS), Luzern, Switzerland
| | - Stephan Salmen
- Stroke Unit, Department of Neurology, Hospital Biel, Biel, Switzerland
| | - Marie-Luise Mono
- Department of Neurology, Stadtspitäler Triemli und Waid, Zurich, Switzerland
| | - Alexandros A Polymeris
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Susanne Wegener
- Department of Neurology and Stroke Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Werner Z'Graggen
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Neurosurgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael Schaerer
- Department of Neurology, Bürgerspital Solothurn, Solothurn, Switzerland
| | - Biljana Rodic
- Stroke Unit, Department of Neurology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Espen Saxhaug Kristoffersen
- Department of Neurology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- Department of General Practice, University of Oslo, Oslo, Norway
| | - Kristin T Larsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Department of Neurology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Torgeir Bruun Wyller
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - Bastian Volbers
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas R Meinel
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan T Engelter
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Neurology and Neurorehabilitation, University of Basel; University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Leo H Bonati
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
- Rehabilitation Clinic Rheinfelden, Rheinfelden, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Ole Morten Rønning
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Neurology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - David J Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Henshaw DS, Edwards CJ, Dobson SW, Jaffe D, Turner JD, Reynolds JW, Thompson GR, Russell G, Weller R. Evaluating residual anti-Xa levels following discontinuation of treatment-dose enoxaparin in patients presenting for elective surgery: a prospective observational trial. Reg Anesth Pain Med 2024; 49:94-101. [PMID: 37280083 DOI: 10.1136/rapm-2023-104571] [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] [Received: 04/06/2023] [Accepted: 05/22/2023] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Prior studies have demonstrated that patients presenting for elective surgery may have higher-than-expected residual anti-Xa level activity at or beyond 24 hours following their last treatment dose of enoxaparin. Given that 24 hours of abstinence is currently recommended by both European and American societies before the performance of neuraxial or deep anesthetic/analgesic procedures, determining the actual timeframe at which residual anti-Xa level activity reliably falls below 0.2 IU/mL, the lower limit of the target range for thromboprophylaxis, is critical. METHODS This was a prospective observational trial. Consenting patients on treatment-dose enoxaparin were randomized to either a 24-hour group (last dose at 07:00 the day prior to surgery) or a 36-hour group (last dose at 19:00 2 days prior to surgery). On arrival for surgery, blood samples were obtained to assess residual anti-Xa level activity and renal function. The primary outcome was residual anti-Xa level activity following the last treatment dose of enoxaparin. Incorporating all patients, linear regression modeling was performed to predict the timepoint at which the level of anti-Xa activity reliably fell below 0.2 IU/mL. RESULTS 103 patients were analyzed. Time from the last dose at which residual anti-Xa activity fell below 0.2 IU/mL, based on the upper bound of the 95% CI, was 31.5 hours. No correlation overall between age, renal function, or sex was found. CONCLUSION Residual levels of anti-Xa activity do not reliably fall below 0.2 IU/mL 24 hours following discontinuation of treatment-dose enoxaparin. Therefore, current time-based guidelines are not conservative enough. Routine anti-Xa testing should be strongly considered, or current time-based guidelines should be reassessed. TRIAL REGISTRATION NUMBER NCT03296033.
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Affiliation(s)
- Daryl S Henshaw
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Christopher J Edwards
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Sean W Dobson
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Doug Jaffe
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - James D Turner
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - J Wells Reynolds
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Garrett R Thompson
- Department of Pharmacy, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Greg Russell
- Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Robert Weller
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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Capela TL, Silva VM, Freitas M, Gonçalves TC, Cotter J. Acute Nonvariceal Upper Gastrointestinal Bleeding in Patients Using Anticoagulants: Does the Timing of Endoscopy Affect Outcomes? Dig Dis Sci 2024; 69:570-578. [PMID: 38117425 PMCID: PMC10861632 DOI: 10.1007/s10620-023-08185-9] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 11/06/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND In patients with acute nonvariceal upper gastrointestinal bleeding (NVUGIB), early (≤ 24 h) endoscopy is recommended following hemodynamic resuscitation. Nevertheless, scarce data exist on the optimal timing of endoscopy in patients with NVUGIB receiving anticoagulants. OBJECTIVE To analyze how the timing of endoscopy may influence outcomes in anticoagulants users admitted with NVUGIB. METHODS Retrospective cohort study which consecutively included all adult patients using anticoagulants presenting with NVUGIB between January 2011 and June 2020. Time from presentation to endoscopy was assessed and defined as early (≤ 24 h) and delayed (> 24 h). The outcomes considered were endoscopic or surgical treatment, length of hospital stay, intermediate/intensive care unit admission, recurrent bleeding, and 30-day mortality. RESULTS From 636 patients presenting with NVUGIB, 138 (21.7%) were taking anticoagulants. Vitamin K antagonists were the most frequent anticoagulants used (63.8%, n = 88). After adjusting for confounders, patients who underwent early endoscopy (59.4%, n = 82) received endoscopic therapy more frequently (OR 2.4; 95% CI 1.1-5.4; P = 0.034), had shorter length of hospital stay [7 (IQR 6) vs 9 (IQR 7) days, P = 0.042] and higher rate of intermediate/intensive care unit admission (OR 2.7; 95% CI 1.3 - 5.9; P = 0.010) than patients having delayed endoscopy. Surgical treatment, recurrent bleeding, and 30-day mortality did not differ significantly between groups. CONCLUSION Early endoscopy (≤ 24 h) in anticoagulant users admitted with acute nonvariceal upper gastrointestinal bleeding is associated with higher rate of endoscopic treatment, shorter hospital stay, and higher intermediate/intensive care unit admission. The timing of endoscopy did not influence the need for surgical intervention, recurrent bleeding, and 30-day mortality.
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Affiliation(s)
- Tiago Lima Capela
- Gastroenterology Department, Hospital da Senhora da Oliveira, Rua Dos Cutileiros, Creixomil, 4835-044, Guimarães, Portugal.
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga/Guimarães, Braga, Portugal.
- ICVS/3B's, PT Government Associate Laboratory, Guimarães/Braga, Braga, Portugal.
| | - Vítor Macedo Silva
- Gastroenterology Department, Hospital da Senhora da Oliveira, Rua Dos Cutileiros, Creixomil, 4835-044, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga/Guimarães, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Guimarães/Braga, Braga, Portugal
| | - Marta Freitas
- Gastroenterology Department, Hospital da Senhora da Oliveira, Rua Dos Cutileiros, Creixomil, 4835-044, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga/Guimarães, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Guimarães/Braga, Braga, Portugal
| | - Tiago Cúrdia Gonçalves
- Gastroenterology Department, Hospital da Senhora da Oliveira, Rua Dos Cutileiros, Creixomil, 4835-044, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga/Guimarães, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Guimarães/Braga, Braga, Portugal
| | - José Cotter
- Gastroenterology Department, Hospital da Senhora da Oliveira, Rua Dos Cutileiros, Creixomil, 4835-044, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga/Guimarães, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Guimarães/Braga, Braga, Portugal
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Kam KKH, Chan JSK, Lee APW. Non-vitamin K oral anticoagulants versus warfarin for the treatment of left ventricular thrombus. Hong Kong Med J 2024; 30:10-15. [PMID: 38327164 DOI: 10.12809/hkmj2210034] [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: 02/09/2024] Open
Abstract
INTRODUCTION Left ventricular thrombus (LVT) is associated with significant morbidity and mortality. Conventional treatment comprises warfarin-mediated anticoagulation; it is unclear whether non-vitamin K oral anticoagulants (NOACs) exhibit comparable efficacy and safety. Limited data are available for Asian patients. This study compared NOACs with warfarin in terms of clinical efficacy and safety for managing LVT. METHODS Clinical and echocardiographic records were retrieved for all adult patients with echocardiography-confirmed LVT at a major regional centre in Hong Kong from January 2011 to January 2020. Discontinuation of anticoagulation by 1 year was recorded. Outcomes were compared between patients receiving NOACs and those receiving warfarin. Primary outcomes were cumulative mortality and net adverse clinical events (NACEs). Secondary outcomes were complete LVT resolution and percentage reduction in LVT size at 3 months. RESULTS Forty-three patients were included; 28 received warfarin and 15 received NOACs, with follow-up periods (mean ± standard deviation) of 20 ± 12 months and 22 ± 9 months, respectively (P=0.522). Use of NOACs was associated with significantly lower NACE risk (hazard ratio [HR]=0.111, 95% confidence interval [CI]=0.012-0.994; P=0.049) and a tendency towards lower cumulative mortality (HR=0.184, 95% CI=0.032-1.059; P=0.058). There were no significant differences in secondary outcomes. Considering LVT resolution, discontinuation of anticoagulation by 1 year was not significantly associated with different outcomes. CONCLUSION Non-vitamin K oral anticoagulants may be an efficacious and safe alternative to warfarin for LVT management. Future studies should explore the safety and efficacy of anticoagulation discontinuation by 1 year as an overall strategy.
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Affiliation(s)
- K K H Kam
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong SAR, China
| | - J S K Chan
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong SAR, China
| | - A P W Lee
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong SAR, China
- Laboratory of Cardiac Imaging and 3D Printing, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China
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Cantu-Martinez O, Bhargav R, Mainigi S. Recurrence of device-related thrombus 3 years after left atrial appendage occlusion. HeartRhythm Case Rep 2024; 10:128-131. [PMID: 38404978 PMCID: PMC10885687 DOI: 10.1016/j.hrcr.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024] Open
Affiliation(s)
- Omar Cantu-Martinez
- Department of Medicine, Jefferson Einstein Medical Center, Philadelphia, Pennsylvania
- Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Ruchika Bhargav
- Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
- Division of Cardiology, Jefferson Einstein Medical Center, Philadelphia, Pennsylvania
| | - Sumeet Mainigi
- Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
- Division of Cardiology, Jefferson Einstein Medical Center, Philadelphia, Pennsylvania
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Yang C, Khan F, MacDonald C, Guglielmo J, Lo M, Young R, Banez MT, Huang L, Nguyen R, Kang S, Saunders IM. Characterization of direct oral anticoagulants use in adult hematopoietic stem cell transplant recipients. J Thromb Thrombolysis 2024; 57:293-301. [PMID: 37932590 PMCID: PMC10869366 DOI: 10.1007/s11239-023-02902-x] [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] [Accepted: 09/24/2023] [Indexed: 11/08/2023]
Abstract
Direct oral anticoagulants (DOACs) for venous thromboembolism (VTE) treatment are of interest in oncology due to ease of administration and lack of need for therapeutic monitoring compared to other anticoagulants. Data supporting their use in patients with hematologic malignancies post-hematopoietic stem cell transplant (HCT) are limited. The purpose of the study is to characterize DOAC use in HCT patients. This multicenter, retrospective cohort analysis included allogeneic and autologous HCT recipients. The primary outcome was major bleeding. Secondary outcomes included clinically relevant non-major bleeding (CRNMB)/minor bleeding and VTE recurrence. Of 126 patients, 91 (72.2%) patients received an autologous HCT, and 35 (27.8%) patients received an allo-HCT. No major bleeding occurred in either transplant recipient groups. In autologous HCT recipients, CRNMB/minor bleeding occurred in four (4.4%) patients and VTE recurrence occurred in one (1.1%) patient. For allogeneic HCT recipients, CRNMB/minor bleeding occurred in five (14.3%) patients and VTE recurrence occurred in two (5.7%) patients. For patients that experienced a CRNMB, five (100%) of the allogeneic HCT and two (50%) of the autologous HCT recipients were thrombocytopenic at the time of bleeding. Only 38.5% of patients who experienced a drug-drug interaction requiring DOAC dose adjustment received the appropriate dose adjustment. DOACs were associated with low rates of recurrent VTE and no major bleeding events, similar to published data on DOAC use in the general cancer patient population. This suggests that DOACs may be safe therapeutic options with proactive management of drug interactions and careful monitoring for bleeding events, especially in the allogeneic HCT population where minor bleeding rates were slightly higher.
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Affiliation(s)
- Claire Yang
- UC Davis Medical Center, 3651 Business Drive, Suite 100, Sacramento, CA, 95820, USA.
| | | | | | - Julie Guglielmo
- UC Davis Medical Center, 3651 Business Drive, Suite 100, Sacramento, CA, 95820, USA
| | - Mimi Lo
- UC San Francisco Medical Center, San Francisco, USA
| | | | | | - Lily Huang
- UC Davis Medical Center, 3651 Business Drive, Suite 100, Sacramento, CA, 95820, USA
| | - Rosalyn Nguyen
- UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, USA
| | - Stephen Kang
- UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, USA
| | - Ila M Saunders
- UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, USA
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Wadhwa H, Rohde M, Oquendo Y, Chen MJ, Tigchelaar SS, Bellino M, Bishop J, Gardner MJ. Interaction of preoperative chemoprophylaxis and tranexamic acid use does not affect transfusion in acetabular fracture surgery. Eur J Orthop Surg Traumatol 2024; 34:1025-1029. [PMID: 37865628 DOI: 10.1007/s00590-023-03763-z] [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] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 10/06/2023] [Indexed: 10/23/2023]
Abstract
PURPOSE While the effects of tranexamic acid (TXA) use on transfusion rates after acetabular fracture surgery are unclear, previous evidence suggests that holding deep vein thrombosis (DVT) chemoprophylaxis may improve TXA efficacy. This study examines whether holding DVT chemoprophylaxis in patients receiving TXA affects intraoperative and postoperative transfusion rates in acetabular fracture surgery. METHODS We reviewed electronic medical records (EMR) of 305 patients who underwent open reduction and internal fixation of acetabular fractures (AO/OTA 62) and stratified patients per the following perioperative treatment: (1) no intraoperative TXA (noTXA), (2) intraoperative TXA and no preoperative DVT prophylaxis (opTXA/noDVTP), or (3) intraoperative TXA and preoperative DVT prophylaxis (opTXA/opDVTP). The primary outcomes were need for intraoperative or postoperative transfusion. Risk factors for each primary outcome were assessed using multivariable regression. RESULTS Intraoperative or postoperative transfusion rates did not significantly differ between opTXA/opDVTP and opTXA/noDVTP groups (46.2% vs. 36%, p = 0.463; 15.4% vs. 28%, p = 0.181). Median units transfused did not differ between groups (2 ± 1 vs. 2 ± 1, p = 0.515; 2 ± 1 vs. 2 ± 0, p = 0.099). There was no association between preoperative DVT chemoprophylaxis and TXA with intraoperative or postoperative transfusions. EBL, preoperative hematocrit, and IV fluids were associated with intraoperative transfusions; age and Charlson Comorbidity Index (CCI) were associated with postoperative transfusions. CONCLUSION Our findings suggest holding DVT prophylaxis did not alter the effect of TXA on blood loss or need for transfusion.
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Affiliation(s)
- Harsh Wadhwa
- Department of Orthopaedic Surgery, Stanford School of Medicine, Stanford, CA, 94305, USA
| | - Matthew Rohde
- Department of Orthopaedic Surgery, Stanford School of Medicine, Stanford, CA, 94305, USA.
| | - Yousi Oquendo
- Department of Orthopaedic Surgery, Stanford School of Medicine, Stanford, CA, 94305, USA
| | - Michael J Chen
- Department of Orthopaedic Surgery, Stanford School of Medicine, Stanford, CA, 94305, USA
| | - Seth S Tigchelaar
- Department of Orthopaedic Surgery, Stanford School of Medicine, Stanford, CA, 94305, USA
| | - Michael Bellino
- Department of Orthopaedic Surgery, Stanford School of Medicine, Stanford, CA, 94305, USA
| | - Julius Bishop
- Department of Orthopaedic Surgery, Stanford School of Medicine, Stanford, CA, 94305, USA
| | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford School of Medicine, Stanford, CA, 94305, USA
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Chen J, Lai YL, Lee JK, Lin HW, Sun WZ, Chen YL, Cheng WF. Does the diagnostic timing of cancer-associated thromboembolism influence the survival outcome in ovarian cancer patients? J Formos Med Assoc 2024; 123:228-237. [PMID: 37596109 DOI: 10.1016/j.jfma.2023.08.005] [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] [Received: 04/03/2023] [Revised: 07/23/2023] [Accepted: 08/04/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND/PURPOSE Efforts were made to explore the influence of diagnostic timing for cancer-associated thromboembolic events on survival of ovarian cancer patients. METHODS We reviewed the medical records of 75 ovarian cancer patients with thromboembolism and evaluated the prognostic factors affecting disease-free survival and overall survival. RESULTS These 75 patients were classified into two categories by the diagnostic timing of the thromboembolism, during (33 cases) and after (42 cases) initial diagnosis of ovarian cancer groups. The diagnostic timing of thromboembolism was not related to disease-free survival or overall survival of the studied population. Advanced disease stage, clear cell histology, interval debulking surgery, no recurrence/persistence of ovarian cancer, and patients treated with anticoagulant(s) treatment >3 months were associated with the disease-free survival. Advanced disease stage, clear cell histology, body mass index (BMI) ≥24 kg/m2 at the diagnosis of ovarian cancer, and no recurrence/persistence of ovarian cancer influenced the overall survival. In the subgroup analysis, compared to the after initial ovarian cancer diagnosis group, patients with stage I/II disease, BMI <24 kg/m2 at the diagnosis of ovarian cancer, or primary debulking surgery in the during cancer diagnosis group had longer disease-free survival, and overall survival benefit was observed in cases with stage I/II disease, or primary debulking surgery. CONCLUSION The diagnostic timing of thromboembolism was not related to disease-free or overall survival of ovarian cancer patients, but associated with that of specific patient subgroups.
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Affiliation(s)
- Jung Chen
- Department of Obstetrics and Gynecology, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Obstetrics and Gynecology, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Taiwan
| | - Yen-Ling Lai
- Department of Obstetrics and Gynecology, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Obstetrics and Gynecology, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Jen-Kuang Lee
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Han-Wei Lin
- Department of Anesthesiology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Wei-Zen Sun
- Department of Anesthesiology, College of Medicine, National Taiwan University, Taipei, Taiwan.
| | - Yu-Li Chen
- Department of Obstetrics and Gynecology, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Obstetrics and Gynecology, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Taiwan.
| | - Wen-Fang Cheng
- Department of Obstetrics and Gynecology, College of Medicine, National Taiwan University, Taipei, Taiwan
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Rogha M, Moshtaghi E. The Effect of Rivaroxaban in the Complementary Therapy of Sudden Sensorineural Hearing Loss. Adv Biomed Res 2024; 13:1. [PMID: 38525395 PMCID: PMC10958720 DOI: 10.4103/abr.abr_143_23] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 06/19/2023] [Accepted: 06/21/2023] [Indexed: 03/26/2024] Open
Abstract
Background Due to the importance of sudden sensorineural hearing loss (SSNHL) and the possible role of blood coagulation in its mechanism and the likely therapeutic effect of anticoagulants and also the lack of studies in this field, this study aimed to evaluate the effect of rivaroxaban (RXA) in the treatment of this disease. Materials and Methods The present double-blind randomized clinical trial study was performed on 34 patients with SSNHL. Patients were randomly divided into two groups. In the first group, in addition to corticosteroid therapy (CST), RXA 10 mg tablets were used daily for 10 days (RXA group), and in the second group, only CST (CST group) treatment was prescribed. Hearing recovery was then assessed and recorded according to the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) criteria. Results This study showed that the grade of hearing recovery in the RXA group (58.8%) was higher than the CST group (47.1%), but this difference was not significant (P value >0.05). Also, RXA treatment increased the odds of hearing recovery, and this difference was not statistically significant (odd ratio (95% confidence interval)(OR (95% CI): 2.327 (0.180-18.082); P value = 0.518). In contrast, delay to treatment, more increased PTA (pure tone average (PTA)), and having vertigo reduced the odds of hearing recovery by 0.138-, 0.019-, and 0.069-fold, respectively (P value <0.05). Conclusion According to the results of this study, although the percentage of hearing recovery was higher in the RXA group, in general, the results of the two treatments were not significantly different.
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Affiliation(s)
- Mehrdad Rogha
- Department of Otorhinolaryngology, Head and Neck Surgery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ehsan Moshtaghi
- Department of Otolaryngology, Isfahan University of Medical Sciences, Isfahan, Iran
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Chiasakul T, Mullier F, Lecompte T, Nguyen P, Cuker A. Laboratory Monitoring of Heparin Anticoagulation in Hemodialysis: Rationale and Strategies. Semin Nephrol 2024:151477. [PMID: 38290962 DOI: 10.1016/j.semnephrol.2023.151477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
Unfractionated heparin (UFH) and low-molecular-weight heparins (LMWHs) are commonly used to prevent clotting of the hemodialysis extracorporeal circuit and optimize hemodialysis adequacy. There is no consensus on the optimal dosing for UFH and LMWHs during hemodialysis. In clinical practice, semiquantitative clotting scoring of the dialyzer and venous chamber may help to guide UFH and LMWH dose adjustment. Laboratory monitoring has not been shown to improve clinical outcomes and is therefore not routinely indicated in most hemodialysis patients. It might, however, be considered in select patients, such as those with extremes of body weight or history of repeated clotting or bleeding. Methods for laboratory monitoring include the activated partial thromboplastin time, activated clotting time, and antifactor Xa assays for UFH and antifactor Xa assay for LMWHs. Target ranges for anticoagulation in hemodialysis have been suggested but not clearly defined. When utilizing these tests, issues such as availability, standardization, interfering factors, and interpretation must be considered. In this narrative review, we discuss the rationale and methods of monitoring anticoagulation in hemodialysis.
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Affiliation(s)
- Thita Chiasakul
- Center of Excellence in Translational Hematology, Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.
| | - François Mullier
- Namur Thrombosis and Hemostasis Center, Université Catholique de Louvain, Centre Hospitalier Universitaire UCL Namur, Hematology Laboratory, Yvoir, Belgium; Institut de Recherche Expérimentale et Clinique, Pôle Mont, Université Catholique de Louvain, Yvoir, Belgium
| | - Thomas Lecompte
- Pharmacy Department, University of Namur, Namur, Belgium; Université de Lorraine, Nancy, France
| | - Philippe Nguyen
- Hematology Laboratory, Reims University Hospital, Reims, France
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Boriani G, Gerra L, Mei DA, Bonini N, Vitolo M, Proietti M, Imberti JF. Detection of subclinical atrial fibrillation with cardiac implanted electronic devices: What decision making on anticoagulation after the NOAH and ARTESiA trials? Eur J Intern Med 2024:S0953-6205(24)00002-5. [PMID: 38281819 DOI: 10.1016/j.ejim.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 01/04/2024] [Indexed: 01/30/2024]
Abstract
Atrial fibrillation (AF) may be asymptomatic and the extensive monitoring capabilities of cardiac implantable electronic devices (CIEDs) revealed asymptomatic atrial tachi-arrhythmias of short duration (minutes-hours) occurring in patients with no prior history of AF and without AF detection at a conventional surface ECG. Both the terms "AHRE" (Atrial High-Rate Episodes) and subclinical AF were used in a series of prior studies, that evidenced the association with an increased risk of stroke. Two randomized controlled studies were planned in order to assess the risk-benefit profile of anticoagulation in patients with AHRE/subclinical AF: the NOAH and ARTESiA trials. The results of these two trials (6548 patients enrolled, overall) show that the risk of stroke/systemic embolism associated with AHRE/subclinical AF is in the range of 1-1.2 % per patient-year, but with an important proportion of severe/fatal strokes occurring in non-anticoagulated patients. The apparent discordance between ARTESiA and NOAH results may be approached by considering the related study-level meta-analysis, which highlights a consistent reduction of ischemic stroke with oral anticoagulants vs. aspirin/placebo (relative risk [RR] 0.68, 95 % CI 0.50-0.92). Oral anticoagulation was found to increase major bleeding (RR 1.62, 95 % CI 1.05-2.5), but no difference was found in fatal bleeding (RR 0.79, 95 % CI 0.37-1.69). Additionally, no difference was found in cardiovascular death or all-cause mortality. Taking into account these results, clinical decision-making for patients with AHRE/subclinical AF at risk of stroke, according to CHA2DS2-VASc, can now be evidence-based, considering the benefits and related risks of oral anticoagulants, to be shared with appropriately informed patients.
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Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Italy University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.
| | - Luigi Gerra
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Italy University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Davide A Mei
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Italy University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Niccolo' Bonini
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Italy University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Italy University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; Division of Subacute Care IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Jacopo F Imberti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Italy University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
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Gómez-Alonso J, Martínez Martínez M, Bonilla Rojas CA, García Díaz HC, Riera Del Brio J, Gorgas Torner MQ, Doménech-Moral L. Management of heparin-induced thrombocytopenia during extracorporeal membrane oxygenation support: a case of neutropenia caused by argatroban anticoagulation. Eur J Hosp Pharm 2024:ejhpharm-2023-003914. [PMID: 38272648 DOI: 10.1136/ejhpharm-2023-003914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 01/15/2024] [Indexed: 01/27/2024] Open
Abstract
We present the case of a man in his 70s admitted to the intensive care unit (ICU) after mitral valve replacement and coronary artery bypass graft surgery requiring extracorporeal membrane oxygenation support due to haemodynamic instability. He received anticoagulation therapy with heparin sodium and, after 5 days, the patient presented with thrombocytopenia and deep venous thrombosis. Heparin-induced thrombocytopenia was suspected based on a positive 4T score and confirmed by antiplatelet factor 4/heparin antibodies, so argatroban was initiated as an alternative anticoagulation therapy. In the following days the patient developed severe neutropenia requiring discontinuation of argatroban and the administration of granulocyte colony-stimulating factor. According to the Naranjo Adverse Drug Reaction Probability Scale, this event would be classified as a 'probable' argatroban-related adverse event. Argatroban should be conisdered as a possible cause of neutropenia and appropriate interventions need to be implemented due to the gravity of this adverse event in the ICU.
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Rockhold M, Kunkel L, Lacoste JL, Szymanski T, Rothenberg P, Zimmerman P, Minc S. Comparison of direct oral anticoagulants and warfarin in chronic limb-threatening ischemia. J Vasc Surg 2024:S0741-5214(24)00256-8. [PMID: 38278371 DOI: 10.1016/j.jvs.2024.01.196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 01/17/2024] [Accepted: 01/19/2024] [Indexed: 01/28/2024]
Abstract
OBJECTIVE The role of direct oral anticoagulants (DOACs) in chronic limb-threatening ischemia after revascularization is unknown. Current evidence-based guidelines do not provide clear guidance on the role of anticoagulation or the selection of anticoagulant. Current practice is highly varied and based on provider and patient preference. The purpose of this study was to measure the impact of different anticoagulants on the incidence of major adverse limb events (MALEs) after revascularization for chronic limb-threatening ischemia, major adverse cardiovascular events (MACEs), all-cause mortality, and hospitalization for major bleeding events. METHODS This was a single-center, observational, retrospective cohort study. Subjects were eligible if they were 18 years or older; underwent endovascular or open revascularization for chronic limb-threatening ischemia, rest pain, or tissue loss; and were subsequently prescribed apixaban, rivaroxaban, or warfarin. The primary end point was the incidence of MALEs, including above-ankle amputation or major index-limb reintervention, within 1 year of index event. Secondary end points included the rate of all-cause mortality, MACEs, and incidence of International Society on Thrombosis and Haemostasis (ISTH) major bleeding. RESULTS From January 1, 2017, to September 20, 2022, 141 patients met the inclusion and exclusion criteria and were reviewed. The median age was 67 years, with 92 patients prescribed apixaban or rivaroxaban and 49 patients prescribed warfarin. Of these, 42 patients were prescribed triple antithrombotic therapy, 88 dual antithrombotic therapy, and 13 anticoagulant monotherapy. The primary outcome of 1-year MALEs occurred in 36.7% of the warfarin group and 33.7% of the DOAC group (relative risk [RR], 1.09; 95% CI, 0.53-2.25; P = .72). Secondary outcomes of 1-year MACEs (10.2% vs 4.3%; RR, 2.35; 95% CI, 0.60-9.18; P = .18) and 1-year all-cause mortality (26.5% vs 16.3%; RR, 1.63; 95% CI, 0.70-3.78; P = .15) did not differ between the groups. The secondary safety outcome of 1-year ISTH major bleeding occurred in 16.3% of the warfarin group and 4.3% of the DOAC group (RR, 3.76; 95% CI, 1.07-13.19; P = .015). CONCLUSIONS In patients with chronic limb-threatening ischemia who were revascularized and prescribed anticoagulation with apixaban, rivaroxaban, or warfarin on discharge, no difference in MALEs, MACEs, or all-cause mortality was found. However, 1-year admissions for ISTH major bleeding were significantly higher among patients prescribed warfarin. A randomized trial may confirm these findings.
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Affiliation(s)
- Matthew Rockhold
- West Virginia University Medicine, Department of Pharmacy, Morgantown, WV.
| | - Lauren Kunkel
- West Virginia University Medicine, Department of Pharmacy, Morgantown, WV
| | - Jordan L Lacoste
- West Virginia University Medicine, Department of Pharmacy, Morgantown, WV
| | - Thomas Szymanski
- West Virginia University Medicine, Department of Pharmacy, Morgantown, WV
| | - Paul Rothenberg
- West Virginia University Medicine, Department of General Surgery, Morgantown, WV
| | - Pamela Zimmerman
- West Virginia University Medicine, Department of Vascular Surgery, Morgantown, WV
| | - Samantha Minc
- West Virginia University Medicine, Department of Vascular Surgery, Morgantown, WV
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Benzon HT, Nelson AM, Patel AG, Chiang S, Agarwal D, Benzon HA, Rozental J, McCarthy RJ. Literature review of spinal hematoma case reports: causes and outcomes in pediatric, obstetric, neuraxial and pain medicine cases. Reg Anesth Pain Med 2024:rapm-2023-105161. [PMID: 38267076 DOI: 10.1136/rapm-2023-105161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 12/18/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND The risk of spinal epidural hematoma (SEH) has been described in the literature but the impact in various patient populations has not been assessed in the same study. We identified the risk factors for SEH and calculated the OR for recovery in the pediatric, adult and obstetric (OB) patients based on the degree of neurological deficit before surgery. METHODS Adult non-OB cases were categorized whether they were on anticoagulants or not; SEH was related to neuraxial or pain procedure; or whether there was adherence to the American Society of Regional Anesthesia (ASRA) guidelines. Eligible cases were identified through PubMed and Embase searches in the English literature from 1954 to July 2022. RESULTS A total of 940 cases were evaluated. In the pediatric cases, SEH was typically spontaneous, related to coagulopathy or athletic trauma. OB cases were spontaneous or related to neuraxial injections. Among adults on anticoagulant(s), SEH was mostly spontaneous with no related etiology or related to neuraxial procedure. SEH occurred despite adherence to the ASRA guidelines. Among non-OB adults not on anticoagulants, SEH was due to trauma, neuraxial injections, surgery or other causes. Neurological recovery was related to the degree of neurological deficit before surgery. CONCLUSIONS Our data show a preponderance of spontaneous SEH in all patient populations. SEH developed even though the ASRA guidelines were followed, especially in patients on multiple anticoagulants. Patients with less impairment prior to surgery had a higher likelihood of complete recovery, regardless of the interval between surgery and onset of symptoms.
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Affiliation(s)
- Honorio T Benzon
- Department of Anesthesiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ariana M Nelson
- Department of Anesthesiology, University of California Irvine, Irvine, California, USA
| | - Arpan G Patel
- Department of Anesthesiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Silvia Chiang
- Department of Anesthesiology, University of California Irvine, Irvine, California, USA
| | - Deepti Agarwal
- Department of Anesthesiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Hubert A Benzon
- Department of Anesthesiology, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Jack Rozental
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Robert J McCarthy
- Department of Anesthesiology, Rush Medical College of Rush University, Chicago, Illinois, USA
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Hurley NC, Schwenk ES. Can artificial intelligence make clinical decisions in regional anesthesia? An infographic. Reg Anesth Pain Med 2024:rapm-2022-104066. [PMID: 38253612 DOI: 10.1136/rapm-2022-104066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 11/16/2023] [Indexed: 01/24/2024]
Affiliation(s)
- Nathan C Hurley
- Anesthesiology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Eric S Schwenk
- Anesthesiology and Perioperative Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Perkins L, Adams L, Lerner D, Santorelli J, Smith AM, Kobayashi L. Predictors of direct oral anticoagulant concentrations in the trauma population. Trauma Surg Acute Care Open 2024; 9:e001208. [PMID: 38274020 PMCID: PMC10806470 DOI: 10.1136/tsaco-2023-001208] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024] Open
Abstract
Introduction Direct oral anticoagulant (DOAC) use is becoming more prevalent in patients presenting after trauma. We sought to identify the prevalence and predictors of subtherapeutic and therapeutic DOAC concentrations and hypothesized that increased anti-Xa levels would correlate with increased risk of bleeding and other poor outcomes. Methods A retrospective cohort study of all trauma patients on apixaban or rivaroxaban admitted to a level 1 trauma center between January 2015 and July 2021 was performed. Patients were excluded if they did not have a DOAC-specific anti-Xa level at presentation. Therapeutic levels were defined as an anti-Xa of 50 ng/mL to 250 ng/mL for rivaroxaban and 75 ng/mL to 250 ng/mL for apixaban. Linear regression was used to identify correlations between study variables and anti-Xa level, and binomial logistic regression was used to test the association of anti-Xa level with outcomes. Results There were 364 trauma patients admitted during the study period who were documented to be on apixaban or rivaroxaban. Of these, 245 patients had anti-Xa levels measured at admission. The population was 53% woman, with median age of 78 years, and median Injury Severity Score of 5. In total, 39% of patients had therapeutic and 20% had supratherapeutic anti-Xa levels. Female sex, increased age, decreased height and weight, and lower estimated creatinine clearance were associated with higher anti-Xa levels at admission. There was no correlation between anti-Xa level and the need for transfusion or reversal agent administration, admission diagnosis of intracranial hemorrhage (ICH), progression of ICH, hospital length of stay, or mortality. Conclusions Anti-Xa levels in trauma patients on DOACs vary widely; female patients who are older, smaller, and have decreased kidney function present with higher DOAC-specific anti-Xa levels after trauma. We were unable to detect an association between anti-Xa levels and clinical outcomes. Level of evidence III-Prognostic and Epidemiological.
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Affiliation(s)
- Louis Perkins
- Department of Surgery, Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego, San Diego, California, USA
| | - Laura Adams
- Department of Surgery, Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego, San Diego, California, USA
| | - Dmitri Lerner
- Department of Pharmacy, University of California San Diego, San Diego, California, USA
| | - Jarrett Santorelli
- Department of Surgery, Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego, San Diego, California, USA
| | - Alan M Smith
- Department of Surgery, Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego, San Diego, California, USA
| | - Leslie Kobayashi
- Department of Surgery, Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego, San Diego, California, USA
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