1
|
Terrier J, Mach A, Fontana P, Bonhomme F, Casini A. Clinicians' adherence to guidelines for the preoperative management of direct oral anticoagulants in a tertiary hospital: a retrospective study. BMC Anesthesiol 2023; 23:314. [PMID: 37715136 PMCID: PMC10503177 DOI: 10.1186/s12871-023-02276-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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 09/10/2023] [Indexed: 09/17/2023] Open
Abstract
INTRODUCTION Despite clear, relatively easy-to-use guidance, many clinicians find the preoperative management of direct oral anticoagulants (DOACs) challenging. Inappropriate management can delay procedures and lead to haemorrhagic or thromboembolic complications. We aimed to describe preoperative management practices regarding DOACs in a tertiary hospital and clinicians' adherence to in-house recommendations. METHOD We included all patients being treated with DOACs who underwent elective surgery in 2019 and 2020 (n = 337). In-house recommendations for perioperative management were largely comparable to the 2022 American College of Chest Physicians guidelines. RESULTS Typical patients were older adults with multiple comorbidities and high thrombotic risk stratification scores, and 65.6% (n = 221) had not undergone recommended preoperative anticoagulation management protocols. Patients operated on using local anaesthesia (adjusted OR = 0.30, 95%CI 0.14-0.66; p < 0.01) were less likely to have been treated following institutional recommendations, but no association between their procedure's bleeding risk and adherence was found. Clinicians' failures to adhere to recommendations mostly involved late or non-indicated interruptions of anticoagulation treatment (n = 89, 26.4%) or inappropriate heparin bridging (n = 54, 16.0%). Forty-five (13.3%) procedures had to be postponed. Incorrect preoperative anticoagulation management was directly responsible for 12/45 postponements (26.7% of postponements). CONCLUSION This study highlights clinicians' low adherence rates to institutional recommendations for patients treated with DOACs scheduled for elective surgery in a tertiary hospital centre. To the best of our knowledge, this is the first clinical study addressing the issue of clinicians' adherence to guidelines for the preoperative management of DOACs. Going beyond the issue of whether clinicians are knowledgeable about guidelines or have them available, this study questions how generalisable guidelines are in a tertiary hospital managing many highly polymorbid patients. Further studies should identify the causes of poor adherence.
Collapse
Affiliation(s)
- Jean Terrier
- Division of General Internal Medicine, Geneva University Hospitals, Geneva, Switzerland.
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, 4 Rue Gabrielle Perret-Gentil, 1205, Geneva, Switzerland.
| | - Amélie Mach
- Division of Angiology and Hemostasis, Geneva University Hospitals, Geneva, Switzerland
| | - Pierre Fontana
- Division of Angiology and Hemostasis, Geneva University Hospitals, Geneva, Switzerland
| | - Fanny Bonhomme
- Division of Anesthesiology, Geneva University Hospitals, Geneva, Switzerland
| | - Alessandro Casini
- Division of Angiology and Hemostasis, Geneva University Hospitals, Geneva, Switzerland
| |
Collapse
|
2
|
Chalos V, A van de Graaf R, Roozenbeek B, C G M van Es A, M den Hertog H, Staals J, van Dijk L, F M Jenniskens S, J van Oostenbrugge R, H van Zwam W, B W E M Roos Y, B L M Majoie C, F Lingsma H, van der Lugt A, W J Dippel D. Multicenter randomized clinical trial of endovascular treatment for acute ischemic stroke. The effect of periprocedural medication: acetylsalicylic acid, unfractionated heparin, both, or neither (MR CLEAN-MED). Rationale and study design. Trials 2020; 21:644. [PMID: 32665035 PMCID: PMC7362523 DOI: 10.1186/s13063-020-04514-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 06/15/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Despite evidence of a quite large beneficial effect of endovascular treatment (EVT) for ischemic stroke caused by anterior circulation large vessel occlusion, many patients do not recover even after complete recanalization. To some extent, this may be attributable to incomplete microvascular reperfusion, which can possibly be improved by antiplatelet agents and heparin. It is unknown whether periprocedural antithrombotic medication in patients treated with EVT improves functional outcome. The aim of this study is to assess the effect of acetylsalicylic acid (ASA) and unfractionated heparin (UFH), alone, or in combination, given to patients with an ischemic stroke caused by an intracranial large vessel occlusion in the anterior circulation during EVT. METHODS MR CLEAN-MED is a multicenter phase III trial with a prospective, 2 × 3 factorial randomized, open label, blinded end-point (PROBE) design, which aims to enroll 1500 patients. The trial is designed to evaluate the effect of intravenous ASA (300 mg), UFH (low or moderate dose), both or neither as adjunctive therapy to EVT. We enroll adult patients with a clinical diagnosis of stroke (NIHSS ≥ 2) and with a confirmed intracranial large vessel occlusion in the anterior circulation on CTA or MRA, when EVT within 6 h from symptom onset is indicated and possible. The primary outcome is the score on the modified Rankin Scale (mRS) at 90 days. Treatment effect on the mRS will be estimated with ordinal logistic regression analysis, with adjustment for main prognostic variables. Secondary outcomes include stroke severity measured with the NIHSS at 24 h and at 5-7 days, follow-up infarct volume, symptomatic intracranial hemorrhage (sICH), and mortality. DISCUSSION Clinical equipoise exists whether antithrombotic medication should be administered during EVT for a large vessel occlusion, as ASA and/or UFH may improve functional outcome, but might also lead to an increased risk of sICH. When one or both of the study treatments show the anticipated effect on outcome, we will be able to improve outcome of patients treated with EVT by 5%. This amounts to more than 50 patients annually in the Netherlands, more than 1800 in Europe, and more than 1300 in the USA. TRIAL REGISTRATION ISRCT, ISRCTN76741621 . Dec 6, 2017.
Collapse
Affiliation(s)
- Vicky Chalos
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Rob A van de Graaf
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Adriaan C G M van Es
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Julie Staals
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Lukas van Dijk
- Department of Radiology & Nuclear Medicine, HagaZiekenhuis, Radiology, Den Haag, The Netherlands
| | - Sjoerd F M Jenniskens
- Department of Radiology & Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Wim H van Zwam
- Department of Radiology & Nuclear Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, location AMC, Amsterdam, The Netherlands
| | - Charles B L M Majoie
- Department of Radiology & Nuclear Medicine, Amsterdam UMC, University of Amsterdam, location AMC, Amsterdam, The Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Aad van der Lugt
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
3
|
Nicoara A, Maldonado Y, Kort S, Swaminathan M, Mackensen GB. Specific Considerations for the Protection of Patients and Echocardiography Service Providers When Performing Perioperative or Periprocedural Transesophageal Echocardiography during the 2019 Novel Coronavirus Outbreak: Council on Perioperative Echocardiography Supplement to the Statement of the American Society of Echocardiography Endorsed by the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr 2020; 33:666-9. [PMID: 32503703 DOI: 10.1016/j.echo.2020.04.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 04/05/2020] [Indexed: 11/20/2022]
Abstract
TEE carries a high risk for SARS-CoV-2 spread. TEE should be performed when clinical benefits outweigh the risks. Proper handling and cleaning of equipment is critical. Airborne precautions should be used in patients suspected or confirmed COVID-19.
Collapse
|
4
|
Leone M, Einav S, Chiumello D, Constantin JM, De Robertis E, De Abreu MG, Gregoretti C, Jaber S, Maggiore SM, Pelosi P, Sorbello M, Afshari A; Guideline contributors. Noninvasive respiratory support in the hypoxaemic peri-operative/ periprocedural patient: a joint ESA/ESICM guideline. Intensive Care Med 2020; 46:697-713. [PMID: 32157356 DOI: 10.1007/s00134-020-05948-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 01/22/2020] [Indexed: 12/12/2022]
Abstract
Hypoxaemia is a potential life-threatening yet common complication in the peri-operative and periprocedural patient (e.g. during an invasive procedure at risk of deterioration of gas exchange, such as bronchoscopy). The European Society of Anaesthesiology (ESA) and the European Society of Intensive Care Medicine (ESICM) developed guidelines for the use of noninvasive respiratory support techniques in the hypoxaemic patient in the peri-operative and periprocedural period. The panel outlined five clinical questions regarding treatment with noninvasive respiratory support techniques [conventional oxygen therapy (COT), high flow nasal cannula, noninvasive positive pressure ventilation (NIPPV) and continuous positive airway pressure (CPAP)] for hypoxaemic patients with acute peri-operative/periprocedural respiratory failure. The goal was to assess the available literature on the various noninvasive respiratory support techniques, specifically studies that included adult participants with hypoxaemia in the peri-operative/periprocedural period. The literature search strategy was developed by a Cochrane Anaesthesia and Intensive Care trial search specialist in close collaboration with the panel members and the ESA group methodologist. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to assess the level of evidence and to grade recommendations. The final process was then validated by both ESA and ESICM scientific committees. Among 19 recommendations, the two grade 1B recommendations state that: in the peri-operative/periprocedural hypoxaemic patient, the use of either NIPPV or CPAP (based on local expertise) is preferred to COT for improvement of oxygenation; and that the panel suggests using NIPPV or CPAP immediately post-extubation for hypoxaemic patients at risk of developing acute respiratory failure after abdominal surgery.
Collapse
|
5
|
Baumgartner C, de Kouchkovsky I, Whitaker E, Fang MC. Periprocedural Bridging in Patients with Venous Thromboembolism: A Systematic Review. Am J Med 2019; 132:722-732.e7. [PMID: 30659809 PMCID: PMC6588421 DOI: 10.1016/j.amjmed.2019.01.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 01/08/2019] [Accepted: 01/08/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Vitamin K antagonists (VKA) are the most widely used anticoagulants, and bridging is commonly administered during periprocedural VKA interruption. Given the unclear benefits and risks of periprocedural bridging in patients with previous venous thromboembolism, we aimed to assess recurrent venous thromboembolism and bleeding outcomes with and without bridging in this population. METHODS We performed a systematic review searching the PubMed and Embase databases from inception to December 7, 2017 for randomized and nonrandomized studies that included adults with previous venous thromboembolism requiring VKA interruption to undergo an elective procedure, and that reported venous thromboembolism or bleeding outcomes. Quality of evidence was graded by consensus. RESULTS We included 28 cohort studies (20 being single-arm cohorts) with, overall, 6915 procedures for analysis. In 27 studies reporting perioperative venous thromboembolism outcomes, the pooled incidence of recurrent venous thromboembolism with bridging was 0.7% (95% confidence interval [CI], 0.4%-1.2%) and 0.5% (95% CI, 0.3%-0.8%) without bridging. Eighteen studies reported major or nonmajor bleeding outcomes. The pooled incidence of any bleeding was 3.9% (95% CI, 2.0%-7.4%) with bridging and 0.4% (95% CI, 0.1%-1.7%) without bridging. In bridged patients at high thromboembolic risk, the pooled incidence for venous thromboembolism was 0.8% (95% CI, 0.3%-2.5%) and 7.5% (95% CI, 3.1%-17.4%) for any bleeding. Quality of available evidence was very low, primarily due to a high risk of bias of included studies. CONCLUSIONS Periprocedural bridging increases the risk of bleeding compared with VKA interruption without bridging, without a significant difference in periprocedural venous thromboembolism rates.
Collapse
Affiliation(s)
- Christine Baumgartner
- Division of Hospital Medicine, University of California, San Francisco; Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Evans Whitaker
- UCSF Medical Library, University of California, San Francisco
| | - Margaret C Fang
- Division of Hospital Medicine, University of California, San Francisco.
| |
Collapse
|
6
|
Hohnloser SH, Camm J, Cappato R, Diener HC, Heidbuchel H, Lanz HJ, Mont L, Morillo CA, Smolnik R, Yin OQP, Kautzner J. Uninterrupted administration of edoxaban vs vitamin K antagonists in patients undergoing atrial fibrillation catheter ablation: Rationale and design of the ELIMINATE-AF study. Clin Cardiol 2018; 41:440-449. [PMID: 29663464 DOI: 10.1002/clc.22918] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [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: 11/13/2017] [Revised: 01/22/2018] [Accepted: 02/02/2018] [Indexed: 12/29/2022] Open
Abstract
Patients with atrial fibrillation (AF) are at an approximately 0.5% to 3% increased risk of thromboembolism during and immediately after catheter ablation. Treatment guidelines recommend periprocedural oral anticoagulation plus unfractionated heparin during ablation. Rivaroxaban and dabigatran are the only non-vitamin K oral anticoagulants for which there are randomized controlled trials assessing uninterrupted anticoagulation in patients undergoing catheter ablation of AF. Edoxaban, a direct factor Xa inhibitor, is noninferior vs warfarin for the prevention of stroke or systemic embolism with less major bleeding in patients with nonvalvular AF. The ELIMINATE-AF (Evaluation of Edoxaban Compared With VKA in Subjects Undergoing Catheter Ablation of Nonvalvular Atrial Fibrillation) trial is a multinational, multicenter, prospective, randomized, open-label, parallel-group, blinded-endpoint evaluation (PROBE) study to assess the safety and efficacy of once-daily edoxaban 60 mg (30 mg in patients indicated for a dose reduction) vs vitamin K antagonists (VKA) in patients with nonvalvular AF undergoing catheter ablation (http://www.ClinicalTrials.gov: NCT02942576). A total of 560 patients are planned for randomization to edoxaban or VKA (2:1 ratio) to obtain 450 patients fully compliant with the protocol. Patients will complete 21 to 28 days of anticoagulation prior to the ablation and a 90-day post-ablation period. The primary efficacy endpoint is the composite of all-cause death, stroke, and major bleeding. The primary safety endpoint is major bleeding. A magnetic resonance imaging substudy will assess the incidence of silent cerebral lesions post-ablation. ELIMINATE-AF will define the efficacy and safety of edoxaban for uninterrupted oral anticoagulation during catheter ablation of AF.
Collapse
Affiliation(s)
- Stefan H Hohnloser
- Division of Clinical Electrophysiology, Department of Cardiology, J.W. Goethe University, Frankfurt, Germany
| | - John Camm
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St. George's University of London, London, UK
| | - Riccardo Cappato
- Arrhythmia and Electrophysiology Research Center, Humanitas Clinical and Research Center, Rozzano, Italy
| | - Hans-Christoph Diener
- Department of Neurology, University Hospital Essen and Medical Faculty of the University Duisburg-Essen, Essen, Germany
| | - Hein Heidbuchel
- Department of Cardiology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Hans-Joachim Lanz
- Department of Global Medical Affairs, Daiichi-Sankyo Europe GmbH, Munich, Germany
| | - Lluís Mont
- Department of Cardiology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Carlos A Morillo
- Department of Cardiac Sciences, Division of Cardiology, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Rüdiger Smolnik
- Department of Global Medical Affairs, Daiichi-Sankyo Europe GmbH, Munich, Germany
| | - Ophelia Q P Yin
- Pharma Development, Modeling, and Simulation, Daiichi-Sankyo, Basking Ridge, New Jersey
| | - Josef Kautzner
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| |
Collapse
|
7
|
Oikawa FTC, Hueb W, Nomura CH, Hueb AC, Villa AV, da Costa LMA, de Melo RMV, Rezende PC, Segre CAW, Garzillo CL, Lima EG, Ramires JAF, Filho RK. Abnormal elevation of myocardial necrosis biomarkers after coronary artery bypass grafting without established myocardial infarction assessed by cardiac magnetic resonance. J Cardiothorac Surg 2017; 12:122. [PMID: 29284532 PMCID: PMC5747262 DOI: 10.1186/s13019-017-0684-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 12/07/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The diagnosis of peri-procedural myocardial infarction is complex, especially after the emergence of high-sensitivity markers of myocardial necrosis. METHODS In this study, patients with normal baseline cardiac biomarkers and formal indication for elective on-pump coronary bypass surgery were evaluated. Electrocardiograms, cardiac biomarkers, and cardiac magnetic resonance imaging with late gadolinium enhancement were performed before and after procedures. Myocardial infarction was defined as more than ten times the upper reference limit of the 99th percentile for troponin I and for creatine kinase isoform (CK-MB) and by the findings of new late gadolinium enhancement on cardiac magnetic resonance. We assessed the release of cardiac biomarkers in patients with no evidence of myocardial infarction on cardiac magnetic resonance. RESULTS Of 75 patients referred for on-pump coronary bypass surgery, 54 (100%) did not have evidence of myocardial infarction on cardiac magnetic resonance. However, all had a peak troponin I above the 99th percentile; 52 (96%) had an elevation 10 times higher than the 99th percentile. Regarding CK-MB, 54 (100%) patients had a peak CK-MB above the 99th percentile limit, and only 13 (24%) had an elevation greater than 10 times the 99th percentile. The median value of troponin I peak was 3.15 (1.2 to 3.9) ng/mL, which represented 78.7 times the 99th percentile. CONCLUSION In this study, different from CK-MB findings, troponin was significantly increased in the absence of myocardial infarction on cardiac magnetic resonance. Thus, CK-MB was more accurate than troponin I for excluding procedure-related myocardial infarction. These data suggest a higher troponin cutoff for the diagnosis of coronary bypass surgery related myocardial infarction. CLINICAL TRIAL REGISTRATION http://www.isrctn.com/ISRCTN09454308 . Registered 08 May 2012.
Collapse
Affiliation(s)
- Fernando Teiichi Costa Oikawa
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Whady Hueb
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Cesar Higa Nomura
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Alexandre Ciappina Hueb
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Alexandre Volney Villa
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Leandro Menezes Alves da Costa
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Rodrigo Morel Vieira de Melo
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Paulo Cury Rezende
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Carlos Alexandre Wainrober Segre
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Cibele Larrosa Garzillo
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Eduardo Gomes Lima
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Jose Antonio Franchini Ramires
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Roberto Kalil Filho
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| |
Collapse
|
8
|
Gunasekaran P, Parashara DK. Periprocedural Management of Non-Vitamin K Oral Anticoagulants in Chronic Kidney Disease: A Review of Existing Heterogeneity and Contemporary Evidence. J Atr Fibrillation 2016; 8:1230. [PMID: 27957221 DOI: 10.4022/jafib.1230] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 07/25/2015] [Accepted: 09/02/2015] [Indexed: 11/10/2022]
Abstract
Non vitamin-K oral anticoagulants (NOAC) have considerably enhanced anticoagulation practice for non-valvular atrial fibrillation with specific advantages of fixed dosing, non-fluctuant therapeutic levels and obviation of therapeutic level monitoring. NOAC pharmacology is remarkable for considerable renal excretion. Heterogeneity in the precise time cut-offs for discontinuation of NOACs prior to elective surgical or percutaneous procedures arise from the non-linear variations of drug excretion with different levels of creatinine clearances as in chronic kidney disease. Multiple authors have suggested cut-offs leading to ambiguity among practicing clinicians. Recent data pertaining to systemic thromboembolism, stroke and major bleeding derived from randomized controlled clinical trials have simplified the periprocedural management of NOACs. This review focusses on heterogeneity in the management of NOACs in patients with CKD in this peculiar scenario and highlights the contemporary evidence to support a unified approach towards perioperative management of NOACs. Multiple antidotes targeted towards binding of specific NOACs have been developed and are in the testing phase, thereby offering immense potential for rapid and complete reversal of NOAC activity in emergent procedures and major bleeding episodes. Targeted research on thromboembolism, stroke and major bleeding following temporary periprocedural interruption of NOACs using multicentric registries could further expand the clinical utility of these agents.
Collapse
Affiliation(s)
- Prasad Gunasekaran
- Chief Fellow, Division of Cardiovascular Diseases, Division of Cardiovascular Diseases, University of Kansas, Kansas City, KS, USA
| | - Deepak K Parashara
- Chief and Director, Division of Cardiology and Cardiac Catheterization Laboratory, Heartland Veterans Affairs Medical Center, Kansas City, MO, USA
| |
Collapse
|
9
|
Abstract
Every year, new studies are undertaken to address the complex issue of periprocedural management of patients on anticoagulants and antiplatelet medications. In addition, newer drugs add to the confusion among clinicians about how to best manage patients taking these agents. Using the most recent data, guidelines, and personal experience, this article discusses recommendations and presents simplified algorithms to assist clinicians in the periprocedural management of patients on anticoagulants.
Collapse
Affiliation(s)
- Lance A Williams
- Department of Pathology, University of Alabama at Birmingham, 619 19th Street South, WPP230F, Birmingham, AL 35249-7331, USA.
| | - James M Hunter
- Department of Anesthesiology, University of Alabama at Birmingham, 1720 2nd Avenue South, JT926C, Birmingham, AL 35249-6810, USA
| | - Marisa B Marques
- Department of Pathology, University of Alabama at Birmingham, 619 19th Street South, WPP230G, Birmingham, AL 35249-7331, USA
| | - Thomas R Vetter
- Department of Anesthesiology, University of Alabama at Birmingham, 619 19th Street South, JT865, Birmingham, AL 35249, USA
| |
Collapse
|
10
|
Cay S, Durmaz T, Canpolat U, Aydogdu S. High dose statins should be used in all patients undergoing percutaneous coronary intervention. Int J Cardiol 2013; 168:5103-4. [PMID: 23962786 DOI: 10.1016/j.ijcard.2013.07.248] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2013] [Accepted: 07/25/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Serkan Cay
- Department of Cardiology, Yuksek Ihtisas Heart-Education and Research Hospital, Ankara, Turkey.
| | | | | | | |
Collapse
|