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Wang B, Tang N, Zhang C. Lupus Anticoagulant-Hypoprothrombinemia Syndrome: Literature Review and Description of Local Case in a 3-Year-Old Chinese Girl. Semin Thromb Hemost 2024; 50:592-604. [PMID: 38395068 DOI: 10.1055/s-0044-1779739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Lupus anticoagulant-hypoprothrombinemia syndrome (LAHPS) is a rare, acquired coagulopathy syndrome. Here, we aim to summarize the clinical features of LAHPS to improve the understanding of the disease. The clinical data of 52 patients with LAHPS retrieved through PubMed from 2019 to 2023, supplemented with a local case of a child with LAHPS, were retrospectively analyzed, and the clinical characteristics were summarized. 56.6% of LAHPS patients were female, the median age at onset was 13.0 years (range, 1.2-85 years), and the median activity of factor II was 18.0% (range, 0.1-69%). 64.2% of LAHPS patients experienced hemorrhage, with 29.4% having multisite hemorrhage and 20.6% experiencing both nonsevere and severe hemorrhage. Most of the reported cases were secondary to autoimmune diseases (60.6%), followed by infections (33.3%). Corticosteroids were administered to 79.3% of patients with hemorrhage, and 90.6% of patients with LAHPS showed improvement. In conclusion, LAHPS is most commonly observed in female patients, particularly those under 18 years of age. LAHPS is characterized by hemorrhage, occurring at various sites and with varying degrees of severity, but the majority of patients improve with appropriate treatment and management.
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Affiliation(s)
- Bin Wang
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ning Tang
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chi Zhang
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Giabicani M, Joly P, Sigaut S, Timsit C, Devauchelle P, Dondero F, Durand F, Froissant PA, Lamamri M, Payancé A, Restoux A, Roux O, Thibault-Sogorb T, Valainathan SR, Lesurtel M, Rautou PE, Weiss E. Predictive role of hepatic venous pressure gradient in bleeding events among patients with cirrhosis undergoing orthotopic liver transplantation. JHEP Rep 2024; 6:101051. [PMID: 38699073 PMCID: PMC11060951 DOI: 10.1016/j.jhepr.2024.101051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 01/31/2024] [Accepted: 02/14/2024] [Indexed: 05/05/2024] Open
Abstract
Background & Aims Major bleeding events during orthotopic liver transplantation (OLT) are associated with poor outcomes. The proportion of this risk related to portal hypertension is unclear. Hepatic venous pressure gradient (HVPG) is the gold standard for estimating portal hypertension. The aim of this study was to analyze the ability of HVPG to predict intraoperative major bleeding events during OLT in patients with cirrhosis. Methods We retrospectively analyzed a prospective database including all patients with cirrhosis who underwent OLT between 2010 and 2020 and had liver and right heart catheterizations as part of their pre-transplant assessment. The primary endpoint was the occurrence of an intraoperative major bleeding event. Results The 468 included patients had a median HVPG of 17 mmHg [interquartile range, 13-22] and a median MELD on the day of OLT of 16 [11-24]. Intraoperative red blood cell transfusion was required in 72% of the patients (median 2 units transfused), with a median blood loss of 1,000 ml [575-1,500]. Major intraoperative bleeding occurred in 156 patients (33%) and was associated with HVPG, preoperative hemoglobin level, severity of cirrhosis at the time of OLT (MELD score, ascites, encephalopathy), hemostasis impairment (thrombocytopenia, lower fibrinogen levels), and complications of cirrhosis (sepsis, acute-on-chronic liver failure). By multivariable regression analysis with backward elimination, HVPG, preoperative hemoglobin level, MELD score, and tranexamic acid infusion were associated with the primary endpoint. Three categories of patients were identified according to HVPG: low-risk (HVPG <16 mmHg), high-risk (HVGP ≥16 mmHg), and very high-risk (HVPG ≥20 mmHg). Conclusions HVPG predicted major bleeding events in patients with cirrhosis undergoing OLT. Including HVPG as part of pre-transplant assessment might enable better anticipation of the intraoperative course. Impact and implications Major bleeding events during orthotopic liver transplantation (OLT) are associated with poor outcomes but the proportion of this risk related to portal hypertension is unclear. Our work shows that hepatic venous pressure gradient (HVPG), the gold standard for estimating portal hypertension, is a strong predictor of major bleeding events and blood loss volume in patients with cirrhosis undergoing OLT. Three groups of patients can be identified according to their risk of major bleeding events: low-risk patients with HVPG <16 mmHg, high-risk patients with HVPG ≥16 mmHg, and very high-risk patients with HVPG ≥20 mmHg. HVPG could be systematically included in the pre-transplant assessment to anticipate intraoperative course and tailor patient management.
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Affiliation(s)
- Mikhael Giabicani
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
- Université Paris-Cité, Paris, France
| | - Pauline Joly
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
| | - Stéphanie Sigaut
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
| | - Clara Timsit
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
| | - Pauline Devauchelle
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
| | - Fédérica Dondero
- Departement of HPB Surgery & Liver Transplantation, AP-HP, Beaujon Hospital, DMU DIGEST, Université Paris-Cité, Clichy, France
| | - François Durand
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
| | | | - Myriam Lamamri
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
| | - Audrey Payancé
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
| | - Aymeric Restoux
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
| | - Olivier Roux
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | | | - Shantha Ram Valainathan
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | - Mickaël Lesurtel
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
- Departement of HPB Surgery & Liver Transplantation, AP-HP, Beaujon Hospital, DMU DIGEST, Université Paris-Cité, Clichy, France
| | - Pierre-Emmanuel Rautou
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
| | - Emmanuel Weiss
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
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Decaix T, Kemache K, Gay P, Ketz F, Laprévote O, Pautas É. Pharmacokinetics and pharmacodynamics of drug‒drug interactions in hospitalized older adults treated with direct oral anticoagulants. Aging Clin Exp Res 2024; 36:113. [PMID: 38776005 PMCID: PMC11111557 DOI: 10.1007/s40520-024-02768-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 04/26/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE Polypharmacy is a frequent situation in older adults that increases the risk of drug-drug interactions (DDIs), both pharmacokinetic (PK) and pharmacodynamic (PD). Direct oral anticoagulants (DOACs) are frequently prescribed in older adults, mainly because of the high prevalence of atrial fibrillation (AF). DOACs are subject to cytochrome P450 3A4 (CYP3A4)- and/or P-glycoprotein (P-gp)-mediated PK DDIs and PD DDIs when co-administered with drugs that interfere with platelet function. The aim of our study was to assess the prevalence of DDIs involving DOACs in older adults and the associated risk factors at admission and discharge. METHODS This was a cross-sectional study conducted in an acute geriatric unit between January 1, 2018 and December 31, 2022, including patients over 75 years of age treated with DOACs at admission and/or discharge, for whom a comprehensive collection of co-medications was performed. RESULTS From 909 hospitalizations collected, the prevalence of PK DDIs involving DOACs was 16.9% at admission and 20.7% at discharge, and the prevalence of PD DDIs was 20.7% at admission and 20.2% at discharge. Factors associated with DDIs were bleeding history [adjusted odds ratio (ORa) 1.74, 95% confidence interval (CI) 1.13-2.68], number of drugs > 6 (ORa 2.54, 95% CI 1.88-3.46) and reduced dose of DOACs (ORa 0.39, 95% CI 0.28-0.54) at admission and age > 87 years (ORa 0.74, 95% CI 0.55-0.99), number of drugs > 6 (ORa 2.01, 95% CI 1.48-2.72) and reduced dose of DOACs (ORa 0.41, 95% CI 0.30-0.57) at discharge. CONCLUSION This study provides an indication of the prevalence of DDIs as well as the profile of DDIs and patients treated with DOACs.
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Affiliation(s)
- Théodore Decaix
- Geriatrics department, APHP Paris Cité University, Lariboisière-Fernand Widal Hospital, Paris, France.
- Paris-Cité University, CNRS, Paris, F-75006, CitCoM, France.
- Faculty of Pharmacy, Paris-Cité University, 4 avenue de l'Observatoire, Paris, 75006, France.
| | - Kenza Kemache
- Acute Geriatrics Unit, Charles Foix Hospital, APHP Sorbonne University, Ivry-sur-Seine, France
| | - Pierre Gay
- Acute Geriatrics Unit, Charles Foix Hospital, APHP Sorbonne University, Ivry-sur-Seine, France
| | - Flora Ketz
- Acute Geriatrics Unit, Charles Foix Hospital, APHP Sorbonne University, Ivry-sur-Seine, France
| | - Olivier Laprévote
- Paris-Cité University, CNRS, Paris, F-75006, CitCoM, France
- Department of biology, National Hospital Center Of ophthalmology, 15-20, F-75012, Paris, France
| | - Éric Pautas
- Acute Geriatrics Unit, Charles Foix Hospital, APHP Sorbonne University, Ivry-sur-Seine, France
- Therapeutic innovations in hemostasis, Paris-Cité University, UMR-S 1140, Inserm, Paris, France
- Medical school, Sorbonne University, Paris, France
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Hisatake S, Kiuchi S, Dobashi S, Murakami Y, Ikeda T. Evaluation of acute thrombus regression effect of edoxaban for deep vein thrombosis in patients with cancer: a single-center prospective observational study. Heart Vessels 2024:10.1007/s00380-024-02418-1. [PMID: 38771333 DOI: 10.1007/s00380-024-02418-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 05/15/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Although there are reports on the recurrence prevention in the chronic phase using direct oral anticoagulants (DOACs) for deep vein thrombosis (DVT) in patients with cancer, acute thrombus regression effect using DOACs has not been assessed. This study aimed to assess the thrombus regression effect of initial treatment using edoxaban for acute lower-extremity DVT in patients with active cancer. METHODS AND RESULTS In this observational study, among the inpatients with cancer and lower-extremity DVT who underwent initial treatment with edoxaban at our hospital from November 2019 to December 2021, 34 consenting patients were recruited in this study. The quantitative ultrasound thrombus (QUT) score of thrombus volume was calculated at baseline (before administration) and 7-14 days after the start of edoxaban administration, using lower-extremity venous ultrasound to evaluate changes in thrombus volume. The primary and secondary endpoints were the acute thrombus regression effect of edoxaban and the impact of patients' clinical frailty on the thrombus regression effect, respectively. Anticoagulant therapy with edoxaban significantly reduced QUT score (p < 0.001). In addition, regardless of the Clinical Frailty Scale scores, QUT score decreased significantly. CONCLUSION Initial treatment with edoxaban was effective for lower-extremity DVT in patients with cancer. In addition, the effect was the same independent of the degree of frailty.
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Affiliation(s)
- Shinji Hisatake
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, 6-11-1 Omorinishi, Ota-Ku, Tokyo, 143-8541, Japan.
| | - Shunsuke Kiuchi
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, 6-11-1 Omorinishi, Ota-Ku, Tokyo, 143-8541, Japan
| | - Shintaro Dobashi
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, 6-11-1 Omorinishi, Ota-Ku, Tokyo, 143-8541, Japan
| | - Yoshiki Murakami
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, 6-11-1 Omorinishi, Ota-Ku, Tokyo, 143-8541, Japan
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, 6-11-1 Omorinishi, Ota-Ku, Tokyo, 143-8541, Japan
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Mol BM, Verwer MC, Fijnheer R, Florie J, Groot OA, Hietbrink F, Nijkeuter M, Vonken EJPA, van Weel V, de Kleijn DPV, de Borst GJ. Predictors of bleeding complications during catHeter-dirEcted thrombolysis for peripheral arterial occlusions (POCHET). PLoS One 2024; 19:e0302830. [PMID: 38722842 PMCID: PMC11081216 DOI: 10.1371/journal.pone.0302830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 04/13/2024] [Indexed: 05/13/2024] Open
Abstract
INTRODUCTION The risk of major bleeding complications in catheter directed thrombolysis (CDT) for acute limb ischemia (ALI) remains high, with reported major bleeding complication rates in up to 1 in every 10 treated patients. Fibrinogen was the only predictive marker used for bleeding complications in CDT, despite the lack of high quality evidence to support this. Therefore, recent international guidelines recommend against the use of fibrinogen during CDT. However, no alternative biomarkers exist to effectively predict CDT-related bleeding complications. The aim of the POCHET biobank is to prospectively assess the rate and etiology of bleeding complications during CDT and to provide a biobank of blood samples to investigate potential novel biomarkers to predict bleeding complications during CDT. METHODS The POCHET biobank is a multicentre prospective biobank. After informed consent, all consecutive patients with lower extremity ALI eligible for CDT are included. All patients are treated according to a predefined standard operating procedure which is aligned in all participating centres. Baseline and follow-up data are collected. Prior to CDT and subsequently every six hours, venous blood samples are obtained and stored in the biobank for future analyses. The primary outcome is the occurrence of non-access related major bleeding complications, which is assessed by an independent adjudication committee. Secondary outcomes are non-major bleeding complications and other CDT related complications. Proposed biomarkers to be investigated include fibrinogen, to end the debate on its usefulness, anti-plasmin and D-Dimer. DISCUSSION AND CONCLUSION The POCHET biobank provides contemporary data and outcomes of patients during CDT for ALI, coupled with their blood samples taken prior and during CDT. Thereby, the POCHET biobank is a real world monitor on biomarkers during CDT, supporting a broad spectrum of future research for the identification of patients at high risk for bleeding complications during CDT and to identify new biomarkers to enhance safety in CDT treatment.
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Affiliation(s)
- Barend M. Mol
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maarten C. Verwer
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rob Fijnheer
- Department of Hematology, Meander Medical Center, Amersfoort, The Netherlands
| | - Jasper Florie
- Department of Interventional Radiology, Meander Medical Center, Amersfoort, The Netherlands
| | - Oscar A. Groot
- Intensive Care Department, Meander Medical Center, Amersfoort, The Netherlands
| | - Falco Hietbrink
- Department Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mathilde Nijkeuter
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Evert-Jan P. A. Vonken
- Department of Interventional Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Vincent van Weel
- Department of Vascular Surgery, Meander Medical Center, Amersfoort, The Netherlands
| | | | - Gert J. de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Ren J, Wang N, Zhang X, Song F, Zheng X, Han X. A systematic review and meta-analysis of the morbidity of efficacy endpoints and bleeding events in elderly and young patients treated with the same dose rivaroxaban. Ann Hematol 2024:10.1007/s00277-024-05767-z. [PMID: 38710878 DOI: 10.1007/s00277-024-05767-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 04/17/2024] [Indexed: 05/08/2024]
Abstract
Rivaroxaban is a new direct oral anticoagulant, and the same dose is recommended for older and young patients. However, recent real-world studies show that older patients may need dose adjustment to prevent major bleeding. At present, the evidence for dose adjustment in older patients is extremely limited with only a few reports on older atrial fibrillation patients. The aim of this study was to review the morbidity data of adverse events and bleeding events across all indications for older and young patients treated with the same dose of rivaroxaban to provide some support for dosage adjustment in older patients. The PubMed, EMBASE, ClinicalTrials, Cochrane and Web of Science databases were searched for randomized controlled trials (RCTs) published between January 1, 2005, and October 10, 2023. The primary outcomes were the morbidity of bleeding events and efficacy-related adverse events. Summary estimates were calculated using a random effects model. Eighteen RCTs were included in the qualitative analysis. The overall morbidity of primary efficacy endpoints was higher in older patients compared to the young patients (3.37% vs. 2.60%, χ2 = 5.24, p = 0.022). Similarly, a higher morbidity of bleeding was observed in older patients compared to the young patients (4.42% vs. 6.03%, χ2 = 13.22, p < 0.001). Among all indications, deep vein thrombosis, pulmonary embolism and atrial fibrillation were associated with the highest incidence of bleeding in older patients, suggesting that these patients may be most need dose adjustment. Patients older than 75 years may require extra attention to prevent bleeding. The same dose of rivaroxaban resulted in higher bleeding morbidity and morbidity of efficacy-related adverse events in older patients compared to the young patients. An individualized dose adjustment may be preferred for older patients rather than a fixed dose that fits all.
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Affiliation(s)
- Jianwei Ren
- Clinical Pharmacology Research Center, Beijing Key Laboratory of Clinical PK and PD Investigation for Innovative Drugs, NMPA Key Laboratory for Clinical Research and Evaluation of Drug, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Na Wang
- Clinical Pharmacology Research Center, Beijing Key Laboratory of Clinical PK and PD Investigation for Innovative Drugs, NMPA Key Laboratory for Clinical Research and Evaluation of Drug, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Xuan Zhang
- Clinical Pharmacology Research Center, Beijing Key Laboratory of Clinical PK and PD Investigation for Innovative Drugs, NMPA Key Laboratory for Clinical Research and Evaluation of Drug, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Fuyu Song
- Center for Food and Drug Inspection, National Medical Products Administration, Beijing, 100053, China
- NHC Key Laboratory of Mental Health, National Clinical Research Center for Mental Disorders, Peking University Sixth Hospital, Peking University Institute of Mental Health, Peking University, Beijing, 100191, China
| | - Xin Zheng
- Clinical Pharmacology Research Center, Beijing Key Laboratory of Clinical PK and PD Investigation for Innovative Drugs, NMPA Key Laboratory for Clinical Research and Evaluation of Drug, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
| | - Xiaohong Han
- Clinical Pharmacology Research Center, Beijing Key Laboratory of Clinical PK and PD Investigation for Innovative Drugs, NMPA Key Laboratory for Clinical Research and Evaluation of Drug, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
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Ghafil C, Park C, Yu J, Drake A, Sundaram S, Thiele L, Graham C, Inaba K, Matsushima K. The risk of hemorrhagic complications after anticoagulation therapy in trauma patients: A multicenter evaluation. J Trauma Acute Care Surg 2024; 96:757-762. [PMID: 37962213 PMCID: PMC11043002 DOI: 10.1097/ta.0000000000004209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
BACKGROUND The use of anticoagulation therapy (ACT) in trauma patients during the postinjury period presents a challenge given the increased risk of hemorrhage. Guidelines regarding whether and when to initiate ACT are lacking, and as a result, practice patterns vary widely. The purpose of this study is to describe the incidence of hemorrhagic complications in patients who received ACT during their hospitalization, identify risk factors, and characterize the required interventions. METHODS In this retrospective cohort study, all trauma admissions at two Level I trauma centers between January 2015 and December 2020 were reviewed. Patients with preexisting ACT use or those who developed a new indication for ACT were included for analysis. Demographic and outcome data were collected for those who received ACT during their admission. Comparisons were then made between the complications and no complications groups. A subgroup analysis was performed for all patients started on ACT within 14 days of injury. RESULTS A total of 812 patients were identified as having an indication for ACT, and 442 patients received ACT during the postinjury period. The overall incidence of hemorrhagic complications was 12.7%. Of those who sustained hemorrhagic complications, 18 required procedural intervention. On regression analysis, male sex, severe injuries, and the need for hemorrhage control surgery on arrival were all found to be associated with hemorrhagic complications after the initiation of ACT. Waiting 7 days to 14 days from the time of injury to initiate ACT reduced the odds of complications by 46% and 71%, respectively. CONCLUSION The use of ACT in trauma during the postinjury period is not without risk. Waiting 7 days to 14 days postinjury might greatly reduce the risk of hemorrhagic complications. LEVEL OF EVIDENCE Therapeutic/Care Management Study; Level IV.
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Affiliation(s)
- Cameron Ghafil
- Department of Surgery, University of Southern California, 2051 Marengo St. Los Angeles, CA, USA 90033
| | - Caroline Park
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd. Dallas, TX, USA 75390
| | - Jeremy Yu
- Department of Preventive Medicine, University of Southern California, 1845 N Soto St. Los Angeles, CA, USA 90032
| | - Andrew Drake
- Department of Surgery, University of Southern California, 2051 Marengo St. Los Angeles, CA, USA 90033
| | - Shivani Sundaram
- Department of Surgery, University of Southern California, 2051 Marengo St. Los Angeles, CA, USA 90033
| | - Lisa Thiele
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd. Dallas, TX, USA 75390
| | - Caleb Graham
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd. Dallas, TX, USA 75390
| | - Kenji Inaba
- Department of Surgery, University of Southern California, 2051 Marengo St. Los Angeles, CA, USA 90033
| | - Kazuhide Matsushima
- Department of Surgery, University of Southern California, 2051 Marengo St. Los Angeles, CA, USA 90033
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Sartori M, Iotti M, Camporese G, Siragusa S, Imberti D, Bucherini E, Corradini S, Ageno W, Prandoni P, Ghirarduzzi A. Six-week low-molecular-weight heparin versus 12-week warfarin for calf deep vein thrombosis: A randomized, prospective, open-label study. Am J Hematol 2024; 99:854-861. [PMID: 38375893 DOI: 10.1002/ajh.27255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/24/2024] [Accepted: 02/05/2024] [Indexed: 02/21/2024]
Abstract
Current guidelines suggest a 3-month anticoagulant treatment course for isolated distal deep vein thrombosis (IDDVT), but shorter durations of treatment are frequently prescribed in clinical practice. We investigated whether a 6-week treatment with low-molecular-weight heparin (LMWH) at intermediate dosage can be an effective and safe alternative to vitamin K antagonists (VKA) in patients with IDDVT (non-inferiority trial). In a multicenter, open-label, randomized trial, 260 outpatients with symptomatic IDDVT were randomly assigned to receive either LMWH followed by VKA for 12 weeks or LMWH 1 mg/kg subcutaneously twice a day for 2 weeks followed by 1 mg/kg subcutaneously once a day for 4 weeks. The follow-up was 6 months and the primary endpoint was the composite measure of recurrent venous thromboembolism (VTE) defined as: recurrence or extension of IDDVT, proximal DVT, and pulmonary embolism (PE). The study was stopped prematurely due to slow recruiting rates. The primary efficacy outcome occurred in 14 patients receiving LMWH (10.8%) and in five patients receiving VKA (3.8%); risk difference was 0.069 (95% CI: 0.006-0.132), hazard ratio 2.8 (95% CI: 1.04-7.55). There was one PE in the VKA group and one proximal DVT in the LMWH group. IDDVT recurrence was 10.0% in the LMWH group versus 3.1% in the VKA group (p = .024). Two patients had clinically relevant bleedings (1.6%) in the LMWH group versus one (0.8%) in VKA group (p = .56). In conclusion, VKA for 12 weeks seems superior to LMWH for 6 weeks in reducing the risk of VTE recurrences in our cohort of outpatients with IDDVT.
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Affiliation(s)
- Michelangelo Sartori
- Angiology and Blood Coagulation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Matteo Iotti
- Cardiovascular Medicine Unit - AUSL-IRCCS, Reggio Emilia, Italy
| | - Giuseppe Camporese
- General Medicine Unit, Thrombotic and Haemorrhagic Disorders Unit, Department of Internal Medicine, University Hospital of Padua, Padua, Italy
| | - Sergio Siragusa
- Haematology Unit, Thrombosis and Haemostasis Reference Regional Center, University of Palermo, Palermo, Italy
| | - Davide Imberti
- Haemostasis and Thrombosis Center, Department of Internal Medicine, Hospital of Piacenza, Piacenza, Italy
| | | | - Sara Corradini
- Cardiovascular Medicine Unit - AUSL-IRCCS, Reggio Emilia, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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Zeinhom MG, Elbassiouny A, Mohamed AM, Ahmed SR. Ticagrelor Versus Clopidogrel in Acute Large-Vessel Ischemic Stroke: A Randomized Controlled Single-Blinded Trial. CNS Drugs 2024; 38:387-398. [PMID: 38619649 PMCID: PMC11026220 DOI: 10.1007/s40263-024-01080-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/06/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND Large-vessel ischemic stroke represents about 25-40% of all ischemic strokes. Few clinical trials compared ticagrelor versus clopidogrel in ischemic stroke patients; all these studies included only patients with a transient ischemic attack or minor stroke; moreover, none of these studies included patients from North Africa. OBJECTIVES We aimed to compare ticagrelor versus clopidogrel in the first-ever large-vessel occlusion (LVO) acute ischemic stroke in Egypt. METHODS Our trial involved 580 first-ever LVO ischemic stroke patients who were randomly assigned to administer loading and maintenance doses of ticagrelor or clopidogrel. Screening, randomization, and start of treatment occurred during the first 24 hours of the stroke. RESULTS 580 patients were included in the intention-to-treat analysis. Thirty patients in the ticagrelor group and 49 patients in the clopidogrel group experienced a new ischemic or hemorrhagic stroke at 90 days (hazard ratio [HR] 0.61; 95% confidence interval [CI] 0.38-0.98; p-value = 0.04), 36 patients in the ticagrelor group, and 57 in the clopidogrel group experienced composite of a new stroke, myocardial infarction, or death due to vascular insults (HR 0.56; 95% CI 0.37-0.87; p = 0.009). Patients who received ticagrelor had better clinical outcomes regarding National Institutes of Health Stroke Scale (NIHSS) reduction and a favorable modified Rankin scale (mRS) score. There were no differences between ticagrelor and clopidogrel regarding hemorrhagic and non-hemorrhagic complications. CONCLUSION Patients with acute large-vessel ischemic stroke who received ticagrelor within the first 24 hours after ischemic stroke had better clinical outcomes based on recurrent stroke rates, NIHSS reduction, and favorable mRS rates compared with those who received clopidogrel. There were no differences between ticagrelor and clopidogrel regarding hemorrhagic and non-hemorrhagic complications. TRIAL REGISTRATION Clinical trials.gov (NCT06120725).
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Affiliation(s)
- Mohamed G Zeinhom
- Neurology Department, Faculty of Medicine, Kafr El-Sheikh University, Elgeish St, Kafr El-Sheikh, Egypt.
| | - Ahmed Elbassiouny
- Neurology Department, Faculty of Medicine, Ain Shams University, Al Khalifa Elmamon St, Cairo, Egypt
| | | | - Sherihan Rezk Ahmed
- Neurology Department, Faculty of Medicine, Kafr El-Sheikh University, Elgeish St, Kafr El-Sheikh, Egypt
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10
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Meinert ÉFRC, Kremer J, Tochtermann U, Sommer W, Warnecke G, Karck M, Meyer AL. Pericardial Closure With Expanded Polytetrafluoroethylene Patch in Left Ventricular Assist Device Surgery. ASAIO J 2024; 70:371-376. [PMID: 38153977 DOI: 10.1097/mat.0000000000002126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2023] Open
Abstract
To reduce adhesions after left ventricular assist device (LVAD) implantation, pericardial closure using an expanded polytetrafluoroethylene (ePTFE) patch has been suggested. However, as foreign material, ePTFE patches could increase the risk of infectious complications. In this single-center retrospective study, we investigated outcomes of pericardial closure using an ePTFE patch in LVAD implantation. We included all patients who underwent LVAD implantation at our center between 2011 and 2020 (n = 166). Primary endpoint was development of mediastinitis at any point of time between LVAD implantation and heart transplantation (HTx) or death. Secondary endpoint was overall survival. Preoperative and postoperative clinical data were collected to ensure comparability between the groups. We included 166 patients with LVAD. A total of 116 patients (70%) underwent pericardial closure using an ePTFE patch. There were significant differences between the groups in treatment setting, previous cardiac surgery, Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) level, development of driveline infection, and HTx. Patients with an ePTFE patch developed mediastinitis more frequently (16%) than patients without ePTFE patch (4%) ( p = 0.039). A significant difference in overall survival between the groups could not be confirmed ( p = 0.29). The use of PTFE patches for pericardial closure in LVAD implantation was associated with a higher incidence of mediastinitis, but not with a difference in overall survival.
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Affiliation(s)
- Étienne F R C Meinert
- From the Department of Cardiac Surgery, Heidelberg University Hospital, Heidelberg, Germany
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11
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Pozzi A, Lucà F, Gelsomino S, Abrignani MG, Giubilato S, Di Fusco SA, Rao CM, Cornara S, Caretta G, Ceravolo R, Parrini I, Geraci G, Riccio C, Grimaldi M, Colivicchi F, Oliva F, Gulizia MM. Coagulation Tests and Reversal Agents in Patients Treated with Oral Anticoagulants: The Challenging Scenarios of Life-Threatening Bleeding and Unplanned Invasive Procedures. J Clin Med 2024; 13:2451. [PMID: 38730979 PMCID: PMC11084691 DOI: 10.3390/jcm13092451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 02/22/2024] [Accepted: 04/07/2024] [Indexed: 05/13/2024] Open
Abstract
In clinical practice, the number of patients treated with direct oral anticoagulants (DOACs) has consistently increased over the years. Since anticoagulant therapy has been associated with an annual incidence of major bleeding (MB) events of approximately 2% to 3.5%, it is of paramount importance to understand how to manage anticoagulated patients with major or life-threatening bleeding. A considerable number of these patients' conditions necessitate hospitalization, and the administration of reversal agents may be imperative to manage and control bleeding episodes effectively. Importantly, effective strategies for reversing the anticoagulant effects of DOACs have been well recognized. Specifically, idarucizumab has obtained regulatory approval for the reversal of dabigatran, and andexanet alfa has recently been approved for reversing the effects of apixaban or rivaroxaban in patients experiencing life-threatening or uncontrolled bleeding events. Moreover, continuous endeavors are being made to develop supplementary reversal agents. In emergency scenarios where specific reversal agents might not be accessible, non-specific hemostatic agents such as prothrombin complex concentrate can be utilized to neutralize the anticoagulant effects of DOACs. However, it is paramount to emphasize that specific reversal agents, characterized by their efficacy and safety, should be the preferred choice when suitable. Moreover, it is worth noting that adherence to the guidelines for the reversal agents is poor, and there is a notable gap between international recommendations and actual clinical practices in this regard. This narrative review aims to provide physicians with a practical approach to managing specific reversal agents.
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Affiliation(s)
- Andrea Pozzi
- Cardiology Division Valduce Hospital, 22100 Como, Italy;
| | - Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano, GOM, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy (C.M.R.)
| | - Sandro Gelsomino
- Cardiothoracic Department, Maastricht University Hospital, 6229 HX Maastricht, The Netherlands
| | | | - Simona Giubilato
- Cardiology Department, Cannizzaro Hospital, 95126 Catania, Italy;
| | - Stefania Angela Di Fusco
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy; (S.A.D.F.); (F.C.)
| | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano, GOM, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy (C.M.R.)
| | - Stefano Cornara
- Arrhytmia Unit, Division of Cardiology, Ospedale San Paolo, Azienda Sanitaria Locale 2, 17100 Savona, Italy;
| | - Giorgio Caretta
- Sant’Andrea Hospital, ASL 5 Regione Liguria, 19124 La Spezia, Italy;
| | - Roberto Ceravolo
- Cardiology Unit, Giovanni Paolo II Hospital, 97100 Lamezia, Italy;
| | - Iris Parrini
- Cardiology Department, Mauriziano Hospital, 10128 Torino, Italy;
| | - Giovanna Geraci
- Cardiology Unit, S. Antonio Abate Hospital, ASP Trapani, 91016 Erice, Italy;
| | - Carmine Riccio
- Cardiovascular Department, Sant’Anna e San Sebastiano Hospital, 81100 Caserta, Italy;
| | - Massimo Grimaldi
- Department of Cardiology, General Regional Hospital “F. Miulli”, 70021 Bari, Italy;
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy; (S.A.D.F.); (F.C.)
| | - Fabrizio Oliva
- Cardiology Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy;
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12
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Sigüenza P, López-Núñez JJ, Falgá C, Gómez-Cuervo C, Riera-Mestre A, Gil-Díaz A, Verhamme P, Montenegro AC, Barbagelata C, Imbalzano E, Monreal M. Enoxaparin for Long-Term Therapy of Venous Thromboembolism in Patients with Cancer and Renal Insufficiency. Thromb Haemost 2024; 124:363-373. [PMID: 37832588 DOI: 10.1055/a-2191-7510] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
BACKGROUND The optimal therapy of venous thromboembolism (VTE) in cancer patients with renal insufficiency (RI) is unknown. Current guidelines recommend to use low-molecular-weight heparin over direct oral anticoagulants to treat VTE in cancer patients at high risk of bleeding. METHODS We used the Registro Informatizado Enfermedad Tromboemb00F3lica (RIETE) registry to compare the 6-month incidence rates of (1) VTE recurrences versus major bleeding and (2) fatal pulmonary embolism (PE) versus fatal bleeding in three subgroups (those with mild, moderate, or severe RI) of cancer patients receiving enoxaparin monotherapy. RESULTS From January 2009 through June 2022, 2,844 patients with RI received enoxaparin for ≥6 months: 1,432 (50%) had mild RI, 1,168 (41%) moderate RI, and 244 (8.6%) had severe RI. Overall, 68, 62, and 12%, respectively, received the recommended doses. Among patients with mild RI, the rates of VTE recurrences versus major bleeding (4.6 vs. 5.4%) and fatal PE versus fatal bleeding (1.3 vs. 1.2%) were similar. Among patients with moderate RI, VTE recurrences were half as common as major bleeding (3.1 vs. 6.3%), but fatal PE and fatal bleeding were close (1.8 vs. 1.2%). Among patients with severe RI, VTE recurrences were threefold less common than major bleeding (4.1 vs. 13%), but fatal PE was threefold more frequent than fatal bleeding (2.5 vs. 0.8%). During the first 10 days, fatal PE was fivefold more common than fatal bleeding (2.1 vs. 0.4%). CONCLUSION Among cancer patients with severe RI, fatal PE was fivefold more common than fatal bleeding. The recommended doses of enoxaparin in these patients should be revisited.
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Affiliation(s)
- Patricia Sigüenza
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan J López-Núñez
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Fundació Institut Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Conxita Falgá
- Department of Internal Medicine, Hospital de Mataró, Spain
| | | | - Antoni Riera-Mestre
- Department of Internal Medicine, Hospital Universitari de Bellvitge, IDIBELL.L'Hospitalet de Llobregat, Universitat de Barcelona, Barcelona, Spain
| | - Aída Gil-Díaz
- Department of Internal Medicine, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
- Department of Medical and Surgical Sciences, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Peter Verhamme
- Vascular Medicine and Haemostasis, University of Leuven, Leuven, Belgium
| | - Ana Cristina Montenegro
- Department of Vascular Medicine, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | | | - Egidio Imbalzano
- Division of Internal Medicine, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Manuel Monreal
- Faculty of Health Sciences, Universidad Católica San Antonio de Murcia, CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
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13
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Al Sulaiman KA, Al-Ramahi G, Aljuhani O, Al-Joudi K, Alhujayri AK, Al-Shomer F, Silas J, Al Dabbagh T, Al Harbi S, AlDekhayel S, Eldali A, Alqahtani R, Vishwakarma R, Al-Dorzi HM. Comparison of the safety and efficacy for different regimens of pharmaco-prophylaxis among severely burned patients: a randomized controlled trial. Eur J Trauma Emerg Surg 2024; 50:567-579. [PMID: 38240791 DOI: 10.1007/s00068-024-02443-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 12/31/2023] [Indexed: 04/23/2024]
Abstract
PURPOSE Venous thromboembolism (VTE) is a common complication in critically ill patients, including severe burn cases. Burn patients respond differently to medications due to pharmacokinetic changes. This study aims to assess the feasibility and safety of different VTE pharmaco-prophylaxis in patients admitted to the ICU with severe burns. METHODS A pilot, open-label randomized controlled trial was conducted on ICU patients with severe burns (BSA ≥ 20%). By using block randomization, patients were allocated to receive high-dose enoxaparin 30 mg q12hours (E30q12), standard-dose enoxaparin 40 mg q24hours (E40q24), or unfractionated heparin (UFH) 5000 Units q8hours. In this study, the primary outcomes assessed were the recruitment and consent rates, as well as bleeding or hematoma at both the donor and graft site. Additionally, secondary measures were evaluated to provide further insights. RESULTS Twenty adult patients out of 114 screened were enrolled and received E30q12 (40%), E40q24 (30%), and UFH (30%). The recruitment rate was one patient per month with a 100% consent rate. Donor site bleeding occurred in one patient (16.7%) in the UFH group. On the other hand, graft site bleeding was only reported in one patient (12.5%) who received E30q12. Major bleeding happened in two patients, one in E30q12 and one in the UFH group. Five patients (25.0%) had minor bleeding; two patients (25.0%) received E30q12, two patients E40q24, and one patient UFH. RBC transfusion was needed in four patients, two on E30q12 and two on UFH. Only one patient had VTE, while four patients died in the hospital. CONCLUSION The study observed a low recruitment rate but a high consent rate. Furthermore, there were no major safety concerns identified with any of the three pharmacologic prophylaxis regimens that were evaluated. TRIAL REGISTRATION NUMBER NCT05237726.
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Affiliation(s)
- Khalid A Al Sulaiman
- Pharmaceutical Care Department, King Abdulaziz Medical City (KAMC) - Ministry of National Guard Health Affairs (MNGHA), King Abdullah International Medical Research Center/King Saud bin Abdulaziz University for Health Sciences, PO Box 22490, 11426, Riyadh, Saudi Arabia.
- College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
- King Abdullah International Medical Research Center-King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia.
- Saudi Critical Care Pharmacy Research (SCAPE) Platform, Riyadh, Saudi Arabia.
| | - Ghassan Al-Ramahi
- Plastic Surgery Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Ohoud Aljuhani
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Khuloud Al-Joudi
- Pharmaceutical Care Department, King Abdulaziz Medical City (KAMC) - Ministry of National Guard Health Affairs (MNGHA), King Abdullah International Medical Research Center/King Saud bin Abdulaziz University for Health Sciences, PO Box 22490, 11426, Riyadh, Saudi Arabia
- College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center-King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Abdulaziz K Alhujayri
- King Abdullah International Medical Research Center-King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
- Plastic Surgery Division, Department of Surgery, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Feras Al-Shomer
- King Abdullah International Medical Research Center-King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
- Plastic Surgery Division, Department of Surgery, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Johanna Silas
- King Abdullah International Medical Research Center-King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
- Nursing Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Tarek Al Dabbagh
- King Abdullah International Medical Research Center-King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
- Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Shmeylan Al Harbi
- Pharmaceutical Care Department, King Abdulaziz Medical City (KAMC) - Ministry of National Guard Health Affairs (MNGHA), King Abdullah International Medical Research Center/King Saud bin Abdulaziz University for Health Sciences, PO Box 22490, 11426, Riyadh, Saudi Arabia
- College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center-King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Salah AlDekhayel
- Plastic Surgery Division, Department of Surgery, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Ahmed Eldali
- Plastic Surgery Division, Department of Surgery, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Rahaf Alqahtani
- Pharmaceutical Care Department, King Abdulaziz Medical City (KAMC) - Ministry of National Guard Health Affairs (MNGHA), King Abdullah International Medical Research Center/King Saud bin Abdulaziz University for Health Sciences, PO Box 22490, 11426, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center-King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | | | - Hasan M Al-Dorzi
- Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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14
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Horner DE, Davis S, Pandor A, Shulver H, Goodacre S, Hind D, Rex S, Gillett M, Bursnall M, Griffin X, Holland M, Hunt BJ, de Wit K, Bennett S, Pierce-Williams R. Evaluation of venous thromboembolism risk assessment models for hospital inpatients: the VTEAM evidence synthesis. Health Technol Assess 2024; 28:1-166. [PMID: 38634415 PMCID: PMC11056814 DOI: 10.3310/awtw6200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
Background Pharmacological prophylaxis during hospital admission can reduce the risk of acquired blood clots (venous thromboembolism) but may cause complications, such as bleeding. Using a risk assessment model to predict the risk of blood clots could facilitate selection of patients for prophylaxis and optimise the balance of benefits, risks and costs. Objectives We aimed to identify validated risk assessment models and estimate their prognostic accuracy, evaluate the cost-effectiveness of different strategies for selecting hospitalised patients for prophylaxis, assess the feasibility of using efficient research methods and estimate key parameters for future research. Design We undertook a systematic review, decision-analytic modelling and observational cohort study conducted in accordance with Enhancing the QUAlity and Transparency Of health Research (EQUATOR) guidelines. Setting NHS hospitals, with primary data collection at four sites. Participants Medical and surgical hospital inpatients, excluding paediatric, critical care and pregnancy-related admissions. Interventions Prophylaxis for all patients, none and according to selected risk assessment models. Main outcome measures Model accuracy for predicting blood clots, lifetime costs and quality-adjusted life-years associated with alternative strategies, accuracy of efficient methods for identifying key outcomes and proportion of inpatients recommended prophylaxis using different models. Results We identified 24 validated risk assessment models, but low-quality heterogeneous data suggested weak accuracy for prediction of blood clots and generally high risk of bias in all studies. Decision-analytic modelling showed that pharmacological prophylaxis for all eligible is generally more cost-effective than model-based strategies for both medical and surgical inpatients, when valuing a quality-adjusted life-year at £20,000. The findings were more sensitive to uncertainties in the surgical population; strategies using risk assessment models were more cost-effective if the model was assumed to have a very high sensitivity, or the long-term risks of post-thrombotic complications were lower. Efficient methods using routine data did not accurately identify blood clots or bleeding events and several pre-specified feasibility criteria were not met. Theoretical prophylaxis rates across an inpatient cohort based on existing risk assessment models ranged from 13% to 91%. Limitations Existing studies may underestimate the accuracy of risk assessment models, leading to underestimation of their cost-effectiveness. The cost-effectiveness findings do not apply to patients with an increased risk of bleeding. Mechanical thromboprophylaxis options were excluded from the modelling. Primary data collection was predominately retrospective, risking case ascertainment bias. Conclusions Thromboprophylaxis for all patients appears to be generally more cost-effective than using a risk assessment model, in hospitalised patients at low risk of bleeding. To be cost-effective, any risk assessment model would need to be highly sensitive. Current evidence on risk assessment models is at high risk of bias and our findings should be interpreted in this context. We were unable to demonstrate the feasibility of using efficient methods to accurately detect relevant outcomes for future research. Future work Further research should evaluate routine prophylaxis strategies for all eligible hospitalised patients. Models that could accurately identify individuals at very low risk of blood clots (who could discontinue prophylaxis) warrant further evaluation. Study registration This study is registered as PROSPERO CRD42020165778 and Researchregistry5216. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR127454) and will be published in full in Health Technology Assessment; Vol. 28, No. 20. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Daniel Edward Horner
- Emergency Department, Northern Care Alliance NHS Foundation Trust, Salford, UK
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Oxford Road, Manchester, UK
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Sarah Davis
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Abdullah Pandor
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Helen Shulver
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel Hind
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Saleema Rex
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Michael Gillett
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Matthew Bursnall
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Xavier Griffin
- Barts Bone and Joint Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mark Holland
- School of Clinical and Biomedical Sciences, Faculty of Health and Wellbeing, University of Bolton, Bolton, UK
| | - Beverley Jane Hunt
- Thrombosis & Haemophilia Centre, St Thomas' Hospital, King's Healthcare Partners, London, UK
| | - Kerstin de Wit
- Department of Emergency Medicine, Queens University, Kingston, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shan Bennett
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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15
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Lobastov K, Shaldina M, Matveeva A, Kovalchuk A, Borsuk D, Schastlivtsev I, Laberko L, Fokin A. The trends in venous thromboembolism occurrence and prevention after minimally invasive varicose vein surgery. Phlebology 2024; 39:183-193. [PMID: 37982381 DOI: 10.1177/02683555231217364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
OBJECTIVES To assess the trends of VTE occurrence and prevention in varicose vein surgery. METHOD The registry-based CAPSIVS trial (NCT03041805) analysis includes results in 1878 lower limbs. The primary outcome is a 28-day symptomatic or asymptomatic DVT revealed with duplex ultrasound. RESULTS Any DVT, including EHIT, was observed in 3.4%, while symptomatic in 0.5%. Prophylactic anticoagulation was administrated in 20.4% with LMWH (13.2%) or DOAC (7.1%) for patients with higher VTE risk but did not reduce the events rate. With propensity score matching DOACs were superior to LMWHs (1.5% vs 9.8%). Duration of anticoagulation was essential: the lowest incidence (4.2%) was associated with prophylaxis for up to 7 days, while a single LMWH injection resulted in a DVT rate of 8.8%. With individual VTE history, any anticoagulation duration appeared insufficient. CONCLUSIONS Prophylactic anticoagulation after varicose vein surgery should be based on the individual VTE risk and provided for ≥7-30 days.
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Affiliation(s)
- Kirill Lobastov
- Department of General Surgery, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Maria Shaldina
- Clinic of Phlebology and Laser Surgery, "Vasculab" Ltd., Chelyabinsk, Russia
| | - Athena Matveeva
- Department of General Surgery, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Anna Kovalchuk
- Department of General Surgery, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Denis Borsuk
- Clinic of Phlebology and Laser Surgery, "Vasculab" Ltd., Chelyabinsk, Russia
| | - Ilya Schastlivtsev
- Department of General Surgery, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Leonid Laberko
- Department of General Surgery, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Alexey Fokin
- Department of Surgery of the Institute of Postgraduate Education, South Ural State Medical University, Chelyabinsk, Russia
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16
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Lavikainen LI, Guyatt GH, Kalliala IEJ, Cartwright R, Luomaranta AL, Vernooij RWM, Tähtinen RM, Tadayon Najafabadi B, Singh T, Pourjamal N, Oksjoki SM, Khamani N, Karjalainen PK, Joronen KM, Izett-Kay ML, Haukka J, Halme ALE, Ge FZ, Galambosi PJ, Devereaux PJ, Cárdenas JL, Couban RJ, Aro KM, Aaltonen RL, Tikkinen KAO. Risk of thrombosis and bleeding in gynecologic noncancer surgery: systematic review and meta-analysis. Am J Obstet Gynecol 2024; 230:390-402. [PMID: 38072372 DOI: 10.1016/j.ajog.2023.11.1255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 11/23/2023] [Accepted: 11/28/2023] [Indexed: 01/13/2024]
Abstract
OBJECTIVE This study aimed to provide procedure-specific estimates of the risk for symptomatic venous thromboembolism and major bleeding in noncancer gynecologic surgeries. DATA SOURCES We conducted comprehensive searches on Embase, MEDLINE, Web of Science, and Google Scholar. Furthermore, we performed separate searches for randomized trials that addressed the effects of thromboprophylaxis. STUDY ELIGIBILITY CRITERIA Eligible studies were observational studies that enrolled ≥50 adult patients who underwent noncancer gynecologic surgery procedures and that reported the absolute incidence of at least 1 of the following: symptomatic pulmonary embolism, symptomatic deep vein thrombosis, symptomatic venous thromboembolism, bleeding that required reintervention (including re-exploration and angioembolization), bleeding that led to transfusion, or postoperative hemoglobin level <70 g/L. METHODS A teams of 2 reviewers independently assessed eligibility, performed data extraction, and evaluated the risk of bias of the eligible articles. We adjusted the reported estimates for thromboprophylaxis and length of follow-up and used the median value from studies to determine the cumulative incidence at 4 weeks postsurgery stratified by patient venous thromboembolism risk factors and used the Grading of Recommendations Assessment, Development and Evaluation approach to rate the evidence certainty. RESULTS We included 131 studies (1,741,519 patients) that reported venous thromboembolism risk estimates for 50 gynecologic noncancer procedures and bleeding requiring reintervention estimates for 35 procedures. The evidence certainty was generally moderate or low for venous thromboembolism and low or very low for bleeding requiring reintervention. The risk for symptomatic venous thromboembolism varied from a median of <0.1% for several procedures (eg, transvaginal oocyte retrieval) to 1.5% for others (eg, minimally invasive sacrocolpopexy with hysterectomy, 1.2%-4.6% across patient venous thromboembolism risk groups). Venous thromboembolism risk was <0.5% for 30 (60%) of the procedures; 0.5% to 1.0% for 10 (20%) procedures; and >1.0% for 10 (20%) procedures. The risk for bleeding the require reintervention varied from <0.1% (transvaginal oocyte retrieval) to 4.0% (open myomectomy). The bleeding requiring reintervention risk was <0.5% in 17 (49%) procedures, 0.5% to 1.0% for 12 (34%) procedures, and >1.0% in 6 (17%) procedures. CONCLUSION The risk for venous thromboembolism in gynecologic noncancer surgery varied between procedures and patients. Venous thromboembolism risks exceeded the bleeding risks only among selected patients and procedures. Although most of the evidence is of low certainty, the results nevertheless provide a compelling rationale for restricting pharmacologic thromboprophylaxis to a minority of patients who undergo gynecologic noncancer procedures.
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Affiliation(s)
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Ilkka E J Kalliala
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
| | - Rufus Cartwright
- Chelsea Centre for Gender Surgery, Chelsea and Westminster NHS Foundation Trust, London, United Kingdom; Department of Gynaecology, Chelsea and Westminster NHS Foundation Trust, London, United Kingdom; Department of Epidemiology & Biostatistics, Imperial College London, London, United Kingdom
| | - Anna L Luomaranta
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Robin W M Vernooij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands; Department of Nephrology & Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Riikka M Tähtinen
- Department of Obstetrics and Gynecology, Tampere University and Tampere University Hospital, Tampere, Finland
| | - Borna Tadayon Najafabadi
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Tino Singh
- Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Negar Pourjamal
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | | | - Nadina Khamani
- Department of Obstetrics and Gynecology, Institute of Childrens' Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Päivi K Karjalainen
- Department of Obstetrics and Gynecology, Central Finland Central Hospital, Jyväskylä, Finland; Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Kirsi M Joronen
- Department of Obstetrics and Gynecology, Turku University Hospital and University of Turku, Finland
| | - Matthew L Izett-Kay
- Urogynaecology Department, The John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom
| | - Jari Haukka
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland; Clinicum/Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Alex L E Halme
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Fang Zhou Ge
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Päivi J Galambosi
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - P J Devereaux
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada; Outcomes Research Consortium, Cleveland, OH
| | - Jovita L Cárdenas
- National Center for Health Technology Excellence (CENETEC), Direction of Health Technologies assessment, Mexico City, Mexico
| | - Rachel J Couban
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Karoliina M Aro
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Riikka L Aaltonen
- Urogynaecology Department, The John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom
| | - Kari A O Tikkinen
- Faculty of Medicine, University of Helsinki, Helsinki, Finland; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland.
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17
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Yelnik CM, Erton ZB, Drumez E, Cheildze D, de Andrade D, Clarke A, Tektonidou MG, Sciascia S, Pardos-Gea J, Pengo V, Ruiz-Irastorza G, Belmont HM, Pedrera CL, Fortin PR, Wahl D, Gerosa M, Kello N, Signorelli F, Atsumi T, Ji L, Efthymiou M, Branch DW, Nalli C, Rodriguez-Almaraz E, Petri M, Cervera R, Shi H, Zuo Y, Artim-Esen B, Pons-Estel G, Willis R, Barber MRW, Skeith L, Bertolaccini ML, Cohen H, Roubey R, Erkan D. Thrombosis recurrence and major bleeding in non-anticoagulated thrombotic antiphospholipid syndrome patients: Prospective study from antiphospholipid syndrome alliance for clinical trials and international networking (APS ACTION) clinical database and repository ("Registry"). Semin Arthritis Rheum 2024; 65:152347. [PMID: 38185079 DOI: 10.1016/j.semarthrit.2023.152347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 11/13/2023] [Accepted: 12/05/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Long-term anticoagulant therapy is generally recommended for thrombotic antiphospholipid syndrome (TAPS) patients, however it may be withdrawn or not introduced in routine practice. OBJECTIVES To prospectively evaluate the risk of thrombosis recurrence and major bleeding in non-anticoagulated TAPS patients, compared to anticoagulated TAPS, and secondly, to identify different features between those two groups. PATIENTS/METHODS Using an international registry, we identified non-anticoagulated TAPS patients at baseline, and matched them with anticoagulated TAPS patients based on gender, age, type of previous thrombosis, and associated autoimmune disease. Thrombosis recurrence and major bleeding were prospectively analyzed using Kaplan-Meier method and compared using a marginal Cox's regression model. RESULTS As of June 2022, 94 (14 %) of the 662 TAPS patients were not anticoagulated; and 93 of them were matched with 181 anticoagulated TAPS patients (median follow-up 5 years [interquartile range 3 to 8]). The 5-year thrombosis recurrence and major bleeding rates were 12 % versus 10 %, and 6 % versus 7 %, respectively (hazard ratio [HR] 1.38, 95 % confidence interval [CI] 0.53 to 3.56, p = 0.50 and HR 0.53; 95 % CI 0.15 to 1.86; p = 0.32, respectively). Non-anticoagulated patients were more likely to receive antiplatelet therapy (p < 0.001), and less likely to have more than one previous thrombosis (p < 0.001) and lupus anticoagulant positivity (p = 0.01). CONCLUSION Fourteen percent of the TAPS patients were not anticoagulated at recruitment. Their recurrent thrombosis risk did not differ compared to matched anticoagulated TAPS patients, supporting the pressing need for risk-stratified secondary thrombosis prevention trials in APS investigating strategies other than anticoagulation.
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Affiliation(s)
- Cecile M Yelnik
- Univ. Lille, CHU Lille, Département de Médecine Interne et d'Immunologie Clinique, INSERM, UMR 1167, F-59000 Lille, France.
| | | | - Elodie Drumez
- Univ. Lille, CHU Lille, Département de Médecine Interne et d'Immunologie Clinique, INSERM, UMR 1167, F-59000 Lille, France
| | - Dachi Cheildze
- Hospital for Special Surgery, New York, NY, USA; Yale New Haven Hospital, New Haven, CT, USA
| | | | - Ann Clarke
- University of Calgary, Calgary, Alberta, Canada
| | | | | | | | | | | | | | | | - Paul R Fortin
- Centre ARThrite - CHU de Québec- Université Laval, Quebec, QC, Canada
| | - Denis Wahl
- Université de Lorraine, Inserm DCAC, and CHRU-Nancy, Nancy, France
| | | | - Nina Kello
- Northwell Health, New Hyde Park, NY, USA
| | | | | | - Lanlan Ji
- Peking University First Hospital, Beijing, China
| | | | - D Ware Branch
- University of Utah and Intermountain Healthcare, Salt Lake City, UT, USA
| | | | | | - Michelle Petri
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Hui Shi
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yu Zuo
- University of Michigan, Ann Arbor, MI, USA
| | | | - Guillermo Pons-Estel
- Centro Regional de Enfermedades Autoinmunes y Reumáticas del Grupo Oroño (GO-CREAR), Rosario, Argentina
| | - Rohan Willis
- University of Texas Medical Branch, Galveston, TX, USA
| | | | | | | | - Hannah Cohen
- University College London, London, United Kingdom
| | | | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Disease, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA
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18
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Augustin P, Andrei S, Iung B, Para M, Matthews P, de Tymowski C, Ajzenberg N, Montravers P. Thromboembolic events after major bleeding events in patients with mechanical heart valves: a 13-year analysis. J Thromb Thrombolysis 2024:10.1007/s11239-024-02964-5. [PMID: 38556579 DOI: 10.1007/s11239-024-02964-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2024] [Indexed: 04/02/2024]
Abstract
Anticoagulation in patients with mechanical heart valves (MHV) is associated with a risk of major bleeding episodes (MBE). In case of MBE, anticoagulant interruption is advocated. However, there is lack of data regarding the thrombo-embolic events (TE) risk associated with anticoagulant interruption. The main objective of the study was to evaluate the rate and risk factors of 6-months of TEs in patients with MHV experiencing MBE. This observational study was conducted over a 13-year period. Adult patients with a MHV presenting with a MBE were included. The main study endpoint was 6-month TEs, defined by clinical TEs or an echocardiographic documented thrombosis, occurring during an ICU stay or within 6-months. Thromboembolic events were recorded at ICU discharge, and 6 months after discharge. Seventy-nine MBEs were analysed, the rate of TEs at 6-months was 19% CI [11-29%]. The only difference of presentation and management between 6-month TEs and free-TE patients was the time without effective anticoagulation (TWA). The Receiver Operator Characteristic curve identified the value of 122 h of TWA as a cut-off. The multivariate analysis identified early bleeding recurrences (OR 3.62, 95% CI [1.07-12.25], p = 0.039), and TWA longer than 122 h (OR 4.24, 95% CI [1.24-14.5], p = 0.021), as independent risk factors for 6-month TEs. A higher rate of TE was associated with anticoagulation interruption longer than 5 days and early bleeding recurrences. However, the management should still be personalized and discussed for each case given the heterogeneity of causes of MBE and possibilities of haemostatic procedures.
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Affiliation(s)
- Pascal Augustin
- Department of Anesthesiology and Critical Care, Groupe Hospitalier Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, 46 Rue Henri Huchard, Paris, 75018, France.
| | - Stefan Andrei
- Department of Anesthesiology and Critical Care, Groupe Hospitalier Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, 46 Rue Henri Huchard, Paris, 75018, France
- Group of Applied Mathematics and Computational Biology, CNRS UMR 8542, Paris, France
| | - Bernard Iung
- Department of Cardiology, Assistance Publique Hôpitaux de Paris, Groupe Hospitalier Bichat Claude Bernard, University of Paris, Paris, France
| | - Marylou Para
- Department of Cardiovascular Surgery and Transplantation, Groupe Hospitalier Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, Paris, France
- Laboratory of Vascular Translational Science, University of Paris, INSERM UMR 1148, Paris, France
| | - Peter Matthews
- Centre de Recherche sur l'Inflammation, University of Paris, INSERM UMR 1149, CNRS ERL8252, Paris, France
| | - Christian de Tymowski
- Department of Anesthesiology and Critical Care, Groupe Hospitalier Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, 46 Rue Henri Huchard, Paris, 75018, France
- Division of Critical Care Services, Northwick Park and St Marks Hospital, London, UK
| | - Nadine Ajzenberg
- Laboratory of Vascular Translational Science, University of Paris, INSERM UMR 1148, Paris, France
- Department of Hematology, Groupe Hospitalier Bichat Claude Bernard, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Philippe Montravers
- Department of Anesthesiology and Critical Care, Groupe Hospitalier Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, 46 Rue Henri Huchard, Paris, 75018, France
- Physiopathology and Epidemiology of respiratory diseases, University of Paris, INSERM UMR1152, Paris, France
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19
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McIntyre WF, Benz AP, Becher N, Healey JS, Granger CB, Rivard L, Camm AJ, Goette A, Zapf A, Alings M, Connolly SJ, Kirchhof P, Lopes RD. Direct Oral Anticoagulants for Stroke Prevention in Patients With Device-Detected Atrial Fibrillation: A Study-Level Meta-Analysis of the NOAH-AFNET 6 and ARTESiA Trials. Circulation 2024; 149:981-988. [PMID: 37952187 DOI: 10.1161/circulationaha.123.067512] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 11/07/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Device-detected atrial fibrillation (also known as subclinical atrial fibrillation or atrial high-rate episodes) is a common finding in patients with an implanted cardiac rhythm device and is associated with an increased risk of ischemic stroke. Whether oral anticoagulation is effective and safe in this patient population is unclear. METHODS We performed a systematic review of MEDLINE and Embase for randomized trials comparing oral anticoagulation with antiplatelet or no antithrombotic therapy in adults with device-detected atrial fibrillation recorded by a pacemaker, implantable cardioverter defibrillator, cardiac resynchronization therapy device, or implanted cardiac monitor. We used random-effects models for meta-analysis and rated the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework (GRADE). The review was preregistered (PROSPERO CRD42023463212). RESULTS From 785 citations, we identified 2 randomized trials with relevant clinical outcome data: NOAH-AFNET 6 (Non-Vitamin K Antagonist Oral Anticoagulants in Patients With Atrial High Rate Episodes; 2536 participants) evaluated edoxaban, and ARTESiA (Apixaban for the Reduction of Thrombo-Embolism in Patients With Device-Detected Sub-Clinical Atrial Fibrillation; 4012 participants) evaluated apixaban. Meta-analysis demonstrated that oral anticoagulation with these agents reduced ischemic stroke (relative risk [RR], 0.68 [95% CI, 0.50-0.92]; high-quality evidence). The results from the 2 trials were consistent (I2 statistic for heterogeneity=0%). Oral anticoagulation also reduced a composite of cardiovascular death, all-cause stroke, peripheral arterial embolism, myocardial infarction, or pulmonary embolism (RR, 0.85 [95% CI, 0.73-0.99]; I2=0%; moderate-quality evidence). There was no reduction in cardiovascular death (RR, 0.95 [95% CI, 0.76-1.17]; I2=0%; moderate-quality evidence) or all-cause mortality (RR, 1.08 [95% CI, 0.96-1.21]; I2=0%; moderate-quality evidence). Oral anticoagulation increased major bleeding (RR, 1.62 [95% CI, 1.05-2.50]; I²=61%; high-quality evidence). CONCLUSIONS The results of the NOAH-AFNET 6 and ARTESiA trials are consistent with each other. Meta-analysis of these 2 large randomized trials provides high-quality evidence that oral anticoagulation with edoxaban or apixaban reduces the risk of stroke in patients with device-detected atrial fibrillation and increases the risk of major bleeding.
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Affiliation(s)
- William F McIntyre
- McMaster University and Population Health Research Institute, Hamilton, Canada (W.F.M., A.P.B., J.S.H., S.J.C.)
| | - Alexander P Benz
- McMaster University and Population Health Research Institute, Hamilton, Canada (W.F.M., A.P.B., J.S.H., S.J.C.)
| | - Nina Becher
- Department of Cardiology, University Heart and Vascular Center Hamburg, Germany (N.B., P.K.)
| | - Jeffrey S Healey
- McMaster University and Population Health Research Institute, Hamilton, Canada (W.F.M., A.P.B., J.S.H., S.J.C.)
| | | | | | - A John Camm
- St George's University of London and Imperial College London, United Kingdom (A.J.C.)
| | - Andreas Goette
- Department of Cardiology and Intensive Care Medicine, St Vincenz Hospital Paderborn, Germany (A.G.)
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Germany (A.Z.)
| | | | - Stuart J Connolly
- McMaster University and Population Health Research Institute, Hamilton, Canada (W.F.M., A.P.B., J.S.H., S.J.C.)
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, Germany (N.B., P.K.)
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G., R.D.L.)
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20
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Boc V, Pelicon K, Petek K, Boc A, Kejžar N, Blinc A. Validation of the OAC 3-PAD Bleeding Risk Score in Patients with Peripheral Arterial Disease after Endovascular Treatment. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00281-8. [PMID: 38548130 DOI: 10.1016/j.ejvs.2024.03.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 02/20/2024] [Accepted: 03/24/2024] [Indexed: 04/25/2024]
Affiliation(s)
- Vinko Boc
- Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia; Department of Internal Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Kevin Pelicon
- Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Klemen Petek
- Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Anja Boc
- Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia; Institute of Anatomy, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Nataša Kejžar
- Institute for Biostatistics and Medical Informatics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Aleš Blinc
- Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia; Department of Internal Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
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21
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Khanafer A, Henkes H, Bücke P, Hennersdorf F, Bäzner H, Forsting M, von Gottberg P. Triple platelet inhibition in intracranial thrombectomy with additional acute cervical stent angioplasty due to tandem lesion: a retrospective single-center analysis. BMC Neurol 2024; 24:99. [PMID: 38500074 PMCID: PMC10946095 DOI: 10.1186/s12883-024-03597-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/11/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Acute stroke treatment with intracranial thrombectomy and treatment of ipsilateral carotid artery stenosis/occlusion ("tandem lesion", TL) in one session is considered safe. However, the risk of stent restenosis after TL treatment is high, and antiplatelet therapy (APT) preventing restenosis must be well balanced to avoid intracranial hemorrhage. We investigated the safety and 90-day outcome of patients receiving TL treatment under triple-APT, focused on stent-patency and possible disadvantageous comorbidities. METHODS Patients receiving TL treatment in the setting of acute stroke between 2013 and 2022 were analyzed regarding peri-/postprocedural safety and stent patency after 90 days. All patients received intravenous eptifibatide and acetylsalicylic acid and one of the three drugs prasugrel, clopidogrel, or ticagrelor. Duplex imaging was performed 24 h after treatment, at discharge and 90 days, and digital subtraction angiography was performed if restenosis was suspected. RESULTS 176 patients were included. Periprocedural complications occurred in 2.3% of the patients at no periprocedural death, and in-hospital death in 13.6%. Discharge mRS score was maintained or improved at the 90-day follow-up in 86%, 4.54% had an in-stent restenosis requiring treatment at 90 days. No recorded comorbidity considered disadvantageous for stent patency showed statistical significance, the duration of the endovascular procedure had no significant effect on outcome. CONCLUSION In our data, TL treatment with triple APT resulted in a low restenosis rate, low rates of sICH and a comparably high number of patients with favorable outcome. Aggressive APT in the initial phase may therefore have the potential to prevent recurrent stroke better than restrained platelet inhibition. Comorbidities did not influence stent patency.
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Affiliation(s)
- Ali Khanafer
- Neuroradiological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Philipp Bücke
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Florian Hennersdorf
- Department of Diagnostic and Interventional Neuroradiology, University of Tübingen, Tübingen, Germany
| | - Hansjörg Bäzner
- Neurological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Michael Forsting
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Philipp von Gottberg
- Neuroradiological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany.
- Klinik für Neuroradiologie, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Germany.
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22
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Hammoudeh A, Badaineh Y, Tabbalat R, Ahmad A, Bahhour M, Ja’ara D, Shehadeh J, Jum’ah MA, Migdad A, Hani M, Alhaddad IA. The Intersection of Atrial Fibrillation and Coronary Artery Disease in Middle Eastern Patients. Analysis from the Jordan Atrial Fibrillation Study. Glob Heart 2024; 19:29. [PMID: 38505303 PMCID: PMC10949804 DOI: 10.5334/gh.1312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 02/21/2024] [Indexed: 03/21/2024] Open
Abstract
Background There is a scarcity of clinical studies which evaluate the association of atrial fibrillation (AF) and coronary artery disease (CAD) in the Middle East. The aim of this study was to evaluate the impact of CAD on baseline clinical profiles and one-year outcomes in a Middle Eastern cohort with AF. Methods Consecutive AF patients evaluated in 29 hospitals and cardiology clinics were enrolled in the Jordan AF Study (May 2019-December 2020). Clinical and echocardiographic features, use of medications and one-year outcomes in patients with AF/CAD were compared to AF/no CAD patients. Results Of 2020 AF patients enrolled, 216 (10.7%) had CAD. Patients with AF/CAD were more likely to be men and had significantly higher prevalence of hypertension, diabetes, dyslipidemia, heart failure and chronic kidney disease compared to the AF/no CAD patients. They also had lower mean left ventricular ejection fraction and larger left atrial size. Mean CHA2DS2 VASc and HAS-BLED scores were higher in AF/CAD patients than those with AF/no CAD (4.3 ± 1.7 vs. 3.6 ± 1.8, p < 0.0001) and (2.0 ± 1.1 vs. 1.6 ± 1.1, p < 0.0001), respectively. Oral anticoagulant agents were used in similar rates in the two groups (83.8% vs. 82.9%, p = 0.81), but more patients with AF/CAD were prescribed additional antiplatelet agents compared to patients with AF/no CAD (73.7% vs. 41.5%, p < 0.0001). At one year, AF/CAD patients, compared to AF/no CAD patients had significantly higher hospitalization rate (39.4% vs. 29.2%, p = 0.003), more acute coronary syndrome and coronary revascularization (6.9% vs. 2.4%, p = 0.004), and higher all-cause mortality (18.5% vs. 10.9%, p = 0.002). Conclusions In this cohort of Middle Eastern patients with AF, one in 10 patients had CAD. The coexistence of AF and CAD was associated with a worse baseline clinical profile and one-year outcomes. Clinical study registration: the study is registered on clinicaltrials.gov (unique identifier number NCT03917992).
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Affiliation(s)
- Ayman Hammoudeh
- Department of Cardiology, Istishari Hospital, 44 Kindi Street, Amman 11954, Jordan
| | - Yahya Badaineh
- Department of Cardiology, Istishari Hospital, 44 Kindi Street, Amman 11954, Jordan
| | - Ramzi Tabbalat
- Department of Cardiology, Abdali Hospital, 1 Istethmar Street/Abdali Boulevard, Amman 11190, Jordan
| | - Anas Ahmad
- Coronary Care Unit, Istishari Hospital, 44 Kindi Street, Amman 11954, Jordan
| | - Mohammad Bahhour
- Department of Internal Medicine, Istishari hospital, 44 Kindi Street, Amman 11954, Jordan
| | - Darya Ja’ara
- Department of Internal Medicine, Istishari hospital, 44 Kindi Street, Amman 11954, Jordan
| | - Joud Shehadeh
- Department of Internal Medicine, Istishari hospital, 44 Kindi Street, Amman 11954, Jordan
| | - Mohammad A. Jum’ah
- Department of Internal Medicine, Istishari hospital, 44 Kindi Street, Amman 11954, Jordan
| | - Afnan Migdad
- Department of Internal Medicine, Istishari hospital, 44 Kindi Street, Amman 11954, Jordan
| | - Mohammad Hani
- Jordan Cardiovascular Center, Jordan Hospital, 4 Queen Rania Hospital, Amman, Jordan
| | - Imad A. Alhaddad
- Jordan Cardiovascular Center, Jordan Hospital, 4 Queen Rania Hospital, Amman, Jordan
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Zeinhom MG, Khalil MFE, Kamel IFM, Kohail AM, Ahmed SR, Elbassiouny A, Shuaib A, Al-Nozha OM. Predictors of the unfavorable outcomes in acute ischemic stroke patients treated with alteplase, a multi-center randomized trial. Sci Rep 2024; 14:5960. [PMID: 38472241 PMCID: PMC10933394 DOI: 10.1038/s41598-024-56067-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 03/01/2024] [Indexed: 03/14/2024] Open
Abstract
Worldwide, stroke is a leading cause of long-term disability in adults. Alteplase is the only approved treatment for acute ischemic stroke (AIS) and results in an improvement in a third of treated patients. We evaluated the post-stroke unfavourable outcome predictors in alteplase-treated patients from Egypt and Saudi Arabia. We assessed the effect of different risk factors on AIS outcomes after alteplase in Egypt and Saudi Arabia. Our study included 592 AIS alteplase-treated patients. The relationship between risk factors, clinical presentation, and imaging features was evaluated to predict factors associated with poor outcomes. An mRS score of three or more was used to define poor outcomes. Poor outcome was seen in 136 patients (23%), and Patients with unfavourable effects had significantly higher admission hyperglycaemia, a higher percentage of diabetes mellitus, cardioembolic stroke, and a lower percentage of small vessel stroke. Patients with higher baseline NIHSS score (OR 1.39; 95% CI 1.12-1.71; P = 0.003), admission hyperglycaemia (OR 13.12; 95% CI 3.37-51.1; P < 0.001), and post-alteplase intracerebral haemorrhage (OR 7.41; 95% CI 1.69-32.43; P = 0.008) independently predicted unfavourable outcomes at three months. In AIS patients treated with alteplase, similar to reports from other regions, in patients from Egypt and Saudi Arabia also reveal that higher NIHSS, higher serum blood sugar, and post-alteplase intracerebral haemorrhage were the predictors of unfavourable outcomes three months after ischemic stroke.Trial registration: (clinicaltrials.gov NCT06058884), retrospectively registered on 28/09/2023.
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Affiliation(s)
- Mohamed G Zeinhom
- Neurology Department, Faculty of Medicine, Kafr El-Sheikh University, Elgeish Street, Kafr El-Sheikh, Egypt.
| | | | | | - Ahmed Mohamed Kohail
- Neurology Department, Faculty of Medicine, Al-Azhar University, ELmokhaim St., Cairo, Egypt
| | - Sherihan Rezk Ahmed
- Neurology Department, Faculty of Medicine, Kafr El-Sheikh University, Elgeish Street, Kafr El-Sheikh, Egypt
| | - Ahmed Elbassiouny
- Neurology Department, Faculty of Medicine, Ain Shams University, ELabbasia St., Cairo, Egypt
| | - Ashfaq Shuaib
- Division of Neurology, Department of Medicine, University of Alberta, Clinical Sciences Building, Edmonton, AB, T6G 2R3, Canada
| | - Omar M Al-Nozha
- Medicine Department, College of Medicine, Taibah University, Janadah Bin Umayyah Rd., Tayba, Madinah, Saudi Arabia
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Kim S, Lim JH, Ko HH, Kwon LM, Lee HK, Ra YJ, Kim K, Kim HS. Gastrointestinal Bleeding in Extracorporeal Membrane Oxygenation Patients: A Comprehensive Analysis of Risk Factors and Clinical Outcomes. J Chest Surg 2024; 57:195-204. [PMID: 38326895 DOI: 10.5090/jcs.23.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 12/16/2023] [Accepted: 12/26/2023] [Indexed: 02/09/2024] Open
Abstract
Background Extracorporeal membrane oxygenation (ECMO) is an intervention for severe heart and lung failure; however, it poses the risk of complications, including gastrointestinal bleeding (GIB). Comprehensive analyses of GIB in patients undergoing ECMO are limited, and its impact on clinical outcomes remains unclear. Methods This retrospective study included 484 patients who received venovenous and venoarterial ECMO between January 2015 and December 2022. Data collected included patient characteristics, laboratory results, GIB details, and interventions. Statistical analyses were performed to identify risk factors and assess the outcomes. Results GIB occurred in 44 of 484 patients (9.1%) who received ECMO. Multivariable analysis revealed that older age (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.01-1.06; p=0.0130) and need to change the ECMO mode (OR, 3.74; 95% CI, 1.75-7.96; p=0.0006) were significant risk factors for GIB, whereas no association was found with antiplatelet or systemic anticoagulation therapies during ECMO management. Half of the patients with GIB (22/44, 50%) underwent intervention, with endoscopy as the primary modality (19/22, 86.4%). Patients who underwent ECMO and developed GIB had higher rates of mortality (40/44 [90.9%] vs. 262/440 [59.5%]) and ECMO weaning failure (38/44 [86.4%] vs. 208/440 [47.3%]). Conclusion GIB in patients undergoing ECMO is associated with adverse outcomes, including increased risks of mortality and weaning failure. Even in seemingly uncomplicated cases, it is crucial to avoid underestimating the significance of GIB.
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Affiliation(s)
- Sahri Kim
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Jung Hyun Lim
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Ho Hyun Ko
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Lyo Min Kwon
- Department of Radiology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Hong Kyu Lee
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Yong Joon Ra
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Kunil Kim
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Hyoung Soo Kim
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Anyang, Korea
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Kim JY, Kim J, Park SJ, Park KM, Kim JS, Kim SH, Shim J, Choi EK, Kim DH, Oh IY, On YK. Comparison of High- and Low-Dose Rivaroxaban Regimens in Elderly East Asian Patients With Atrial Fibrillation. J Korean Med Sci 2024; 39:e72. [PMID: 38442717 PMCID: PMC10911935 DOI: 10.3346/jkms.2024.39.e72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 12/29/2023] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND In the Rivaroxaban Once-daily oral direct factor Xa inhibition Compared with vitamin K antagonism for prevention of stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF) trial, rivaroxaban 20 mg was the on-label dose, and the dose-reduction criterion for rivaroxaban was a creatinine clearance of < 50 mL/min. Some Asian countries are using reduced doses label according to the J-ROCKET AF trial. The aim of this study was to assess the safety and efficacy of a high-dose rivaroxaban regimen (HDRR, 20/15 mg) and low-dose rivaroxaban regimen (LDRR, 15/10 mg) among elderly East Asian patients with atrial fibrillation (AF) in real-world practice. METHODS This study was a multicenter, prospective, non-interventional observational study designed to evaluate the efficacy and safety of rivaroxaban in AF patients > 65 years of age with or without renal impairment. RESULTS A total of 1,093 patients (mean age, 72.8 ± 5.8 years; 686 [62.9%] men) were included in the analysis, with 493 patients allocated to the HDRR group and 598 patients allocated to the LDRR group. A total of 765 patients received 15 mg of rivaroxaban (203 in the HDRR group and 562 in the LDRR group). There were no significant differences in the incidence rates of major bleeding (adjusted hazard ratio [HR], 0.64; 95% confidential interval [CI], 0.21-1.93), stroke (adjusted HR, 3.21; 95% CI, 0.54-19.03), and composite outcomes (adjusted HR, 1.13; 95% CI, 0.47-2.69) between the HDRR and LDRR groups. CONCLUSION This study revealed the safety and effectiveness of either dose regimen of rivaroxaban in an Asian population for stroke prevention of AF. Considerable numbers of patients are receiving LDRR therapy in real-world practice in Asia. Both regimens were safe and effective for these patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04096547.
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Affiliation(s)
- Ju Youn Kim
- Division of Cardiology, Department of Internal Medicine, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Juwon Kim
- Division of Cardiology, Department of Internal Medicine, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Jung Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyoung-Min Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - June Soo Kim
- Division of Cardiology, Department of Internal Medicine, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung-Hwan Kim
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jaemin Shim
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Anam Hospital, Seoul, Korea
| | - Eue Keun Choi
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital, Seoul, Korea
| | - Dae-Hyeok Kim
- Inha University College of Medicine and Inha University Hospital, Incheon, Korea
| | - Il-Young Oh
- Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Young Keun On
- Division of Cardiology, Department of Internal Medicine, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Maier CL, Brohi K, Curry N, Juffermans NP, Mora Miquel L, Neal MD, Shaz BH, Vlaar APJ, Helms J. Contemporary management of major haemorrhage in critical care. Intensive Care Med 2024; 50:319-331. [PMID: 38189930 DOI: 10.1007/s00134-023-07303-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 12/05/2023] [Indexed: 01/09/2024]
Abstract
Haemorrhagic shock is frequent in critical care settings and responsible for a high mortality rate due to multiple organ dysfunction and coagulopathy. The management of critically ill patients with bleeding and shock is complex, and treatment of these patients must be rapid and definitive. The administration of large volumes of blood components leads to major physiological alterations which must be mitigated during and after bleeding. Early recognition of bleeding and coagulopathy, understanding the underlying pathophysiology related to specific disease states, and the development of individualised management protocols are important for optimal outcomes. This review describes the contemporary understanding of the pathophysiology of various types of coagulopathic bleeding; the diagnosis and management of critically ill bleeding patients, including major haemorrhage protocols and post-transfusion management; and finally highlights recent areas of opportunity to better understand optimal management strategies for managing bleeding in the intensive care unit (ICU).
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Affiliation(s)
- Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, USA
| | - Karim Brohi
- Centre for Trauma Sciences, Queen Mary University of London, London, UK
| | - Nicola Curry
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Clinical and Laboratory Sciences, Radcliffe Department of Medicine, Oxford University, Oxford, UK
| | - Nicole P Juffermans
- Department of Intensive Care and Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Lidia Mora Miquel
- Department of Anaesthesiology, Intensive Care and Pain Clinic, Vall d'Hebron Trauma, Rehabilitation and Burns Hospital, Autonomous University of Barcelona, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Matthew D Neal
- Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Beth H Shaz
- Department of Pathology, Duke University School of Medicine, Durham, NC, USA
| | | | - Julie Helms
- Service de Médecine Intensive-Réanimation, Department of Intensive Care, Nouvel Hôpital Civil, Université de Strasbourg (UNISTRA), 1, Place de L'Hôpital, 67091, Strasbourg Cedex, France.
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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] [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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Shaw JR, Li N, Abdulrehman J, Stella SF, St John M, Nixon J, Spyropoulos AC, Schulman S, Wang TF, Carrier M, Douketis JD. Periprocedural management of direct oral anticoagulants in patients with atrial fibrillation and active cancer. J Thromb Haemost 2024; 22:727-737. [PMID: 37949316 DOI: 10.1016/j.jtha.2023.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 10/25/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Cancer and atrial fibrillation (AF) are common concurrent disorders. Direct oral anticoagulants (DOACs) are prescribed to prevent stroke in patients with AF. Patients with cancer often undergo invasive procedures for diagnostic or therapeutic purposes, necessitating interruption of anticoagulation. There are limited data to guide best periprocedural anticoagulation management practices in the setting of active cancer. OBJECTIVES To describe patient characteristics, periprocedural management, and clinical outcomes in DOAC-treated patients with AF according to active cancer status. METHODS We conducted descriptive and comparative analyses using data from the PAUSE study. Multivariable logistic regression was used to determine whether active cancer status was an independent risk factor for bleeding outcomes. Covariates were selected a priori based on biological rationale and preexisting knowledge. RESULTS Patients with active cancer were older (P < .001), more likely to be thrombocytopenic (P = .026), have moderate renal dysfunction (P = .005), and more likely to receive low-dose DOAC therapy (P < .001). A greater proportion of patients with active cancer underwent a high-bleed-risk procedure (P < .001), with longer periprocedural DOAC-interruption intervals (P <.001) and lower preprocedural residual DOAC levels (P = .002). Active cancer was an independent predictor for surgical major bleeding (OR = 2.45; 95% CI, 1.08-5.14) after adjusting for study center, procedure category and bleed risk, thrombocytopenia, hypertension, and the use of a P2Y12 inhibitor. CONCLUSIONS Active cancer status is associated with an increased risk of surgical major bleeding among DOAC-treated patients with AF undergoing interruption of anticoagulation for elective invasive procedures.
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Affiliation(s)
- Joseph R Shaw
- Department of Medicine, University of Ottawa, and the Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | - Na Li
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada; Department of Computing and Software, McMaster University, Hamilton, ON, Canada
| | | | | | - Melanie St John
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
| | - Joanne Nixon
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
| | - Alex C Spyropoulos
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Medicine, Northwell Health at Lenox Hill Hospital, New York, New York, USA. https://twitter.com/AlexSpyropoul
| | - Sam Schulman
- Department of Obstetrics and Gynecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Tzu-Fei Wang
- Department of Medicine, University of Ottawa, and the Ottawa Hospital Research Institute, Ottawa, ON, Canada. https://twitter.com/TzufeiWang
| | - Marc Carrier
- Department of Medicine, University of Ottawa, and the Ottawa Hospital Research Institute, Ottawa, ON, Canada. https://twitter.com/MarcCarrier1
| | - James D Douketis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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Saunders JA, Vazquez SR, Hill JA, Witt DM. Clinical outcomes associated with anti-Xa-monitored enoxaparin for venous thromboembolism prophylaxis. Pharmacotherapy 2024; 44:224-230. [PMID: 38088033 DOI: 10.1002/phar.2900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 11/10/2023] [Accepted: 11/16/2023] [Indexed: 12/27/2023]
Abstract
STUDY OBJECTIVE The objective of the study was to assess clinical outcomes (composite of any venous thromboembolism [VTE], any bleeding, and mortality) associated with anti-Xa monitoring in the 30 days following enoxaparin initiation for VTE prophylaxis. DESIGN Retrospective cohort study. SETTING Hospital within an academic healthcare system. PATIENTS Propensity score-matched hospitalized adults receiving enoxaparin for VTE prophylaxis. INTERVENTION Low-molecular-weight heparin anti-Xa monitoring. MEASUREMENTS AND MAIN RESULTS During the 13-month study period, a total of 6611 patients received enoxaparin for VTE prophylaxis, 301 in the anti-Xa monitored group and 6310 in the unmonitored group (4.6% received monitoring). The mean age was 52.9 years and 52% of patients were male. The mean body mass index was 31 kg/m2 and the mean creatinine clearance was 109 mL/min. Twenty percent of patients had active cancer. The most common indication for enoxaparin prophylaxis was hospitalization for medical illness (52%) followed by nonorthopedic surgery (37%). The adjusted odds ratio for the primary outcome comparing monitored to unmonitored patients was 1.26 (95% confidence interval, 0.75-2.11). None of the between-group differences in the individual components of the composite outcome were statistically significant. CONCLUSIONS Thirty-day clinical outcomes in patients receiving enoxaparin for VTE prophylaxis were not improved by anti-Xa monitoring. Our results support current evidence-based guideline recommendations against anti-Xa monitoring for patients receiving enoxaparin for VTE prophylaxis.
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Affiliation(s)
- John A Saunders
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, Utah, USA
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Sara R Vazquez
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, Utah, USA
- University of Utah Health Thrombosis Service, Murray, Utah, USA
| | - Joseph A Hill
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, Utah, USA
| | - Daniel M Witt
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, Utah, USA
- University of Utah Health Thrombosis Service, Murray, Utah, USA
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Kollmann L, Gruber M, Lock JF, Germer CT, Seyfried F. Clinical Management of Major Postoperative Bleeding After Bariatric Surgery. Obes Surg 2024; 34:751-759. [PMID: 38244170 PMCID: PMC10899369 DOI: 10.1007/s11695-023-07040-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/26/2023] [Accepted: 12/27/2023] [Indexed: 01/22/2024]
Abstract
INTRODUCTION Major postoperative bleeding (mPOB) is the most common complication after bariatric surgery. Its intesity varies from self-limiting to life-threatening situations. Comprehensive decision-making and treatment strategies are mandatory but not established yet. METHODS We retrospectively analyzied our prospectively collected database of our bariatric patients during 2012-2022. The primary study endpoint was major postoperative bleeding (mPOB) defined as hemoglobin drop > 2 g/dl or clinically relevant bleeding requiring intervention (transfusion, endoscopy or surgery). Secondary endpoints were overall complications according to Clavien-Dindo-Classification and comprehensive-complication-index (CCI). RESULTS We identified 1017 patients, of whom 667 underwent gastric bypass (GB) and 350 sleeve gastrectomy (SG). Major postoperative bleeding occured in 39 patients (total 3.8%; 5.1% after GB and 2.3% after SG). Patients with mPOB were more often diagnosed with type 2 diabetes (p = 0.039), chronic kidney failure (p = 0.013) or received antiplatelet drug treatment (p = 0.003). The interval from detection to intervention within 24 h was 92.1% (35/39). Blood transfusions were necessary in 20/39 cases (total 51.3%; 45.2% after GB and 75% after SG; p = 0.046). Luminal bleeding only occured after GB (19/31; 61.3%), while all mPOB after SG were intraabdominal (p = 0.002). Reoperations were performed in 21/39 (total 53.8%; 48.4% after GB and 75% after SG; p = 0.067). CCI in patients with mPOB was 34.7 overall, with 31.2 after GB and 47.9 after SG (p = 0.005). CONCLUSION The clinical appearance of mPOB depends on the type of surgery with severe bleedings after SG. We suggest a surgery first approach for mPOB after SG and an endoscopy first approach after GB.
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Affiliation(s)
- Lars Kollmann
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital Wuerzburg, Würzburg, Germany
| | - Maximilian Gruber
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital Wuerzburg, Würzburg, Germany
| | - Johan F Lock
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital Wuerzburg, Würzburg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital Wuerzburg, Würzburg, Germany
| | - Florian Seyfried
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital Wuerzburg, Würzburg, Germany.
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Yu Q, Chen C, Cao J, Xu J, Lu J, Yuan L. Efficiency and safety of dual pathway inhibition for the prevention of femoropopliteal artery restenosis in repeated endovascular interventions. J Vasc Surg 2024; 79:623-631.e2. [PMID: 37951514 DOI: 10.1016/j.jvs.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/18/2023] [Accepted: 11/03/2023] [Indexed: 11/14/2023]
Abstract
OBJECTIVE There is a lack of consensus regarding the optimal strategy for evaluating the efficiency and safety of dual-pathway inhibition (DPI) in preventing femoropopliteal restenosis in patients undergoing repeated endovascular interventions. Despite several therapeutic interventions available for preventing femoropopliteal restenosis post repeated endovascular interventions, the ideal strategy, particularly evaluating the efficacy and safety of DPI, remains a matter of debate. METHODS From January 2015 to September 2021, patients who underwent repeated endovascular interventions for femoropopliteal restenosis were compared with those who underwent DPI or dual antiplatelet therapy (DAPT) after surgery using a propensity score-matched analysis. The primary outcome was clinically driven target lesion revascularization (CD-TLR). The principal safety outcome was a composite of major bleeding and clinically relevant non-major (CRNM) bleeding. To further enhance the rigor, Kaplan-Meier plots, Cox proportional hazards modeling, and sensitivity analyses, as well as subgroup analyses were employed, reducing potential confounders. RESULTS A total of 441 patients were included in our study, of whom 294 (66.7%) received DAPT and 147 (33.1%) received DPI, with 114 matched pairs (mean age, 72.21 years; 84.2% male). Cumulative probability of CD-TLR at 36 months in the DPI group (17%) trended lower than that in the DAPT group (32%) (hazard ratio [HR], 0.45; 95% confidence interval [CI], 0.26-0.78; P =.004). The cumulative probability of freedom from CD-TLR at 36 months in the DPI group was 83%. No significant difference was observed in the composite outcome of major or CRNM bleeding between the DPI and DAPT groups (HR, 1.26; 95% CI, 0.34 to 4.69; P = .730). The DPI group was associated with significantly lower rates of CD-TLR in the main subgroup analyses of diabetes (P = .001), previous smoking history (P = .008), longer lesion length (>10 cm) (P = .003), and treatment with debulking strategy (P = .003). CONCLUSIONS In our investigation focused on CD-TLR, we found that DPI exhibited a significant reduction in the risk of reintervention compared with other treatment modalities. This underscores the potential of DPI as a viable therapeutic strategy in preventing reinterventions. Moreover, our assessment of safety outcomes revealed that the bleeding risks associated with DPI were on par with DAPT, thereby not compromising patient safety. These findings pave the way for potential broader clinical implications, emphasizing the effectiveness and safety of DPI in the context of reducing reintervention risks.
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Affiliation(s)
- Qingyuan Yu
- Department of Vascular Surgery, Changhai Hospital, Navy Military Medical University, Shanghai, China
| | - Cheng Chen
- ChangZheng Hospital, Navy Military Medical University, Shanghai, China
| | - Jingzhu Cao
- Department of Endocrinology, Changhai Hospital, Navy Military Medical University, Shanghai, China
| | - Jinyan Xu
- Department of Vascular Surgery, Changhai Hospital, Navy Military Medical University, Shanghai, China
| | - Jin Lu
- Department of Endocrinology, Changhai Hospital, Navy Military Medical University, Shanghai, China
| | - Liangxi Yuan
- Department of Vascular Surgery, Changhai Hospital, Navy Military Medical University, Shanghai, China.
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Karonen E, Eek F, Butt T, Acosta S. Sex differences in outcomes after revascularization for acute lower limb ischemia: Propensity score adjusted analysis. World J Surg 2024; 48:746-755. [PMID: 38501573 DOI: 10.1002/wjs.12058] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 12/13/2023] [Indexed: 03/20/2024]
Abstract
BACKGROUND Previous reports have suggested higher rates of mortality and amputation for female patients in acute lower limb ischemia (ALI). The aims of the present study were to investigate if there is a difference in mortality, amputation, and fasciotomy between the sexes. METHODS A retrospective cohort study of consecutive patients undergoing index revascularization for ALI between 2001 and 2018 was conducted. A propensity score was created through a logistic regression with female/male sex as an outcome. Cox regression analyses for 90-day and 1-year mortality, combining major amputation/mortality, and logistic regression for major bleeding and fasciotomy, were performed. All analyses were performed with and without adjusting for propensity score. RESULTS A total of 709 patients were included in the study of which 45.9% were women. Mean age was 72.1 years. Females were older and had higher rates of atrial fibrillation, embolic disease, and lower estimated glomerular filtration rate, while men more often had anemia and chronic peripheral arterial disease. Mortality at 1 year was 21.2% for women and 14.7% for men. The adjusted hazard ratio for 1-year mortality was 0.99 (95% CI 0.67-1.46). Fasciotomy was performed in 7.1% of female and 12.8% of male patients; the adjusted odds ratio was 0.52 (95% CI 0.29-0.91). CONCLUSION Sex was not found to be an independent risk factor for mortality or combined major amputation/mortality after revascularization for acute lower limb ischemia, whereas women had lower odds of undergoing fasciotomy. Whether women are underdiagnosed or do not develop acute compartment syndrome in the lower leg as often as men should be evaluated prospectively.
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Affiliation(s)
- Emil Karonen
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Vascular Centre, Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
| | - Frida Eek
- Department of Health Sciences, Lund University, Lund, Sweden
| | - Talha Butt
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Vascular Centre, Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
| | - Stefan Acosta
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Vascular Centre, Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
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Kamel H, Longstreth WT, Tirschwell DL, Kronmal RA, Marshall RS, Broderick JP, Aragón García R, Plummer P, Sabagha N, Pauls Q, Cassarly C, Dillon CR, Di Tullio MR, Hod EA, Soliman EZ, Gladstone DJ, Healey JS, Sharma M, Chaturvedi S, Janis LS, Krishnaiah B, Nahab F, Kasner SE, Stanton RJ, Kleindorfer DO, Starr M, Winder TR, Clark WM, Miller BR, Elkind MSV. Apixaban to Prevent Recurrence After Cryptogenic Stroke in Patients With Atrial Cardiopathy: The ARCADIA Randomized Clinical Trial. JAMA 2024; 331:573-581. [PMID: 38324415 PMCID: PMC10851142 DOI: 10.1001/jama.2023.27188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 12/13/2023] [Indexed: 02/09/2024]
Abstract
Importance Atrial cardiopathy is associated with stroke in the absence of clinically apparent atrial fibrillation. It is unknown whether anticoagulation, which has proven benefit in atrial fibrillation, prevents stroke in patients with atrial cardiopathy and no atrial fibrillation. Objective To compare anticoagulation vs antiplatelet therapy for secondary stroke prevention in patients with cryptogenic stroke and evidence of atrial cardiopathy. Design, Setting, and Participants Multicenter, double-blind, phase 3 randomized clinical trial of 1015 participants with cryptogenic stroke and evidence of atrial cardiopathy, defined as P-wave terminal force greater than 5000 μV × ms in electrocardiogram lead V1, serum N-terminal pro-B-type natriuretic peptide level greater than 250 pg/mL, or left atrial diameter index of 3 cm/m2 or greater on echocardiogram. Participants had no evidence of atrial fibrillation at the time of randomization. Enrollment and follow-up occurred from February 1, 2018, through February 28, 2023, at 185 sites in the National Institutes of Health StrokeNet and the Canadian Stroke Consortium. Interventions Apixaban, 5 mg or 2.5 mg, twice daily (n = 507) vs aspirin, 81 mg, once daily (n = 508). Main Outcomes and Measures The primary efficacy outcome in a time-to-event analysis was recurrent stroke. All participants, including those diagnosed with atrial fibrillation after randomization, were analyzed according to the groups to which they were randomized. The primary safety outcomes were symptomatic intracranial hemorrhage and other major hemorrhage. Results With 1015 of the target 1100 participants enrolled and mean follow-up of 1.8 years, the trial was stopped for futility after a planned interim analysis. The mean (SD) age of participants was 68.0 (11.0) years, 54.3% were female, and 87.5% completed the full duration of follow-up. Recurrent stroke occurred in 40 patients in the apixaban group (annualized rate, 4.4%) and 40 patients in the aspirin group (annualized rate, 4.4%) (hazard ratio, 1.00 [95% CI, 0.64-1.55]). Symptomatic intracranial hemorrhage occurred in 0 patients taking apixaban and 7 patients taking aspirin (annualized rate, 1.1%). Other major hemorrhages occurred in 5 patients taking apixaban (annualized rate, 0.7%) and 5 patients taking aspirin (annualized rate, 0.8%) (hazard ratio, 1.02 [95% CI, 0.29-3.52]). Conclusions and Relevance In patients with cryptogenic stroke and evidence of atrial cardiopathy without atrial fibrillation, apixaban did not significantly reduce recurrent stroke risk compared with aspirin. Trial Registration ClinicalTrials.gov Identifier: NCT03192215.
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Affiliation(s)
- Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York
| | - W. T. Longstreth
- Department of Neurology, University of Washington, Seattle
- Department of Medicine, University of Washington, Seattle
- Department of Epidemiology, University of Washington, Seattle
| | | | | | - Randolph S. Marshall
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Joseph P. Broderick
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Rebeca Aragón García
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Pamela Plummer
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Noor Sabagha
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Qi Pauls
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | - Christy Cassarly
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | - Catherine R. Dillon
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | - Marco R. Di Tullio
- Division of Cardiology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Eldad A. Hod
- Department of Pathology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Elsayed Z. Soliman
- Epidemiological Cardiology Research Center, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - David J. Gladstone
- Sunnybrook Research Institute, Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, and Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jeff S. Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Mukul Sharma
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Seemant Chaturvedi
- Department of Neurology, University of Maryland, and Baltimore VA Hospital, Baltimore
| | - L. Scott Janis
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Balaji Krishnaiah
- Department of Neurology, University of Tennessee Health Sciences Center, Memphis
| | - Fadi Nahab
- Departments of Neurology and Pediatrics, Emory University, Atlanta, Georgia
| | - Scott E. Kasner
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Robert J. Stanton
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Matthew Starr
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Wayne M. Clark
- Department of Neurology, Oregon Health & Science University, Portland
| | | | - Mitchell S. V. Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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Hrubesz G, Dwyer K, McIsaac DI, Sood MM, Clark E, Douketis J, Carrier M, Shaw JR. Perioperative management of apixaban in patients with advanced CKD undergoing a planned invasive procedure. Blood Adv 2024; 8:732-735. [PMID: 38181766 PMCID: PMC10847030 DOI: 10.1182/bloodadvances.2023012380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 12/26/2023] [Accepted: 12/26/2023] [Indexed: 01/07/2024] Open
Affiliation(s)
- Gabriella Hrubesz
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Kevin Dwyer
- Analytics, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Daniel I. McIsaac
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Manish M. Sood
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Edward Clark
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Canada
| | - James Douketis
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Marc Carrier
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Joseph R. Shaw
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
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Gostev AA, Valiev E, Zeidlits GA, Shmidt EA, Osipova OS, Cheban AV, Saaya SB, Barbarash OL, Karpenko AA. Treatment of acute pulmonary embolism after catheter-directed thrombolysis with dabigatran vs warfarin: results of a multicenter randomized RE-SPIRE trial. J Vasc Surg Venous Lymphat Disord 2024:101848. [PMID: 38346475 DOI: 10.1016/j.jvsv.2024.101848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND Thrombolytic therapy is effective method in the high-risk acute pulmonary embolism (PE) treatment. Reduced-dose thrombolysis (RDT) plus oral anticoagulation therapy is effective and safe method in the moderate and severe PE treatment. It is leading to good early and intermediate-term outcomes. In the RE-COVER and RE-COVER II studies, dabigatran showed similar effectiveness as warfarin in the treatment of acute PE. Dabigatran leads to fewer hemorrhagic complications and is not inferior in efficacy to warfarin in the prevention of PE after mechanical fragmentation and RDT (catheter-directed treatment [CDT]+RDT) in patients with high and intermediate to high PE risk. We sought to evaluate the efficacy and safety (incidence of clinically significant recurrence of venous thromboembolic complications and deaths) during a 6-month course of treatment with dabigatran or warfarin in patients with high and intermediate to high acute PE risk after endovascular mechanical thrombus fragmentation procedure with RDT (CDT+RDT). METHODS The RE-SPIRE is a prospective, multicenter randomized double-arm study. Over a 5-year period, 66 consecutive patients with symptomatic high and intermediate to high PE risk after endovascular mechanical thrombus fragmentation procedure with RDT (CDT+RDT) were randomized into two groups within the next 48 hours. The first group continued treatment with dabigatran 150 mg twice a day for 6 months; the second group continued treatment with warfarin under the control of international normalized ratio (2.0-3.0) for 6 months. Both groups received low molecular weight heparins for 2 days after surgery. Then, group 1 continued to receive low molecular-weight-heparin for 5 to 7 days, followed by a switch to dabigatran at a dosage of 150 mg two times a day. Group 2 received both low-molecular-weight heparin and warfarin up to an international normalized ratio of >2.0, followed by heparin withdrawal. The follow-up period was 6 months. RESULTS There were 63 patients who completed the study (32 in the dabigatran group and 31 in the warfarin group). In both groups, there was a statistically significant decrease in the mean pulmonary artery pressure. The mean pulmonary artery pressure at the 6-month follow-up after surgery was 24 mm Hg (interquartile range, 20.3-29.25 mm Hg) in the dabigatran group and 23 mm Hg (interquartile range, 20.0-26.3 mm Hg) in the warfarin group. The groups did not differ statistically in the deep vein thrombosis dynamics. Partial recanalization occurred in 52.0% vs 73.1% in the dabigatran and warfarin groups, respectively (P = .15). Complete recanalization occurred in 28.0% vs 19.2% in the dabigatran and warfarin groups, respectively (P = .56). The groups did not differ in the frequency of major bleeding events according to the International Society for Thrombosis and Hemostasis (0% vs 3.2% in the dabigatran and warfarin groups, respectively; P = 1.00). However, there were more nonmajor bleeding events in the warfarin group than in the dabigatran group (16.1% vs 0%, respectively; P = .02). CONCLUSIONS The results of the study show that dabigatran is comparable in effectiveness to warfarin. Dabigatran has greater safety in comparison with warfarin in the occurrence of all cases of bleeding in the postoperative and long-term periods. Thus, dabigatran may be recommended for the treatment and prevention of PE after CDT with RDT in patients with high and intermediate to high PE risk.
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Affiliation(s)
- Alexander A Gostev
- Meshalkin National Medical Research Center, Novosibirsk, Russian Federation.
| | - Emin Valiev
- Meshalkin National Medical Research Center, Novosibirsk, Russian Federation
| | - Galina A Zeidlits
- Meshalkin National Medical Research Center, Novosibirsk, Russian Federation
| | - Evgeniya A Shmidt
- Scientific and Research Institute of Complex Cardiovascular Problems, Kemerovo, Russian Federation
| | - Olesya S Osipova
- Meshalkin National Medical Research Center, Novosibirsk, Russian Federation
| | - Alexey V Cheban
- Meshalkin National Medical Research Center, Novosibirsk, Russian Federation
| | - Shoraan B Saaya
- Meshalkin National Medical Research Center, Novosibirsk, Russian Federation
| | - Olga L Barbarash
- Scientific and Research Institute of Complex Cardiovascular Problems, Kemerovo, Russian Federation
| | - Andrey A Karpenko
- Meshalkin National Medical Research Center, Novosibirsk, Russian Federation
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Galanaud JP, Trujillo-Santos J, Bikdeli B, Bertoletti L, Di Micco P, Poénou G, Falgá C, Zdraveska M, Lima J, Rivera-Civico F, Muixi JF, Monreal M. Clinical Presentation and Outcomes of Patients With Cancer-Associated Isolated Distal Deep Vein Thrombosis. J Clin Oncol 2024; 42:529-537. [PMID: 37471683 DOI: 10.1200/jco.23.00429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/26/2023] [Accepted: 05/23/2023] [Indexed: 07/22/2023] Open
Abstract
PURPOSE Patients with isolated distal deep vein thrombosis (DVT) have lower rates of adverse outcomes (death, venous thromboembolism [VTE] recurrence or major bleeding) than those with proximal DVT. It is uncertain if such findings are also observed in patients with cancer. METHODS Using data from the international Registro Informatizado de la Enfermedad TromboEmbolica venosa registry, we compared the risks of adverse outcomes at 90 days (adjusted odds ratio [aOR]; 95% CI) and 1 year (adjusted hazard ratio [aHR; 95% CI]) in 886 patients with cancer-associated distal DVT versus 5,196 patients with cancer-associated proximal DVT and 5,974 patients with non-cancer-associated distal DVT. RESULTS More than 90% of patients in each group were treated with anticoagulants for at least 90 days. At 90 days, the adjusted risks of death, VTE recurrence, or major bleeding were lower in patients with non-cancer-associated distal DVT than in patients with cancer-associated distal DVT (reference): aOR = 0.16 (0.11-0.22), aOR = 0.34 (0.22-0.54), and aOR = 0.47 (0.27-0.80), respectively. The results were similar at 1-year follow-up: aHR = 0.12 (0.09-0.15), aHR = 0.39 (0.28-0.55), and aHR = 0.51 (0.32-0.82), respectively. Risks of death, VTE recurrence, and major bleeding were not statistically different between patients with cancer-associated proximal versus distal DVT, both at 90 days: aOR = 1.11 (0.91-1.36), aOR = 1.10 (0.76-1.62), and aOR = 1.18 (0.76-1.83), respectively, and 1 year: aHR = 1.01 (0.89-1.15), aHR = 1.02 (0.76-1.35), and aHR = 1.10 (0.76-1.61), respectively. However, more patients with cancer-associated proximal DVT, compared with cancer-associated distal DVT, developed fatal pulmonary embolism (PE) during follow-up: The risk difference was 0.40% (95% CI, 0.23 to 0.58). CONCLUSION Cancer-associated distal DVT has serious and relatively comparable outcomes compared with cancer-associated proximal DVT. The lower risk of fatal PE from cancer-associated distal DVT needs further investigation.
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Affiliation(s)
- Jean-Philippe Galanaud
- Department of Medicine, Sunnybrook Heath Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Javier Trujillo-Santos
- Department of Internal Medicine, Hospital General Universitario Santa Lucía, Universidad Católica San Antonio de Murcia, Murcia, Spain
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT
- Cardiovascular Research Foundation (CRF), New York, NY
| | - Laurent Bertoletti
- Department of Vascular Medicine and Therapeutics, Hôpital Nord-CHU St-Etienne, Saint-Etienne, France
| | - Pierpaolo Di Micco
- Department of Internal Medicine and Emergency Room, Ospedale Buon Consiglio Fate bene fratelli, Naples, Italy
| | - Géraldine Poénou
- Department of Vascular Medicine and Therapeutics, Hôpital Nord-CHU St-Etienne, Saint-Etienne, France
| | - Conxita Falgá
- Department of Internal Medicine, Hospital de Mataró, Barcelona, Spain
| | - Marija Zdraveska
- University Clinic of Pneumology and Allergy Skopje, Skopje, Republic of Macedonia
| | - Jorge Lima
- Department of Pneumonology, Hospital Universitario Virgen de Valme, Sevilla, Spain
| | | | | | - Manuel Monreal
- Chair for the Study of Thromboembolic Disease, Faculty of Health Sciences, UCAM-Universidad Católica San Antonio de Murcia, Murcia, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
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Rostagno C, Mannarino GM, Civinini R, Gori AM, Marcucci R. DOACs levels in patients with hip fracture: is there a relation with renal function and time from last drug intake? Intern Emerg Med 2024:10.1007/s11739-024-03546-2. [PMID: 38324043 DOI: 10.1007/s11739-024-03546-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 01/16/2024] [Indexed: 02/08/2024]
Affiliation(s)
- Carlo Rostagno
- Dipartimento Medicina Sperimentale e Clinica, Università di Firenze, Florence, Italy.
- Medicina Interna e Post-Chirurgica, AOU Careggi Firenze, Viale Morgagni 85, 50134, Florence, Italy.
| | - Giulio Maria Mannarino
- Medicina Interna e Post-Chirurgica, AOU Careggi Firenze, Viale Morgagni 85, 50134, Florence, Italy
| | | | - Anna Maria Gori
- Dipartimento Medicina Sperimentale e Clinica, Università di Firenze, Florence, Italy
- Malattie Aterotrombotiche, AOU Careggi, Florence, Italy
| | - Rossella Marcucci
- Dipartimento Medicina Sperimentale e Clinica, Università di Firenze, Florence, Italy
- Malattie Aterotrombotiche, AOU Careggi, Florence, Italy
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de Maat MMR, van Leeuwen HJ, Roovers L, Ahlers SJGM, Lambers J, Hovens MMC. Large variation in anti-factor Xa levels with nadroparin as thromboprophylaxis in COVID-19 and non-COVID-19 critically ill patients. BMC Pharmacol Toxicol 2024; 25:16. [PMID: 38321487 PMCID: PMC10848501 DOI: 10.1186/s40360-024-00733-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 01/12/2024] [Indexed: 02/08/2024] Open
Abstract
PURPOSE Critically ill COVID-19 and non-COVID-19 patients receive thromboprophylaxis with the LMWH nadroparin. Whether a standard dosage is adequate in attaining the target anti-FXa levels (0.20-0.50 IU/ml) in these groups is unknown. METHODS This study was a prospective, observational study in the ICU of a large general teaching hospital in the Netherlands. COVID-19 and non-COVID-19 patients admitted to the ICU who received LMWH in a prophylactic dosage of 2850 IU, 5700 IU or 11400 IU subcutaneously were eligible for the study. Anti-FXa levels were determined 4 h after administration. Relevant laboratory parameters, prespecified co-variates and clinical data were extracted from the electronic health record system. The primary goal was to evaluate anti-FXa levels in critically ill patients on a prophylactic dosage of nadroparin. The second goal was to investigate whether covariates had an influence on anti-FXa levels. RESULTS A total of 62 patients were included in the analysis. In the COVID-19 group and non-COVID-19 group, 29 (96%) and 12 patients (38%) reached anti-FXa levels above 0.20 IU/ml, respectively. In the non-COVID-19 group, 63% of the patients had anti-FXA levels below the target range. When adjusted for nadroparin dosage a significant relation was found between body weight and the anti-FXa level (p = 0.013). CONCLUSION A standard nadroparin dosage of 2850 IU sc in the critically ill patient is not sufficient to attain target anti-FXa levels in the majority of the studied patient group. We suggest a standard higher dosage in combination with body-weight dependent dosing as it leads to better exposure to nadroparin. CLINICAL TRIALS REGISTRATION Retrospectively registered, ClinicalTrials.gov ID NTC 05926518 g, date of registration 06/01/23, unique ID 2020/1725.
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Affiliation(s)
- Monique M R de Maat
- Department of Clinical Pharmacy, Rijnstate Hospital, Arnhem, The Netherlands.
| | - Henk J van Leeuwen
- Department of Internal Medicine and Intensive Care, Rijnstate Hospital, Arnhem, The Netherlands
| | - Lian Roovers
- Department of Epidemiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Sabine J G M Ahlers
- Department of Clinical Pharmacy, Rijnstate Hospital, Arnhem, The Netherlands
| | - Jolanda Lambers
- Department of Clinical Chemistry and Hematology Laboratory, Rijnstate Hospital, Arnhem, The Netherlands
| | - Marcel M C Hovens
- Department of Internal Medicine, Rijnstate Hospital, Arnhem, The Netherlands
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Elahifar A, Rafati A, Alemzadeh-Ansari MJ, Pasebani Y, Naghshtabrizi B, Mohammadi Y, Hosseini SK. The Comparison of the Initial TIMI Flow Grade in Acute ST-Elevation Myocardial Infarction Patients Receiving Ticagrelor vs. Clopidogrel before Undergoing Primary Percutaneous Coronary Intervention: A Prospective Cohort Study. Cardiol Res Pract 2024; 2024:6632656. [PMID: 38348469 PMCID: PMC10861275 DOI: 10.1155/2024/6632656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 01/01/2024] [Accepted: 01/19/2024] [Indexed: 02/15/2024] Open
Abstract
Objective Primary percutaneous coronary intervention (PCI) is the best treatment for acute ST-elevation myocardial infarction (STEMI). Evidence is in favor of ticagrelor over clopidegrel in STEMI patients regarding the reduction of stent thrombosis risk during and after PCI. We compared initial thrombolysis in myocardial infarction (TIMI) flow in STEMI patients on ticagrelor vs. clopidogrel. Methods This prospective cohort recruited 160 patients with acute STEMI, referred to the emergency department of Farshchian Heart Center, during March 2018-2019. Before angiography, the patients received clopidogrel (600 mg) or ticagrelor (180 mg) on top of aspirin. Initial TIMI flow was compared between the two groups as the primary outcome. A logistic regression was performed to calculate the predictors of initial TIMI flow. Analyses were performed using R, version 4.2.1. Results In ticagrelor and clopidogrel groups, the mean ± standard deviation age of the patients was 59.46 ± 13.11 and 61.34 ± 11.08 years (p value = 0.33), respectively. In the ticagrelor and clopidogrel groups, initial TIMI flow grades were as follows: 0 : 50% and 71.2%, I: 26.2% and 16.2%, II: 12.5% and 10%, and III: 12.9% and 2.5%, respectively (p value = 0.005). Final TIMI flow grades were as follows: I: 26.2% and 16.2%, II: 7.5% and 13.8%, and III: 66.3% and 70%, respectively (p value = 0.41). Ticagrelor was associated with significantly higher initial TIMI flow grade compared to the clopidogrel group (adjusted odds ratio: 2.90 (95% CI: 1.51-5.72)). Conclusion In STEMI patients who were candidates for primary PCI, ticagrelor administration led to a better initial TIMI flow grade compared to clopidogrel.
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Affiliation(s)
- Amin Elahifar
- Rajaie Cardiovascular Medical and Research Center, Medical School, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Rafati
- Rajaie Cardiovascular Medical and Research Center, Medical School, Iran University of Medical Sciences, Tehran, Iran
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Javad Alemzadeh-Ansari
- Rajaie Cardiovascular Medical and Research Center, Medical School, Iran University of Medical Sciences, Tehran, Iran
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Yeganeh Pasebani
- Rajaie Cardiovascular Medical and Research Center, Medical School, Iran University of Medical Sciences, Tehran, Iran
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | | | - Younes Mohammadi
- Department of Epidemiology, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran
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Ma S, Fan G, Xu F, Zhang X, Chen Y, Tao Y, Li Y, Lyu Y, Yang P, Wang D, Zhai Z, Wang C. Efficacy and safety of anticoagulant for treatment and prophylaxis of VTE patients with renal insufficiency: a systemic review and meta-analysis. Thromb J 2024; 22:17. [PMID: 38317247 PMCID: PMC10840151 DOI: 10.1186/s12959-023-00576-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 12/25/2023] [Indexed: 02/07/2024] Open
Abstract
Patients with venous thromboembolism (VTE) comorbid renal insufficiency (RI) are at higher risk of bleeding and thrombosis. Recommendations in guidelines on anticoagulation therapy for those patients remain ambiguous. The goal of this study is to compare the efficacy and safety between different anticoagulant regimens in VTE patients comorbid RI at different stages of treatment and prophylaxis. We performed English-language searches of Pubmed, EMBASE, and Web of Science (inception to Nov 2022). RCTs evaluated anticoagulants for VTE treatment at the acute phase, extension phase, and prophylaxis in patients with RI and reported efficacy and safety outcomes were selected. The methodological quality of the studies was assessed at the outcome level using the risk-of-bias assessment tool developed by the Cochrane Bias Methods Group. A meta-analysis of twenty-five RCTs was conducted, comprising data from twenty-three articles, encompassing a total of 9,680 participants with RI. In the acute phase, the risk of bleeding was increased with novel oral anticoagulants (NOACs) compared to LMWH (RR 1.29, 95% CI 1.04-1.60). For the prophylaxis of VTE, NOACs were associated with an elevated risk of bleeding compared with placebo (RR 1.31, 95%CI 1.02-1.68). In comparison to non-RI patients, both NOACs and vitamin K antagonists (VKA) could increase the risk of bleeding among RI patients (RR 1.45, 95%CI 1.14-1.84 and RR 1.53, 95%CI 1.25-1.88, respectively) during acute phase, while NOACs may increase the incidence of VTE in RI population (RR 1.74, 95%CI 1.29-2.34). RI patients who are under routine anticoagulation have a significantly higher risk of adverse outcomes. LMWH is the most effective and safe option for VTE treatment or prophylaxis in patients with RI.
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Affiliation(s)
- Shuangshuang Ma
- Beijing University of Chinese Medicine. National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Guohui Fan
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College; State Key Laboratory of Respiratory Health and Multimorbidity; Key Laboratory of Pathogen Infection Prevention and Control (Peking Union Medical College), Ministry of Education, Beijing, China
- National Center for Respiratory Medicine; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Clinical Research and Data Management, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Feiya Xu
- Graduate School of Capital Medical University, Beijing, China
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Xiaomeng Zhang
- Peking University China‑Japan Friendship School of Clinical Medicine, Beijing, P.R. China
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Yinong Chen
- Peking University China‑Japan Friendship School of Clinical Medicine, Beijing, P.R. China
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Yuzhi Tao
- The First Bethune Hospital of Jilin University, Beijing, China
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Yishan Li
- The First Clinical Medical College, Shanxi Medical University, Taiyuan, China
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Yanshuang Lyu
- Changping Laboratory, Beijing, China
- Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Peiran Yang
- Department of Physiology, Institute of Basic Medical Sciences, State Key Laboratory of Respiratory Health and Multimorbidity, Chinese Academy of Medical Sciences and School of Basic Medicine, Peking Union Medical College; National Center for Respiratory Medicine; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Dingyi Wang
- National Center for Respiratory Medicine; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Clinical Research and Data Management, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.
| | - Zhenguo Zhai
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, 100029, China.
| | - Chen Wang
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases, Beijing, 100029, China.
- Chinese Academy of Medical Sciences, Peking Union Medical College, No 2, East Yinghua Road, Chaoyang District, Beijing, 100029, China.
- Department of Respiratory Medicine, Capital Medical University, No 2, East Yinghua Road, Chaoyang District, Beijing, 100029, China.
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Carter C, Denny K, Carver TW, Jung B, Rein L, Peppard WJ. Evaluation of an Association Between Enoxaparin Dose per Estimated Blood Volume and Clinically Relevant Bleeding in Low-Weight Trauma Patients. Ann Pharmacother 2024; 58:118-125. [PMID: 37138511 DOI: 10.1177/10600280231169523] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023] Open
Abstract
BACKGROUND The optimal dosing for enoxaparin venous thromboembolism (VTE) prophylaxis in low-weight trauma patients is unknown. Estimated blood volume (EBV) has shown promise as a dose modifier. OBJECTIVE To characterize the association of enoxaparin dose per EBV with the prevalence of VTE and bleeding in low-weight trauma patients. METHODS This was a retrospective study of trauma patients admitted over a 4-year period. Included patients were adults weighing <60 kg who received a minimum of 3 consecutive doses of enoxaparin. The primary endpoint was a comparison of enoxaparin dose per EBV in patients experiencing bleeding and VTE. Secondary endpoints included comparisons of dose per body mass index (BMI) and total body weight (TBW) and the ability of dose per EBV to predict clinical endpoints. Subgroup analyses for patients weighing <50 kg were performed for all endpoints. RESULTS A total of 189 patients were included. Statistical comparisons for VTE were not performed because of low prevalence. The dose of enoxaparin per EBV was not statistically different between patients who did and did not bleed in all analyses. Doses per BMI and TBW were also not statistically different between the groups. In patients weighing <50 kg, numerically higher doses per EBV, BMI, and TBW were noted in patients that bled versus those that did not. Enoxaparin dose per EBV was not a statistically significant predictor of bleeding in logistic regression models. CONCLUSION AND RELEVANCE No significant associations between enoxaparin dose per EBV, BMI, or TBW and bleeding were noted in the study. Future analyses of EBV and other dose modifiers should consider inclusion of patients weighing <50 kg.
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Affiliation(s)
- Chris Carter
- Department of Pharmacy, SSM Health St. Clare Hospital-Fenton, Fenton, MO, USA
| | - Kailey Denny
- Department of Pharmacy, Froedtert & the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Thomas W Carver
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Benjamin Jung
- Department of Pharmacy, Froedtert & the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Lisa Rein
- Division of Biostatistics, Institute for Health & Equity, Medical College of Wisconsin, Milwaukee, WI, USA
| | - William J Peppard
- Department of Pharmacy, Froedtert & the Medical College of Wisconsin, Milwaukee, WI, USA
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
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42
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Sarmiento IA, Guzmán MF, Chapochnick J, Meier J. Implementation of a Bleeding Management Algorithm in Liver Transplantation: A Pilot Study. Transfus Med Hemother 2024; 51:1-11. [PMID: 38314241 PMCID: PMC10836948 DOI: 10.1159/000530579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 04/03/2023] [Indexed: 02/06/2024] Open
Abstract
Objectives The aims of the study were to compare the consumption of blood products before and after the implementation of a bleeding management algorithm in patients undergoing liver transplantation and to determine the feasibility of a multicentre, randomized study. Background Liver transplantation remains the only curative therapy for patients with end-stage liver disease, but it carries a high risk of surgical bleeding. Materials and Methods Retrospective study of patients treated before (group 1) and after (group 2) implementation of a haemostatic algorithm guided by viscoelastic testing, including use of lyophilized coagulation factor concentrates (prothrombin complex and fibrinogen concentrates). Primary outcome was the number of units of blood products transfused in 24 h after surgery. Secondary outcomes included hospital stay, mortality, and cost. Results Data from 30 consecutive patients was analysed; 14 in group 1 and 16 in group 2. Baseline data were similar between groups. Median total blood product consumption 24 h after surgery was 33 U (IQR: 11-57) in group 1 and 1.5 (0-23.5) in group 2 (p = 0.028). Significantly fewer units of red blood cells, fresh frozen plasma, and cryoprecipitate were transfused in group 2 versus group 1. There was no significant difference in complications, hospital stay, or in-hospital mortality between groups. The cost of haemostatic therapy was non-significantly lower in group 2 versus group 1 (7,400 vs. 15,500 USD; p = 0.454). Conclusion The haemostatic management algorithm was associated with a significant reduction in blood product use during 24 h after liver transplantation. This study demonstrated the feasibility and provided a sample size calculation for a larger, randomized study.
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Affiliation(s)
| | - María F Guzmán
- Department of Anesthesiology, Universidad de los Andes, Santiago de Chile, Chile
| | | | - Jens Meier
- Department for Anesthesiology and Critical Care, Kepler University Hospital, Johannes Kepler University, Linz, Austria
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43
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Zhou X, Yang Y, Zhai Z, Wang D, Lei J, Xu X, Ji Y, Yi Q, Chen H, Hu X, Liu Z, Mao Y, Zhang J, Shi J, Zhang Z, Wu S, Gao Q, Tao X, Xie W, Wan J, Zhang Y, Zhang S, Zhen K, Zhang Z, Fang B, Wang C. Clinical characteristics and mortality predictors among very old patients with pulmonary thromboembolism: a multicenter study report. BMC Pulm Med 2024; 24:26. [PMID: 38200493 PMCID: PMC10782748 DOI: 10.1186/s12890-023-02824-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Clinical characteristics of patients with pulmonary thromboembolism have been described in previous studies. Although very old patients with pulmonary thromboembolism are a special group based on comorbidities and age, they do not receive special attention. OBJECTIVE This study aims to explore the clinical characteristics and mortality predictors among very old patients with pulmonary thromboembolism in a relatively large population. DESIGN AND PARTICIPANTS The study included a total of 7438 patients from a national, multicenter, registry study, the China pUlmonary thromboembolism REgistry Study (CURES). Consecutive patients with acute pulmonary thromboembolism were enrolled and were divided into three groups. Comparisons were performed between these three groups in terms of clinical characteristics, comorbidities and in-hospital prognosis. Mortality predictors were analyzed in very old patients with pulmonary embolism. KEY RESULTS In 7,438 patients with acute pulmonary thromboembolism, 609 patients aged equal to or greater than 80 years (male 354 (58.1%)). There were 2743 patients aged between 65 and 79 years (male 1313 (48%)) and 4095 patients aged younger than 65 years (male 2272 (55.5%)). Patients with advanced age had significantly more comorbidities and worse condition, however, some predisposing factors were more obvious in younger patients with pulmonary thromboembolism. PaO2 < 60 mmHg, eGFR < 60 mL/min/1.73m2, malignancy, anticoagulation as first therapy were mortality predictors for all-cause death in very old patients with pulmonary thromboembolism. The analysis found that younger patients were more likely to have chest pain, hemoptysis (the difference was statistically significant) and dyspnea triad. CONCLUSION In very old population diagnosed with pulmonary thromboembolism, worse laboratory results, atypical symptoms and physical signs were common. Mortality was very high and comorbid conditions were their features compared to younger patients. PaO2 < 60 mmHg, eGFR < 60 mL/min/1.73m2 and malignancy were positive mortality predictors for all-cause death in very old patients with pulmonary thromboembolism while anticoagulation as first therapy was negative mortality predictors.
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Affiliation(s)
- Xia Zhou
- Shijingshan Teaching Hospital of Capital Medical University, Shijingshan Hospital, Capital Medical University, BeijingBeijing, China
| | - Yuanhua Yang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.
| | - Zhenguo Zhai
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, Chinese Academy of Medical Sciences, China-Japan Friendship Hospital, No.2 East Yinghua Road, Beijing, 100029, China.
| | - Dingyi Wang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, Chinese Academy of Medical Sciences, China-Japan Friendship Hospital, No.2 East Yinghua Road, Beijing, 100029, China
- Data and Project Management Unit, Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
| | - Jieping Lei
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, Chinese Academy of Medical Sciences, China-Japan Friendship Hospital, No.2 East Yinghua Road, Beijing, 100029, China
- Data and Project Management Unit, Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
| | - Xiaomao Xu
- Department of Pulmonary and Critical Care Medicine, Beijing Hospital, Beijing, China
| | - Yingqun Ji
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Qun Yi
- Department of Pulmonary and Critical Care Medicine, West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Hong Chen
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaoyun Hu
- Department of Pulmonary and Critical Care Medicine, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Zhihong Liu
- Fuwai Hospital, Chinese Academy of Medical Science, National Center for Cardiovascular Diseases, Beijing, China
| | - Yimin Mao
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Henan University of Science and Technology, Luoyang, China
| | - Jie Zhang
- Department of Pulmonary and Critical Care Medicine, The Second Hospital of Jilin University, Changchun, China
| | - Juhong Shi
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Zhu Zhang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, Chinese Academy of Medical Sciences, China-Japan Friendship Hospital, No.2 East Yinghua Road, Beijing, 100029, China
- Data and Project Management Unit, Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Sinan Wu
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, Chinese Academy of Medical Sciences, China-Japan Friendship Hospital, No.2 East Yinghua Road, Beijing, 100029, China
- Data and Project Management Unit, Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
| | - Qian Gao
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, Chinese Academy of Medical Sciences, China-Japan Friendship Hospital, No.2 East Yinghua Road, Beijing, 100029, China
- Data and Project Management Unit, Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
| | - Xincao Tao
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, Chinese Academy of Medical Sciences, China-Japan Friendship Hospital, No.2 East Yinghua Road, Beijing, 100029, China
- Data and Project Management Unit, Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
| | - Wanmu Xie
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, Chinese Academy of Medical Sciences, China-Japan Friendship Hospital, No.2 East Yinghua Road, Beijing, 100029, China
- Data and Project Management Unit, Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
| | - Jun Wan
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, Chinese Academy of Medical Sciences, China-Japan Friendship Hospital, No.2 East Yinghua Road, Beijing, 100029, China
- Data and Project Management Unit, Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
| | - Yunxia Zhang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, Chinese Academy of Medical Sciences, China-Japan Friendship Hospital, No.2 East Yinghua Road, Beijing, 100029, China
| | - Shuai Zhang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, Chinese Academy of Medical Sciences, China-Japan Friendship Hospital, No.2 East Yinghua Road, Beijing, 100029, China
| | - Kaiyuan Zhen
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, Chinese Academy of Medical Sciences, China-Japan Friendship Hospital, No.2 East Yinghua Road, Beijing, 100029, China
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Zhonghe Zhang
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Baomin Fang
- Department of Pulmonary and Critical Care Medicine, Beijing Hospital, Beijing, China
| | - Chen Wang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, Chinese Academy of Medical Sciences, China-Japan Friendship Hospital, No.2 East Yinghua Road, Beijing, 100029, China
- Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College, Beijing, China
- Department of Respiratory Medicine, Capital Medical University, Beijing, China
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Kobayashi T, Pugliese S, Sethi SS, Parikh SA, Goldberg J, Alkhafan F, Vitarello C, Rosenfield K, Lookstein R, Keeling B, Klein A, Gibson CM, Glassmoyer L, Khandhar S, Secemsky E, Giri J. Contemporary Management and Outcomes of Patients With High-Risk Pulmonary Embolism. J Am Coll Cardiol 2024; 83:35-43. [PMID: 38171708 DOI: 10.1016/j.jacc.2023.10.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/11/2023] [Accepted: 10/13/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Contemporary care patterns/outcomes in high-risk pulmonary embolism (PE) patients are unknown. OBJECTIVES This study sought to characterize the management of high-risk PE patients and identify factors associated with poor outcomes. METHODS A retrospective analysis of the PERT (Pulmonary Embolism Response Team) Consortium Registry was performed. Patients presenting with intermediate-risk PE, high-risk PE, and catastrophic PE (those with hemodynamic collapse) were identified. Patient characteristics were compared with chi-square testing for categorical covariates and Student's t-test for continuous covariates. Multivariable logistic regression was used to assess associations between clinical characteristics and outcomes in the high-risk population. RESULTS Of 5,790 registry patients, 2,976 presented with intermediate-risk PE and 1,442 with high-risk PE. High-risk PE patients were more frequently treated with advanced therapies than intermediate-risk PE patients (41.9% vs 30.2%; P < 0.001). In-hospital mortality (20.6% vs 3.7%; P < 0.001) and major bleeding (10.5% vs. 3.5%; P < 0.001) were more common in high-risk PE. Multivariable regression analysis demonstrated vasopressor use (OR: 4.56; 95% CI: 3.27-6.38; P < 0.01), extracorporeal membrane oxygenation use (OR: 2.86; 95% CI: 1.12-7.30; P = 0.03), identified clot-in-transit (OR: 2.26; 95% CI: 1.13-4.52; P = 0.02), and malignancy (OR: = 1.70; 95% CI: 1.13-2.56; P = 0.01) as factors associated with in-hospital mortality. Catastrophic PE patients (n = 197 [13.7% of high-risk PE patients]) had higher in-hospital mortality (42.1% vs 17.2%; P < 0.001) than those presenting with noncatastrophic high-risk PE. Extracorporeal membrane oxygenation (13.3% vs. 4.8% P < 0.001) and systemic thrombolysis (25% vs 11.3%; P < 0.001) were used more commonly in catastrophic PE. CONCLUSIONS In the largest analysis of high-risk PE patients to date, mortality rates were high with the worst outcomes among patients with hemodynamic collapse.
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Affiliation(s)
- Taisei Kobayashi
- Cardiovascular Medicine Division, Perelman School of Medicine. University of Pennsylvania, Philadelphia, Pennsylvania, USA; Penn Cardiovascular Outcomes, Quality and Evaluative Research Center, Philadelphia, Pennsylvania, USA
| | - Steven Pugliese
- Division of Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sanjum S Sethi
- Center for Interventional Cardiovascular Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Sahil A Parikh
- Center for Interventional Cardiovascular Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Joshua Goldberg
- Cardiothoracic Surgery Division, Westchester Medical Center, Westchester, New York, USA
| | - Fahad Alkhafan
- Boston Clinical Research Institute, Boston, Massachusetts, USA
| | - Clara Vitarello
- Boston Clinical Research Institute, Boston, Massachusetts, USA
| | - Kenneth Rosenfield
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Robert Lookstein
- Department of Radiology, Mount Sinai Medical Center, New York, New York, USA
| | - Brent Keeling
- Division of Cardiothoracic Surgery, Emory University Hospital, Atlanta, Georgia, USA
| | | | - C Michael Gibson
- Boston Clinical Research Institute, Boston, Massachusetts, USA; Smith Center for Cardiovascular Outcomes Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Lauren Glassmoyer
- Cardiovascular Medicine Division, Perelman School of Medicine. University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sameer Khandhar
- Cardiovascular Medicine Division, Perelman School of Medicine. University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eric Secemsky
- Smith Center for Cardiovascular Outcomes Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jay Giri
- Cardiovascular Medicine Division, Perelman School of Medicine. University of Pennsylvania, Philadelphia, Pennsylvania, USA; Penn Cardiovascular Outcomes, Quality and Evaluative Research Center, Philadelphia, Pennsylvania, USA.
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Bergler-Klein J, Gotcheva N, Kalējs O, Kalarus Z, Kovačić D, Peršić V, Shlyakhto E, Uuetoa T, Huisman MV, Lip GYH, Vinereanu D. Antithrombotic Usage, Including Three-Year Outcomes With Dabigatran and Vitamin K Antagonists for Atrial Fibrillation, in Eastern Europe: A Descriptive Analysis From Phase 3 of the GLORIA-AF Registry. Am J Ther 2024; 31:e1-e12. [PMID: 38231576 DOI: 10.1097/mjt.0000000000001655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
BACKGROUND Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation (GLORIA-AF) is a prospective registry of outcomes from patients with newly diagnosed AF at risk of stroke. In the propensity score (PS)-matched global population of phase 3 GLORIA-AF, at 3 years, dabigatran-treated patients experienced reduced risk for major bleeding, and similar risk for stroke and myocardial infarction, compared with vitamin K antagonist (VKA)-treated patients. STUDY QUESTION Do patients in Eastern Europe benefit from treatment with dabigatran versus VKA? STUDY DESIGN Descriptive analysis, without PS matching. To contextualize the Eastern Europe results of GLORIA-AF phase 3, we also descriptively analyzed the global population without PS matching. Consecutive patients with newly diagnosed AF and CHA2DS2-VASc-score ≥1 were enrolled until December 2016 in 38 countries (9 in Eastern Europe). MEASURES AND OUTCOMES Three-year outcomes with dabigatran and VKA. RESULTS In Eastern Europe, 1341 patients were eligible (6% of patients globally), and incidence rates (per 100 patient-years) for the following outcomes were numerically lower with dabigatran (N = 498) versus VKA (N = 466): major bleeding (0.26 vs. 0.90), all-cause death (2.04 vs. 3.50), and a composite of stroke, systemic embolism, myocardial infarction, life-threatening bleeding, and vascular death (1.37 vs. 1.92); stroke was comparable (0.51 vs. 0.50). All incidence rates were numerically lower in Eastern Europe versus the global population for both treatments. Chronic concomitant use of high bleeding risk medications (eg, nonsteroidal anti-inflammatories) was lower in Eastern Europe (dabigatran 3.8%, VKA 9.3%) than globally (dabigatran 14.8%, VKA 20.6%) and persistence with dabigatran was higher in Eastern Europe (76%) than globally (64%). CONCLUSIONS Dabigatran was associated with numerically reduced major bleeding, all-cause death, and cardiovascular (CV) composite, with comparable risk of stroke versus VKA, in Eastern Europe. Limitations of this descriptive analysis include few CV events (n = 11 for stroke, in the dabigatran and VKA groups combined) and a lack of statistical analysis and PS matching, which precludes definitive conclusions; however, the CV outcomes in Eastern Europe were consistent with the beneficial impact of dabigatran versus VKA in the statistically analyzed global population with PS matching.
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Affiliation(s)
- Jutta Bergler-Klein
- Department of Cardiology, University Clinic of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Nina Gotcheva
- Department of Cardiology, National Heart Hospital, Sofia, Bulgaria
| | - Oskars Kalējs
- Department of Arrhythmology, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Zbigniew Kalarus
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Dragan Kovačić
- Department of Cardiology, General Hospital Celje, Celje, Slovenia
| | - Viktor Peršić
- Department of Medical Rehabilitation, Medical Faculty, University of Rijeka, Rijeka, Croatia
- Division of Cardiology, Hospital for Medical Rehabilitation of the Heart and Lung Diseases and Rheumatism "Thalassotherapia Opatija," Opatija, Croatia
| | - Evgeny Shlyakhto
- Clinical Endocrinology Laboratory, Department of Endocrinology, Almazov National Medical Research Centre, Saint Petersburg, Russia
| | | | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Dragos Vinereanu
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania; and
- Department of Cardiology and Cardiovascular Surgery, University and Emergency Hospital, Bucharest, Romania
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Espitia O, Raimbeau A, Planquette B, Katsahian S, Sanchez O, Espinasse B, Bénichou A, Murris J. A systematic review and meta-analysis of the incidence of post-thrombotic syndrome, recurrent thromboembolism, and bleeding after upper extremity vein thrombosis. J Vasc Surg Venous Lymphat Disord 2024; 12:101688. [PMID: 37717788 DOI: 10.1016/j.jvsv.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/26/2023] [Accepted: 09/04/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Data on complications after upper extremity vein thrombosis (UEVT) are limited and heterogeneous. METHODS The aim of the present study was to evaluate the pooled proportions of venous thromboembolism (VTE) recurrence, bleeding, and post-thrombotic syndrome (PTS) in patients with UEVT. A systematic literature review was conducted of PubMed, Embase, and the Cochrane Library databases from January 2000 to April 2023 in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. All studies included patients with UEVT and were published in English. Meta-analyses of VTE recurrence, bleeding, and of PTS after UEVT were performed to compute pooled estimates and associated 95% confidence intervals (CIs). Subgroup analyses of cancer-associated UEVT and catheter-associated venous thrombosis were conducted. Patients with Paget-Schroetter syndrome or effort thrombosis were excluded. RESULTS A total of 55 studies with 15,694 patients were included. The pooled proportions for VTE recurrence, major bleeding, and PTS were 4.8% (95% CI, 3.8%-6.2%), 3.0% (95% CI, 2.2%-4.0%), and 23.8% (95% CI, 17.0%-32.3%), respectively. The pooled proportion of VTE recurrence was 2.7% (95% CI, 1.6%-4.6%) for patients treated with direct oral anticoagulants (DOACs), 1.7% (95% CI, 0.8%-3.7%) for patients treated with low-molecular-weight heparin (LMWH), and 4.4% (95% CI, 1.5%-11.8%) for vitamin K antagonists (VKAs; P = .36). The pooled proportion was 6.3% (95% CI, 4.3%-9.1%) for cancer patients compared with 3.1% (95% CI, 2.1%-4.6%) for patients without cancer (P = .01). The pooled proportion of major bleeding for patients treated with DOACs, LMWH, and VKAs, was 2.1% (95% CI, 0.9%-5.1%), 3.2% (95% CI, 1.4%-7.2%), and 3.4% (95% CI, 1.4%-8.4%), respectively (P = .72). The pooled proportion of PTS for patients treated with DOACs, LMWH, and VKAs was 11.8% (95% CI, 6.5%-20.6%), 27.9% (95% CI, 20.9%-36.2%), and 24.5% (95% CI, 17.6%-33.1%), respectively (P = .02). CONCLUSIONS The results from this study suggest that UEVT is associated with significant rates of PTS and VTE recurrence. Treatment with DOACs might be associated with lower PTS rates than treatment with other anticoagulants.
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Affiliation(s)
- Olivier Espitia
- Department of Vascular Medicine, Nantes Université, CHU Nantes, l'institut du Thorax, INSERM UMR1087/CNRS UMR 6291, Team III Vascular & Pulmonary Diseases, Nantes, France; UNAV, Nantes Vascular Access Unit, Nantes Université, CHU Nantes, Nantes, France.
| | - Alizée Raimbeau
- Department of Vascular Medicine, Nantes Université, CHU Nantes, l'institut du Thorax, INSERM UMR1087/CNRS UMR 6291, Team III Vascular & Pulmonary Diseases, Nantes, France; UNAV, Nantes Vascular Access Unit, Nantes Université, CHU Nantes, Nantes, France
| | - Benjamin Planquette
- Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Centre - Université Paris Cité, INSERM UMR S1140, Innovative Therapies in Hemostasis, Paris, France, F-CRIN INNOVTE, Université Paris Cité, St-Etienne, France
| | - Sandrine Katsahian
- INSERM, Centre d'Investigation Clinique 1418 (CIC1418) Epidémiologie Clinique, AP-HP, Hôpital Européen Georges Pompidou, Unité de Recherche Clinique, Service d'Informatique Médicale, Biostatistiques et Santé Publique, AP-HP Centre, Paris, France; Inserm, Centre de Recherche des Cordeliers, Université de Paris, Sorbonne Université, Paris, France; HeKA, Inria, Paris, France
| | - Olivier Sanchez
- Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Centre - Université Paris Cité, INSERM UMR S1140, Innovative Therapies in Hemostasis, Paris, France, F-CRIN INNOVTE, Université Paris Cité, St-Etienne, France
| | | | - Antoine Bénichou
- Department of Vascular Medicine, Nantes Université, CHU Nantes, l'institut du Thorax, INSERM UMR1087/CNRS UMR 6291, Team III Vascular & Pulmonary Diseases, Nantes, France; UNAV, Nantes Vascular Access Unit, Nantes Université, CHU Nantes, Nantes, France
| | - Juliette Murris
- Inserm, Centre de Recherche des Cordeliers, Université de Paris, Sorbonne Université, Paris, France; HeKA, Inria, Paris, France; RWE and Data, Pierre Fabre, Boulogne-Billancourt, France
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Costa TA, Felix N, Clemente M, Teixeira L, Braga MAP, Silva LTM. Safety and efficacy of catheter ablation for atrial fibrillation in cancer survivors: a systematic review and meta-analysis. J Interv Card Electrophysiol 2024; 67:211-219. [PMID: 37950145 DOI: 10.1007/s10840-023-01677-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 10/16/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Cancer survivors are at increased risk for atrial fibrillation (AF). However, data on the efficacy and safety of catheter ablation (CA) in this population remain limited. Therefore, we aimed to perform a systematic review and meta-analysis comparing outcomes after CA for AF in patients with versus without prior or active cancer. METHODS We systematically searched PubMed, Cochrane Library, and Embase from inception to April 2023 for studies comparing the safety and efficacy of CA for AF in cancer survivors. Outcomes of interest were bleeding events, late AF recurrence, and need for repeat ablation. Statistical analyses were performed using Review Manager 5.4.1. We pooled odds ratios (OR) with 95% confidence intervals (CI) for binary endpoints. RESULTS We included 5 retrospective cohort studies comprising 998 patients, of whom 41.4% had a history of cancer. Cancer survivors were at significantly higher risk of clinically relevant bleeding (OR 2.17; 95% CI 1.17-4.0; p=0.01) as compared with those without cancer. The efficacy of CA for AF was similar between groups. Late AF recurrence at 12 months was not significantly different between patients with vs. without a history of cancer (OR 1.29; 95% CI 0.78-2.13; p=0.32). Similar findings were observed in the outcome of repeat ablations (OR 0.71; 95% CI 0.37-1.37; p=0.31). CONCLUSIONS These findings suggest that cancer survivors have an increased risk of bleeding after CA for AF relative to patients without cancer, with no significant difference in the efficacy of CA for maintenance of sinus rhythm between groups. STUDY REGISTRATION This systematic review is registered in the International Prospective Register of Systematic Reviews (PROSPERO) under registration number CRD42023394538.
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Affiliation(s)
| | - Nicole Felix
- Federal University of Campina Grande, Campina Grande, Paraiba, Brazil
| | - Mariana Clemente
- Faculdade de Medicina de Petrópolis, Petrópolis, Rio de Janeiro, Brazil
| | - Larissa Teixeira
- Federal University of Campina Grande, Campina Grande, Paraiba, Brazil
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Zhao Y, Cheng Y, Luo Y, Yao Q, Qu J, Sun J, Liu S, Xu M, Xiong W. International Normalized Ratio Predicts Recurrence and Bleeding in Patients With Acute Venous Thromboembolism Who Undergo Direct Oral Anticoagulants. Clin Appl Thromb Hemost 2024; 30:10760296241246004. [PMID: 38566600 PMCID: PMC10993680 DOI: 10.1177/10760296241246004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/16/2024] [Accepted: 03/21/2024] [Indexed: 04/04/2024] Open
Abstract
Prothrombin time/international normalized ratio (PT/INR) is related to both antithrombotic effect and risk of bleeding. Its role in the prediction of venous thromboembolism (VTE) recurrence and bleeding for patients with acute VTE who undergo direct oral anticoagulants (DOACs) treatment is unclear, despite previous studies revealed some association between them. The predictive efficiency of INR for VTE recurrence and bleeding were analyzed in a retrospective cohort with VTE patients who underwent DOACs treatment. Then its predictive efficiency for VTE recurrence and bleeding were validated in a prospective cohort with the acquired cutoffs range, and compared with anti-Xa level, DASH and VTE-BLEED scores. In the retrospective cohort (n = 1083), the sensitivity and specificity of INR for the prediction of VTE recurrence were 79.4% and 92.8%, respectively. The area under the curve (AUC) was 0.881 (0.803-0.960)(P = .025). The cutoff value of INR was 0.9. The sensitivity and specificity of INR for the prediction of bleeding were 85.7% and 77.9%, respectively. The AUC was 0.876 (0.786-0.967)(P < .001). The cutoff value of INR was 2.1. In the prospective cohort (n = 202), the calibration showed that there were 4 (50%) patients with VTE recurrence, 156 (97.5%) patients with non-recurrence and bleeding (non-R&B), and 20 (58.8%) patients with bleeding in the low (INR < 0.9)(n = 8), intermediate (0.9 ≤ INR ≤ 2.1)(n = 160), and high (INR > 2.1)(n = 34) groups, respectively. The baseline PT/INR value at the initiation of DOACs treatment is an independent predictor for VTE recurrence and bleeding in patients with acute VTE who undergo DOACs treatment.
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Affiliation(s)
- Yunfeng Zhao
- Department of Pulmonary and Critical Care Medicine, Punan Hospital, Shanghai, China
| | - Yi Cheng
- Department of Pulmonary and Critical Care Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yong Luo
- Department of Pulmonary and Critical Care Medicine, Chongming Hospital, Shanghai University of Medicine and Health Science, Shanghai, China
| | - Qihuan Yao
- Department of Traditional Chinese Medicine, Kongjiang Hospital, Shanghai, China
| | - Jianmin Qu
- Department of Critical Care Medicine, Tongxiang First People's Hospital, Tongxiang, Zhejiang Province, China
| | - Jinyuan Sun
- Department of Pulmonary and Critical Care Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Song Liu
- Department of Pulmonary and Critical Care Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Mei Xu
- Department of General Practice, North Bund Community Health Service Center, Shanghai, China
| | - Wei Xiong
- Department of Pulmonary and Critical Care Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Campos-Staffico AM, Jacoby JP, Dorsch MP, Limdi NA, Barnes GD, Luzum JA. Risk scores for major bleeding from direct oral anticoagulants: comparing predictive performance in patients with atrial fibrillation. Res Pract Thromb Haemost 2024; 8:102285. [PMID: 38292348 PMCID: PMC10826825 DOI: 10.1016/j.rpth.2023.102285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 11/09/2023] [Accepted: 11/11/2023] [Indexed: 02/01/2024] Open
Abstract
Background Despite direct oral anticoagulants (DOACs) being safer than warfarin for stroke prevention in atrial fibrillation (AF), major bleeding concerns persist. Most bleeding risk scores predate DOAC approval. Objectives This study aimed to compare the Age, history of Bleeding, and non-bleeding related Hospitalisation [ABH] score's performance-derived for DOAC-treated patients-with those of 5 other scores (Anticoagulation and Risk Factors in Atrial Fibrillation [ATRIA], Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly [>65 years], Drugs/alcohol concomitantly [HAS-BLED], Hepatic, Hepatic or Renal Disease, Ethanol Abuse, Malignancy, Older Age, Reduced Platelet Count or Function, Re-Bleeding, Hypertension, Anemia, Genetic Factors, Excessive Fall Risk and Stroke [HEMORR2HAGES], Outcomes Registry for Better Informed Treatment of Atrial Fibrillation [ORBIT-AF], and Congestive heart failure, Hypertension, Age ≥75 [doubled], Diabetes, Stroke [doubled]-Vascular disease, Age 65-74, Sex category [CHA2DS2-VASc]) in predicting DOAC-related major bleeding in patients with AF. Methods In this retrospective study of 2364 patients with nonvalvular AF on rivaroxaban or apixaban (median age, 68.3 years; 32.1% women), International Society on Thrombosis and Haemostasis-defined major bleeding (incidence, 4.1%; n = 97) was analyzed. C-statistics from time-dependent receiver operating characteristic (ROC) curves for continuous risk scores were the primary comparison metric, but other metrics, such as decision curves, were also compared. Results At 100 days, C-statistics were highest for ORBIT-AF and ATRIA (0.62 and 0.61, respectively, with other scores having an area under the ROC curve of <0.60); some significant differences favored ORBIT-AF. At 1100 days, C-statistics remained highest for ORBIT-AF and ATRIA (0.62 and 0.61, respectively, with other scores having an area under the ROC curve of <0.60 again), and ORBIT-AF had significantly higher C-statistics than those for all other risk scores (P < .05), except for ATRIA. At 2100 days, all C-statistics were <0.60 with no significant differences. Decision curves showed the greatest net benefit for ORBIT-AF and ATRIA at 100 days and for ATRIA at 1100 days, with no discernible net benefit for any of the scores at 2100 days. Conclusion ORBIT-AF and ATRIA provided the best bleeding risk prediction within the first 1100 days. None of the 6 bleeding risk scores provided predictive benefit over 2100 days of DOAC treatment.
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Affiliation(s)
| | - Juliet P. Jacoby
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael P. Dorsch
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Nita A. Limdi
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Geoffrey D. Barnes
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jasmine A. Luzum
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
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50
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Schastlivtsev I, Pankov A, Tsaplin S, Stepanov E, Zhuravlev S, Lobastov K. Oral Rivaroxaban Versus Warfarin After inferior Vena cava Filter Implantation: A Retrospective Cohort Study. Clin Appl Thromb Hemost 2024; 30:10760296241256938. [PMID: 38778542 PMCID: PMC11113020 DOI: 10.1177/10760296241256938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/16/2024] [Accepted: 05/06/2024] [Indexed: 05/25/2024] Open
Abstract
OBJECTIVES To assess the efficacy and safety of rivaroxaban compared to warfarin after inferior vena cava (IVC) filter implantation. METHOD This retrospective analysis includes data from 100 patients with deep vein thrombosis (DVT) who underwent IVC filter implantation due to a free-floating thrombus (n = 64), thrombus propagation (n = 8), or acute bleeding (n = 8) on therapeutic anticoagulation, catheter-directed thrombolysis (n = 8), or had previously implanted filter with DVT recurrence. Patients were treated with warfarin (n = 41) or rivaroxaban (n = 59) for 3-12 months. Symptomatic venous thromboembolism (VTE) recurrence and bleeding events were assessed at 12 months follow-up. RESULTS Three (7.3%) cases of VTE recurrence without IVC filter occlusion occurred on warfarin and none on rivaroxaban. The only (2.4%) major bleeding occurred on warfarin. Three (5.1%) clinically relevant non-major bleedings were detected on rivaroxaban. No significant differences existed between groups when full and propensity scores matched datasets were compared. CONCLUSIONS Rivaroxaban seems not less effective and safe than warfarin after IVC filter implantation.
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Affiliation(s)
- Ilya Schastlivtsev
- Department of General Surgery, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Aleksey Pankov
- Clinical Hospital No. 1 of the President's Administration of the Russian Federation, Moscow, Russia
| | - Sergey Tsaplin
- Department of General Surgery, Pirogov Russian National Research Medical University, Moscow, Russia
- Clinical Hospital No. 1 of the President's Administration of the Russian Federation, Moscow, Russia
| | - Evgeny Stepanov
- Department of General Surgery, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Sergey Zhuravlev
- Clinical Hospital No. 1 of the President's Administration of the Russian Federation, Moscow, Russia
| | - Kirill Lobastov
- Department of General Surgery, Pirogov Russian National Research Medical University, Moscow, Russia
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