1
|
Favaloro EJ, Arunachalam S, Dean E. Performance of direct oral anticoagulant (DOAC) testing by hemostasis laboratories: The Australasian/Asia-Pacific experience. Int J Lab Hematol 2024. [PMID: 38644463 DOI: 10.1111/ijlh.14288] [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: 02/04/2024] [Accepted: 04/08/2024] [Indexed: 04/23/2024]
Abstract
INTRODUCTION Direct oral anticoagulants (DOACs) reflect anticoagulation agents given to treat or prevent thrombosis, having largely replaced vitamin K antagonists (VKAs) such as warfarin. DOACs are given in fixed daily doses and generally do not need monitoring. However, there may be a variety of reasons that justify measurement of plasma DOAC levels in individual patients. METHODS We report updated findings for DOAC testing in our geographic region, using recent data from the RCPAQAP, an international external quality assessment (EQA) program, currently with some 40-60 participants in each of the different DOAC (rivaroxaban, apixaban, dabigatran) modules, to assess laboratory performance in this area. Data has been assessed for the past 5 years (2019-2023 inclusive), with 20 samples each per DOAC. RESULTS Data shows a limited repertoire of assays in use, and mostly consistency in reported numerical values when assessing proficiency samples. Available assays mostly comprised reagents from four manufacturing suppliers. There was good consistency across what participants identified as 'DOAC detected', but some variability when participants attempted to grade DOAC levels as low vs moderate vs high. Inter-laboratory/method coefficient of variation (CVs) were generally <15% for each DOAC, when present at >100 ng/mL. CONCLUSION We hope our findings, reflecting on mostly consistent reporting of DOAC levels and interpretation provides reassurance for clinicians requesting these measurements, and helps support their implementation in regions where there is a paucity of test availability.
Collapse
Affiliation(s)
- Emmanuel J Favaloro
- Department of Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia
- Faculty of Science and Health, Charles Sturt University, Wagga Wagga, New South Wales, Australia
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Westmead Hospital, Westmead, New South Wales, Australia
| | | | - Elysse Dean
- RCPAQAP Haematology, St Leonards, New South Wales, Australia
| |
Collapse
|
2
|
Stretton B, Kovoor J, Bacchi S, Gupta A, Edwards S, Boey JP, Gluck S, Reddi B, Maddern G, Boyd M. Quantifying time from last dose: do direct oral anticoagulant assays correlate with patient's reported last dose. Blood Coagul Fibrinolysis 2023; 34:451-455. [PMID: 37756218 DOI: 10.1097/mbc.0000000000001254] [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: 09/29/2023]
Abstract
INTRODUCTION In the absence of a patient's last direct oral anticoagulant (DOAC) dose time, best practice regarding preoperative DOAC cessation remains unclear. The aim of this study was to investigate, in a real-life patient cohort, if there was an association between subjective patient recall and objective DOAC assay titre. METHODS/MATERIALS A multicentre cohort study of consecutive surgical inpatients was conducted. DOAC assays were 'expected' if they satisfied both time and titre-based guidelines. RESULTS Patient-recalled last dose and DOAC assay was available in 285 individuals. DOAC assay titres correlated strongly with the expected levels based on a patient's reported last dose time(rho = 0.70, P value < 0.0001). However, underweight (<50 kg; P = 0.0339) and elderly (>80 years; P = 0.0134) were more likely to have an unexpectedly high assay titre. CONCLUSIONS A significant portion (∼25%) of patients had unexpected DOAC titres. DOAC levels can be clinically impactful in a significant percentage of patients, particularly in elderly and/or underweight.
Collapse
Affiliation(s)
- Brandon Stretton
- Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide
- University of Adelaide, Discipline of Surgery, The Queen Elizabeth Hospital
- Central Adelaide Local Health Network
| | - Joshua Kovoor
- Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide
- University of Adelaide, Discipline of Surgery, The Queen Elizabeth Hospital
- Central Adelaide Local Health Network
| | - Stephen Bacchi
- Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide
- Central Adelaide Local Health Network
- Flinders Medical Centre, Southern Adelaide Local Health Network
| | - Aashray Gupta
- Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide
- Gold Coast University Hospital, Southport, Queensland
| | - Suzanne Edwards
- Adelaide Health Technology Assessment, The University of Adelaide, Adelaide
| | - Jir Ping Boey
- Flinders Medical Centre, Southern Adelaide Local Health Network
| | - Samuel Gluck
- Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide
- Northern Adelaide Local Health Network, Adelaide, South Australia
| | - Benjamin Reddi
- Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide
- Central Adelaide Local Health Network
| | - Guy Maddern
- Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide
- University of Adelaide, Discipline of Surgery, The Queen Elizabeth Hospital
- Central Adelaide Local Health Network
- Research, Audit and Academic Surgery, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Mark Boyd
- Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide
- Northern Adelaide Local Health Network, Adelaide, South Australia
| |
Collapse
|
3
|
Heubner L, Vicent O, Beyer-Westendorf J, Spieth PM. Bleeding management in patients with direct oral anticoagulants. Minerva Anestesiol 2023; 89:707-715. [PMID: 37079285 DOI: 10.23736/s0375-9393.23.17230-0] [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: 04/21/2023]
Abstract
Bleeding events in patients under direct oral anticoagulation (DOAC) can be life-threating but are commonly not related to drug overdose. However, a relevant DOAC plasma concentration impairs the hemostasis and should therefore be ruled out immediately after hospital admission. The effect of DOAC is typically not visible in standard coagulation tests such as activated partial thrombin time or thromboplastin time. Specific anti-Xa or anti-IIa assays allow a specific drug monitoring, but they are too time-consuming in critical bleeding events and typically not available 24 h/7 d in routine care. Recent advantages in point-of-care (POC) testing might improve patient care by early exclusion of relevant DOAC levels, but sufficient validation is still lacking. POC urine analysis help to exclude DOAC in emergency patients, but does not provide a quantitative information about plasma concentration. POC viscoelastic testing (VET) can determine the DOAC effect on clotting time and helps further to reveal other concomitant bleeding disorders in emergency, e.g., factor deficiency or hyperfibrinolysis. If a relevant plasma concentration of the DOAC is assumed or was proven by either laboratory assays or POC testing, restoration of factor IIa or factor IIa activity is key for effective hemostasis. Limited evidence suggests that specific reversals for DOAC, e.g., idarucizumab for dabigatran and andexanet alfa for apixaban or rivaroxaban, might be superior to increasing thrombin generation by administration of prothrombin complex concentrates. To determinate, if DOAC reversal is indicated or not, time from last intake, anti-Xa/dTT values or results from POC tests can be considered. This experts' opinion provides a feasible decision algorithm for clinical practice.
Collapse
Affiliation(s)
- Lars Heubner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden (TU Dresden), Dresden, Germany -
| | - Oliver Vicent
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden (TU Dresden), Dresden, Germany
| | - Jan Beyer-Westendorf
- Unit of Thrombosis Research, Division of Hematology and Hemostasis, Department of Medicine I, University Hospital Carl Gustav Carus, Technische Universität Dresden (TU Dresden), Dresden, Germany
| | - Peter M Spieth
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden (TU Dresden), Dresden, Germany
| |
Collapse
|
4
|
Tripodi A, Chantarangkul V, Poli D, Testa S, Bucciarelli P, Peyvandi F. The role of anticoagulation clinics needs to be reassessed to include follow up of patients on direct oral anticoagulants. Thromb Res 2023; 225:11-15. [PMID: 36905699 DOI: 10.1016/j.thromres.2023.01.030] [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: 11/28/2022] [Revised: 01/17/2023] [Accepted: 01/27/2023] [Indexed: 02/05/2023]
Abstract
A survey was carried out to assess the state of organization of care (including clinical and laboratory) delivered to patients on vitamin K antagonists (VKA) or direct oral anticoagulants (DOAC) followed by clinics affiliated with the Italian Federation of Thrombosis Centers (FCSA), traditionally engaged to assist anticoagulated outpatients within the country. Participants were asked to answer questions concerning (i) proportion of patients on VKA-vs-DOAC and (ii) whether dedicated testing for DOAC is available. The proportion of patients on VKA-vs-DOAC was 60 % vs 40 %. This proportion is in sharp contrast with the real-life distribution where DOAC outweigh VKA prescriptions. Furthermore, the proportion of anticoagulation clinics that provide DOAC testing (even in special situations) is relatively small (i.e., 31 % of the respondents). Furthermore, 25 % of those that declared to follow DOAC patients do not provide any testing at all. The answers to the above questions cause concerns as (i) most patients on DOAC within the country are probably on self-management, or they are managed by general practitioners or specialists outside thrombosis centers. (ii) Most patients on DOAC have no access to testing even in special situations where it would be needed. We feel that there is a (false) perception that the care needed for DOAC treatment can be much less than that required for VKA, as DOAC require prescription and not regular follow-up. A call for action should be urgently made to reassess the role of anticoagulation clinics, which should pay the same attention to patients on DOAC as those on VKA.
Collapse
Affiliation(s)
- Armando Tripodi
- IRCCS Ca' Granda Maggiore Hospital Foundation, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milano, Italy.
| | - Veena Chantarangkul
- IRCCS Ca' Granda Maggiore Hospital Foundation, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milano, Italy
| | | | | | - Paolo Bucciarelli
- IRCCS Ca' Granda Maggiore Hospital Foundation, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milano, Italy
| | - Flora Peyvandi
- IRCCS Ca' Granda Maggiore Hospital Foundation, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milano, Italy; Università degli Studi di Milano, Department of Pathophysiology and Transplantation, Milano, Italy
| |
Collapse
|
5
|
Chao TF, Chan YH, Tsai PC, Lee HF, Chang SH, Kuo CT, Lip GYH, Chen SA, Yeh YH. Prothrombin Time-International Normalized Ratio Predicts the Outcome of Atrial Fibrillation Patients Taking Rivaroxaban. Biomedicines 2022; 10:biomedicines10123210. [PMID: 36551966 PMCID: PMC9775588 DOI: 10.3390/biomedicines10123210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/04/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022] Open
Abstract
Background: Although direct oral anticoagulants (DOACs) for patients with atrial fibrillation (AF) are considered to be safe, over or under anticoagulation and increased bleeding or thromboembolic risk are still considered individually. We aimed to investigate whether there is an association between prothrombin time and international normalized ratio (PT-INR) or activated partial thromboplastin time (aPTT) ratio, and the risks of ischemic stroke/systemic embolism (IS/SE) and major bleeding among AF patients taking rivaroxaban or dabigatran. Methods: This multi-center cohort study in Taiwan included 3192 AF patients taking rivaroxaban and 958 patients taking dabigatran for stroke prevention where data about PT-INR and aPTT were available. Results: For patients treated with rivaroxaban, a higher INR level was not associated with a higher risk of major bleeding compared to an INR level < 1.1. The risk of IS/SE was lower for patients having an INR ≥ 1.5 compared to those with an INR < 1.1 (aHR:0.57; [95%CI: 0.37−0.87]; p = 0.01). On-label dosing of rivaroxaban and use of digoxin were independent factors associated with an INR ≥ 1.5 after taking rivaroxaban. For patients taking dabigatran, a higher aPTT ratio was not associated with a higher risk of major bleeding. The risk of IS/SE was lower for patients having an aPTT ratio of 1.1−1.2 and 1.3−1.4 than those with an aPTT ratio < 1.1. Conclusions: In AF patients, rivaroxaban with an INR ≥ 1.5 was associated with a lower risk of IS/SE. PT-INR or aPTT ratios were not associated with bleeding events for rivaroxaban or dabigatran. INR may help predict the outcome of AF patients who take rivaroxaban.
Collapse
Affiliation(s)
- Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
- Cardiovascular Research Center, Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
| | - Yi-Hsin Chan
- The Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Microscopy Core Laboratory, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
| | - Pei-Chien Tsai
- Department and Graduate Institute of Biomedical Sciences, Chang Gung University, Taoyuan 33302, Taiwan
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
| | - Hsin-Fu Lee
- The Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Shang-Hung Chang
- The Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
| | - Chi-Tai Kuo
- The Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK
- Department of Clinical Medicine, Aalborg University, 9100 Aalborg, Denmark
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
- Cardiovascular Research Center, Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
| | - Yung-Hsin Yeh
- The Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Correspondence: ; Tel.: +886-(3)-3281200 (ext. 8162); Fax: +886-(3)-3271192
| |
Collapse
|
6
|
Kahlon N, Doddi S, Ning Y, Akpunonu B, Murphy J. Elevated International Normalized Ratio Due to Apixaban in Patient With End-Stage Renal Disease on Hemodialysis. Cureus 2022; 14:e25907. [PMID: 35844332 PMCID: PMC9278791 DOI: 10.7759/cureus.25907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2022] [Indexed: 11/16/2022] Open
Abstract
Apixaban is known to prolong international normalized ratio (INR) per some observational and in vitro studies. In patients with elevated INR secondary to apixaban use, median INR of 1.4-1.7 has been reported. Extreme elevation in INR is rare with apixaban. In patients with end-stage renal disease (ESRD) on hemodialysis (HD), there are no labeled indications for apixaban use; however, there are some pharmacokinetic data supporting its use in such patients. We present a case of a 68-year-old Hispanic man with ESRD who presented to the emergency room (ER) with INR of 27.42. INR testing was done as a part of routine workup in rehabilitation facility. Medication list was reviewed and included apixaban 2.5 mg twice daily which was recently started for postoperative thromboprophylaxis. INR testing was repeated for confirmation in ER and was reported as >18.5 and prothrombin time >200 seconds. His liver function tests were stable as compared to baseline testing five days ago with normal bilirubin, low normal transaminases, and mild hypoalbuminemia. The patient didn’t have any active bleeding. An elevation of INR to >20 with apixaban is a rare event. No other factors including patient characteristics, laboratory results, co-existing conditions, or other medications except the direct oral anticoagulant (DOAC) were found to be responsible for elevated INR. Liver cirrhosis or vitamin K deficiency as cause for INR elevation was ruled out as the baseline INR was normal prior to starting apixaban, liver function tests were stable and INR normalized again shortly after discontinuing the medication. Plasma concentration of DOACs has been found to be correlating with the INR according to a pharmacokinetic study which potentially means that the high INR likely was secondary to high serum concentration of apixaban in this patient. However, INR monitoring is not recommended for monitoring anticoagulant activity of DOACs. As of note, renal clearance accounts for 27% of apixaban clearance. Pharmacokinetic studies have concluded that half dose apixaban, i.e., 2.5 mg twice daily in patients on hemodialysis (dose used in this case) results in drug exposure similar to that of the standard dose of 5 mg twice daily in patients with preserved renal function. Future studies are necessary to address questions about safety of DOACs in patients with ESRD, further elucidate the clinical significance of such high INR values associated with DOACs, and establish appropriate management guidelines. Andexanet alfa has since been approved for apixaban reversal in patients with life-threatening bleeding; however, would not be indicated in such cases when there is no evidence of bleeding.
Collapse
|
7
|
Volod O, Rollins-Raval M, Goodwin AJ, Higgins RA, Long T, Chandler WL, Harris NS, Pham HP, Isom JA, Moser K, Olson JD, Smock KJ, VanSandt A, Wool G, Chen D. The Interlaboratory Performance in Measurement of Dabigatran and Rivaroxaban: Results of the College of American Pathologists External Quality Assessment Program. Arch Pathol Lab Med 2021; 146:145-153. [PMID: 34133726 DOI: 10.5858/arpa.2020-0633-cp] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2021] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Assessing direct oral anticoagulant (DOAC) drug levels by reliable laboratory assays is necessary in a number of clinical scenarios. OBJECTIVE.— To evaluate the performance of DOAC-specific assays for various concentrations of dabigatran and rivaroxaban, assess the interlaboratory variability in measurement of these DOACs, and investigate the responsiveness of the routine clotting assays to various concentrations of these oral anticoagulants. DESIGN.— College of American Pathologists proficiency testing survey data from 2013 to 2016 were summarized and analyzed. RESULTS.— For dabigatran, the interlaboratory coefficient of variation (CV) of ecarin chromogenic assay was broad (ranging from 7.5% to 29.1%, 6.3% to 15.5%, and 6.8% to 9.0% for 100-ng/mL, 200-ng/mL, and 400-ng/mL targeted drug concentrations, respectively). The CV for diluted thrombin time for dabigatran was better overall (ranging from 11.6% to 17.2%, 9.3% to 12.3, and 7.1% to 11.2% for 100 ng/mL, 200 ng/mL, and 400 ng/mL, respectively). The rivaroxaban-calibrated anti-Xa assay CVs also showed variability (ranging from 11.5% to 22.2%, 7.2% to 10.9%, and 6.4% to 8.1% for 50-ng/mL, 200-ng/mL, and 400-ng/mL targeted drug concentrations, respectively). The prothrombin time (PT) and activated partial thromboplastin time (aPTT) showed variable dose and reagent-dependent responsiveness to DOACs: PT was more responsive to rivaroxaban and aPTT to dabigatran. The undiluted thrombin time showed maximum prolongation across all 3 dabigatran concentrations, making it too sensitive for drug-level monitoring, but supporting its use as a qualitative screening assay. CONCLUSIONS.— DOAC-specific assays performed reasonably well. While PT and aPTT cannot be used safely to determine DOAC degree of anticoagulation, a normal thrombin time excludes the presence of dabigatran.
Collapse
Affiliation(s)
- Oksana Volod
- From the Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California (Volod)
| | - Marian Rollins-Raval
- The Department of Pathology, The University of New Mexico, Albuquerque (Rollins-Raval)
| | - Andrew J Goodwin
- The Department of Pathology, University of Vermont Medical Center, Burlington (Goodwin IV)
| | - Russell A Higgins
- The Department of Pathology and Laboratory Medicine, University of Texas Health, San Antonio (Higgins, Olson)
| | - Thomas Long
- Biostatistics, College of American Pathologists, Northfield, Illinois (Long)
| | - Wayne L Chandler
- The Department of Pathology and Laboratory Medicine, Seattle Children's Hospital, Seattle, Washington (Chandler)
| | - Neil S Harris
- The Department of Pathology, University of Florida Health, Gainesville (Harris)
| | - Huy P Pham
- National Marrow Donor Program, Seattle Collection Center, Seattle, Washington (Pham)
| | - James Alexander Isom
- The Department of Pathology, University of South Florida Moffitt Cancer Center, Tampa (Isom)
| | - Karen Moser
- The Department of Pathology, University of Utah, Salt Lake City (Moser, Smock)
| | - John D Olson
- The Department of Pathology and Laboratory Medicine, University of Texas Health, San Antonio (Higgins, Olson)
| | - Kristi J Smock
- The Department of Pathology, University of Utah, Salt Lake City (Moser, Smock)
| | - Amanda VanSandt
- The Department of Pathology Oregon Health & Science University, Portland (VanSandt)
| | - Geoffrey Wool
- The Department of Pathology and Laboratory Medicine, University of Chicago, Chicago, Illinois (Wool)
| | - Dong Chen
- The Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, Minnesota (Chen)
| |
Collapse
|
8
|
Paciaroni M, Agnelli G, Giustozzi M, Caso V, Toso E, Angelini F, Canavero I, Micieli G, Antonenko K, Rocco A, Diomedi M, Katsanos AH, Shoamanesh A, Giannopoulos S, Ageno W, Pegoraro S, Putaala J, Strbian D, Sallinen H, Mac Grory BC, Furie KL, Stretz C, Reznik ME, Alberti A, Venti M, Mosconi MG, Vedovati MC, Franco L, Zepponi G, Romoli M, Zini A, Brancaleoni L, Riva L, Silvestrelli G, Ciccone A, Zedde ML, Giorli E, Kosmidou M, Ntais E, Palaiodimou L, Halvatsiotis P, Tassinari T, Saia V, Ornello R, Sacco S, Bandini F, Mancuso M, Orlandi G, Ferrari E, Pezzini A, Poli L, Cappellari M, Forlivesi S, Rigatelli A, Yaghi S, Scher E, Frontera JA, Masotti L, Grifoni E, Caliandro P, Zauli A, Reale G, Marcheselli S, Gasparro A, Terruso V, Arnao V, Aridon P, Abdul-Rahim AH, Dawson J, Saggese CE, Palmerini F, Doronin B, Volodina V, Toni D, Risitano A, Schirinzi E, Del Sette M, Lochner P, Monaco S, Mannino M, Tassi R, Guideri F, Acampa M, Martini G, Lotti EM, Padroni M, Pantoni L, Rosa S, Bertora P, Ntaios G, Sagris D, Baldi A, D’Amore C, Mumoli N, Porta C, Denti L, Chiti A, Corea F, Acciarresi M, Flomin Y, Popovic N, Tsivgoulis G. Risk Factors for Intracerebral Hemorrhage in Patients With Atrial Fibrillation on Non-Vitamin K Antagonist Oral Anticoagulants for Stroke Prevention. Stroke 2021; 52:1450-1454. [PMID: 33657853 PMCID: PMC10561687 DOI: 10.1161/strokeaha.120.031827] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 12/16/2020] [Accepted: 01/28/2021] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
Collapse
Affiliation(s)
- Maurizio Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Paciaroni, G.A., M.G., V.C., A.A., M.V., M.G.M., M.C.V., L.F., G.Z.)
| | - Giancarlo Agnelli
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Paciaroni, G.A., M.G., V.C., A.A., M.V., M.G.M., M.C.V., L.F., G.Z.)
| | - Michela Giustozzi
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Paciaroni, G.A., M.G., V.C., A.A., M.V., M.G.M., M.C.V., L.F., G.Z.)
| | - Valeria Caso
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Paciaroni, G.A., M.G., V.C., A.A., M.V., M.G.M., M.C.V., L.F., G.Z.)
| | - Elisabetta Toso
- Division of Cardiology, Città della Salute e della Scienza Hospital, University of Torino, Italy (E.T., F.A.)
| | - Filippo Angelini
- Division of Cardiology, Città della Salute e della Scienza Hospital, University of Torino, Italy (E.T., F.A.)
| | - Isabella Canavero
- Emergency Neurology, IRCCS Casimiro Mondino Foundation, Pavia, Italy (I.C., G. Micieli)
| | - Giuseppe Micieli
- Emergency Neurology, IRCCS Casimiro Mondino Foundation, Pavia, Italy (I.C., G. Micieli)
| | - Kateryna Antonenko
- Department of Neurology, Bogomolets National Medical University, Kyiv, Ukraine (K.A.)
| | - Alessandro Rocco
- Stroke Unit, Department of Systems Medicine, University of Tor Vergata, Rome, Italy (A. Rocco, M.D.)
| | - Marina Diomedi
- Stroke Unit, Department of Systems Medicine, University of Tor Vergata, Rome, Italy (A. Rocco, M.D.)
| | - Aristeidis H. Katsanos
- Department of Medicine (Neurology), McMaster University/Population Health Research Institute, Hamilton, Canada (A.H.K., A.S.)
| | - Ashkan Shoamanesh
- Department of Medicine (Neurology), McMaster University/Population Health Research Institute, Hamilton, Canada (A.H.K., A.S.)
| | - Sotirios Giannopoulos
- Department of Neurology, University of Ioannina School of Medicine, Greece (S.G., E.N.)
| | - Walter Ageno
- Department of Medicine, University of Insubria, Ospedale di Circolo, Varese, Italy (W.A., S.P.)
| | - Samuela Pegoraro
- Department of Medicine, University of Insubria, Ospedale di Circolo, Varese, Italy (W.A., S.P.)
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and Neurosciences University of Helsinki, Finland (J.P., D. Strbian, H.S.)
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and Neurosciences University of Helsinki, Finland (J.P., D. Strbian, H.S.)
| | - Hanne Sallinen
- Department of Neurology, Helsinki University Hospital and Neurosciences University of Helsinki, Finland (J.P., D. Strbian, H.S.)
| | - Brian C. Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, NC (B.C.M.G.)
| | - Karen L. Furie
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (K.L.F., C.S., M.E.R.)
| | - Christoph Stretz
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (K.L.F., C.S., M.E.R.)
| | - Michael E. Reznik
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (K.L.F., C.S., M.E.R.)
| | - Andrea Alberti
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Paciaroni, G.A., M.G., V.C., A.A., M.V., M.G.M., M.C.V., L.F., G.Z.)
| | - Michele Venti
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Paciaroni, G.A., M.G., V.C., A.A., M.V., M.G.M., M.C.V., L.F., G.Z.)
| | - Maria Giulia Mosconi
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Paciaroni, G.A., M.G., V.C., A.A., M.V., M.G.M., M.C.V., L.F., G.Z.)
| | - Maria Cristina Vedovati
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Paciaroni, G.A., M.G., V.C., A.A., M.V., M.G.M., M.C.V., L.F., G.Z.)
| | - Laura Franco
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Paciaroni, G.A., M.G., V.C., A.A., M.V., M.G.M., M.C.V., L.F., G.Z.)
| | - Giorgia Zepponi
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Paciaroni, G.A., M.G., V.C., A.A., M.V., M.G.M., M.C.V., L.F., G.Z.)
| | - Michele Romoli
- Neurology Unit, Rimini “Infermi” Hospital–AUSL Romagna, Rimini, Italy (M. Romoli)
| | - Andrea Zini
- Department of Neurology and Stroke Center, IRCCS Istituto di Scienze Neurologiche di Bologna (A. Zini, L.B.), Maggiore Hospital, Bologna, Italy
| | - Laura Brancaleoni
- Department of Neurology and Stroke Center, IRCCS Istituto di Scienze Neurologiche di Bologna (A. Zini, L.B.), Maggiore Hospital, Bologna, Italy
| | - Letizia Riva
- Division of Cardiology (L.R.), Maggiore Hospital, Bologna, Italy
| | - Giorgio Silvestrelli
- S.C. di Neurologia e S.S. di Stroke Unit, ASST di Mantova, Italy (G.S., A. Ciccone)
| | - Alfonso Ciccone
- S.C. di Neurologia e S.S. di Stroke Unit, ASST di Mantova, Italy (G.S., A. Ciccone)
| | - Maria Luisa Zedde
- Neurology Unit, Stroke Unit, Local Health Unit–IRCCS of Reggio Emilia, Italy (M.L.Z.)
| | - Elisa Giorli
- Department of Neurology, Stroke Unit, Sant’Andrea Hospital, La Spezia, Italy (E. Giorli)
| | - Maria Kosmidou
- First Department of Internal Medicine, University of Ioannina School of Medicine, Greece (M.K.)
| | - Evangelos Ntais
- Department of Neurology, University of Ioannina School of Medicine, Greece (S.G., E.N.)
| | - Lina Palaiodimou
- Second Department of Neurology, “Attikon” Hospital, National and Kapodistrian University of Athens, School of Medicine, Greece (L. Palaiodimou, G.T.)
| | - Panagiotis Halvatsiotis
- Second Department of Internal Medicine “Attikon” University Hospital Medical School, National and Kapodistrian University of Athens, Greece (P.H.)
| | - Tiziana Tassinari
- Department of Neurology and Stroke Unit, Santa Corona Hospital, Pietra Ligure (Savona), Italy (T.T., V.S.)
| | - Valentina Saia
- Department of Neurology and Stroke Unit, Santa Corona Hospital, Pietra Ligure (Savona), Italy (T.T., V.S.)
| | - Raffaele Ornello
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, Italy (R.O., S.S.)
| | - Simona Sacco
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, Italy (R.O., S.S.)
| | - Fabio Bandini
- Department of Neurology, Ospedale San Paolo, Savona, Italy (F.B.)
| | - Michelangelo Mancuso
- Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Italy (M. Mancuso, G.O., E.F.)
| | - Giovanni Orlandi
- Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Italy (M. Mancuso, G.O., E.F.)
| | - Elena Ferrari
- Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Italy (M. Mancuso, G.O., E.F.)
| | - Alessandro Pezzini
- Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Italy (A.P., L. Poli)
| | - Loris Poli
- Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Italy (A.P., L. Poli)
| | - Manuel Cappellari
- SSO Stroke Unit, UO Neurologia, DAI di Neuroscienze, AOUI Verona, Italy (M.C., S.F.)
| | - Stefano Forlivesi
- SSO Stroke Unit, UO Neurologia, DAI di Neuroscienze, AOUI Verona, Italy (M.C., S.F.)
| | - Alberto Rigatelli
- Pronto Soccorso, Ospedale Borgo Trento, DAI Emergenza e Accettazione, AOUI Verona, Italy (A. Rigatelli)
| | - Shadi Yaghi
- Department of Neurology, NYU Langone Health, New York, NY (S.Y., E. Scher, J.A.F.)
| | - Erica Scher
- Department of Neurology, NYU Langone Health, New York, NY (S.Y., E. Scher, J.A.F.)
| | - Jennifer A. Frontera
- Department of Neurology, NYU Langone Health, New York, NY (S.Y., E. Scher, J.A.F.)
| | - Luca Masotti
- Internal Medicine, San Giuseppe Hospital, Empoli, Italy (L.M., E. Grifoni)
| | - Elisa Grifoni
- Internal Medicine, San Giuseppe Hospital, Empoli, Italy (L.M., E. Grifoni)
| | - Pietro Caliandro
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy (P.C.)
| | - Aurelia Zauli
- Department of Geriatrics, Neurosciences and Orthopedics, Università Cattolica del Sacro Cuore, Rome, Italy (A. Zauli, G.R.)
| | - Giuseppe Reale
- Department of Geriatrics, Neurosciences and Orthopedics, Università Cattolica del Sacro Cuore, Rome, Italy (A. Zauli, G.R.)
| | - Simona Marcheselli
- Humanitas Clinical and Research Center–IRCCS, Rozzano, Milano, Italy (S. Marcheselli)
| | | | | | - Valentina Arnao
- Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Italy (V.A., P.A.)
| | - Paolo Aridon
- Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Italy (V.A., P.A.)
| | - Azmil H. Abdul-Rahim
- Medical School and Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (A.H.A.-R., J.D.)
| | - Jesse Dawson
- Medical School and Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (A.H.A.-R., J.D.)
| | - Carlo Emanuele Saggese
- Unità di Terapia Neurovascolare, Ospedale “Fabrizio Spaziani,” Frosinone, Italy (C.E.S.)
| | | | - Boris Doronin
- Municipal Budgetary Healthcare Institution of Novosibirsk, City Clinical Hospital No. 1, Novosibirsk State Medical University, Russia (B.D., V.V.)
| | - Vera Volodina
- Municipal Budgetary Healthcare Institution of Novosibirsk, City Clinical Hospital No. 1, Novosibirsk State Medical University, Russia (B.D., V.V.)
| | - Danilo Toni
- Department of Human Neurosciences, Sapienza University of Rome, Italy (D.T., A. Risitano)
| | - Angela Risitano
- Department of Human Neurosciences, Sapienza University of Rome, Italy (D.T., A. Risitano)
| | - Erika Schirinzi
- Struttura Complessa di Neurologia, Ente Ospedaliero Ospedali Galliera, Genoa, Italy (E. Schirinzi, M.D.S.)
| | - Massimo Del Sette
- Struttura Complessa di Neurologia, Ente Ospedaliero Ospedali Galliera, Genoa, Italy (E. Schirinzi, M.D.S.)
| | - Piergiorgio Lochner
- Department of Neurology, Saarland University, Medical Center, Homburg, Germany (P.L.)
| | - Serena Monaco
- Stroke Unit, Ospedale Civico, Palermo, Italy (S. Monaco, M. Mannino)
| | - Marina Mannino
- Stroke Unit, Ospedale Civico, Palermo, Italy (S. Monaco, M. Mannino)
| | - Rossana Tassi
- Stroke Unit, AOU Senese, Siena, Italy (R.T., F.G., M. Acampa, G. Martini)
| | - Francesca Guideri
- Stroke Unit, AOU Senese, Siena, Italy (R.T., F.G., M. Acampa, G. Martini)
| | - Maurizio Acampa
- Stroke Unit, AOU Senese, Siena, Italy (R.T., F.G., M. Acampa, G. Martini)
| | - Giuseppe Martini
- Stroke Unit, AOU Senese, Siena, Italy (R.T., F.G., M. Acampa, G. Martini)
| | - Enrico Maria Lotti
- U.O. Neurologia Presidio Ospedaliero di Ravenna Azienda USL della Romagna, Italy (E.M.L., M. Padroni)
| | - Marina Padroni
- U.O. Neurologia Presidio Ospedaliero di Ravenna Azienda USL della Romagna, Italy (E.M.L., M. Padroni)
| | - Leonardo Pantoni
- ‘L. Sacco’ Department of Biomedical and Clinical Sciences, University of Milan, Italy (L. Pantoni, P.B.)
| | - Silvia Rosa
- Neurology Unit, ASST Fatebenefratelli–Sacco, Milan, Italy (S.R.)
| | - Pierluigi Bertora
- ‘L. Sacco’ Department of Biomedical and Clinical Sciences, University of Milan, Italy (L. Pantoni, P.B.)
| | - George Ntaios
- Department of Medicine, University of Thessaly, Larissa, Greece (G.N., D. Sagris)
| | - Dimitrios Sagris
- Department of Medicine, University of Thessaly, Larissa, Greece (G.N., D. Sagris)
| | - Antonio Baldi
- Stroke Unit, Ospedale di Portogruaro, Venice, Italy (A.B., C.D.)
| | - Cataldo D’Amore
- Stroke Unit, Ospedale di Portogruaro, Venice, Italy (A.B., C.D.)
| | - Nicola Mumoli
- Department of Internal Medicine, Magenta Hospital, Italy (N.M., C.P.)
| | - Cesare Porta
- Department of Internal Medicine, Magenta Hospital, Italy (N.M., C.P.)
| | - Licia Denti
- Stroke Unit, Dipartimento Geriatrico Riabilitativo, University of Parma, Italy (L.D.)
| | - Alberto Chiti
- Neurologia, Ospedale Apuano, Massa Carrara, Italy (A. Chiti)
| | - Francesco Corea
- UO Gravi Cerebrolesioni, San Giovanni Battista Hospital, Foligno, Italy (F.C., M. Acciarresi)
| | - Monica Acciarresi
- UO Gravi Cerebrolesioni, San Giovanni Battista Hospital, Foligno, Italy (F.C., M. Acciarresi)
| | - Yuriy Flomin
- Stroke and Neurorehabilitation Unit, MC Universal Clinic ‘Oberig’ Kyiv, Ukraine (Y.F.)
| | - Nemanja Popovic
- Clinic of Neurology, Clinical Center of Vòsvodina, University of Novi Sad, Serbia (N.P.)
| | - Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” Hospital, National and Kapodistrian University of Athens, School of Medicine, Greece (L. Palaiodimou, G.T.)
| |
Collapse
|
9
|
Gutiérrez-Zúñiga R, Rigual R, Torres-Iglesias G, Sánchez-Velasco S, Alonso de Leciñana M, Masjuan J, Álvarez Velasco R, Navas I, Izquierdo-Esteban L, Fernández-Ferro J, Rodríguez-Pardo J, Ruiz-Ares G, Zapata-Wainberg G, Fuentes B, Díez-Tejedor E. Long-Term Anticoagulation in Secondary Ischemic Stroke Prevention: The Prospective Multicenter RESTAIC Registry. Front Neurol 2020; 11:575634. [PMID: 33193025 PMCID: PMC7641639 DOI: 10.3389/fneur.2020.575634] [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: 06/23/2020] [Accepted: 08/28/2020] [Indexed: 11/13/2022] Open
Abstract
Background and Objective: Oral anticoagulation (OAC) for secondary stroke prevention is recommended in atrial fibrillation (AF) and other sources of cardioembolic stroke. Our objectives were to explore the differences in ischemic and hemorrhagic events when using OAC for secondary stroke prevention according to the type of anticoagulant treatment and to analyze the number and reasons for OAC switches during long-term follow-up. Methods: Ischemic stroke (IS) patients who were discharged on OAC for secondary stroke prevention from January 2014 to October 2017 were recruited in a prospective, multicenter, hospital-based registry. Follow-up at 3 months was scheduled at the outpatient clinic with subsequent annual phone interviews for 3 years. Patients were classified into three study groups according to OAC at discharge: Vitamin K antagonist (VKA), Factor Xa inhibitor (FXa), or direct thrombin inhibitor (DTI). We compared stroke recurrences, intracranial hemorrhage, major bleeding, and all-cause mortality during the follow-up. We recorded any switches in OAC and the main reasons for the change. Results: A total of 241 patients were included. An anticoagulant was indicated in the presence of a source of cardioembolic stroke in 240 patients (99.6%) and lupus plus antiphospholipid syndrome in one patient. Up to 86 patients (35.6%) were on OAC before the index stroke; in 71 (82.5%) of them, this was VKA. At hospital discharge, 105 were treated with FXa (43.8%), 96 with VKA (39.6%), and 40 with DTI (16.6%). The cumulative incidences at 3 years were 17% for stroke recurrence, 1.6% for intracranial hemorrhage, 4.9% for major hemorrhage, and 22.8% for all-cause mortality, with no differences among the OAC groups in any outcomes. During the follow-up, 40 OAC switches were recorded (63% of them to FXa), mostly due to stroke recurrence. Conclusion: Long-term OAC in secondary stroke prevention is associated with a lower frequency of bleeding complications than stroke recurrences. No differences between anticoagulant drugs were found in any of the analyzed outcomes. The main cause for OAC switch during follow-up was stroke recurrence.
Collapse
Affiliation(s)
- Raquel Gutiérrez-Zúñiga
- Neurology Department and Stroke Centre, Hospital La Paz Institute for Heath Research-IdiPAZ, La Paz Univerisity Hospital, Universidad Autónoma de Madrid, Madrid, Spain
| | - Ricardo Rigual
- Neurology Department and Stroke Centre, Hospital La Paz Institute for Heath Research-IdiPAZ, La Paz Univerisity Hospital, Universidad Autónoma de Madrid, Madrid, Spain
| | - Gabriel Torres-Iglesias
- Neurology Department and Stroke Centre, Hospital La Paz Institute for Heath Research-IdiPAZ, La Paz Univerisity Hospital, Universidad Autónoma de Madrid, Madrid, Spain
| | - Sara Sánchez-Velasco
- Neurology Department and Stroke Centre, Hospital La Paz Institute for Heath Research-IdiPAZ, La Paz Univerisity Hospital, Universidad Autónoma de Madrid, Madrid, Spain
| | - María Alonso de Leciñana
- Neurology Department and Stroke Centre, Hospital La Paz Institute for Heath Research-IdiPAZ, La Paz Univerisity Hospital, Universidad Autónoma de Madrid, Madrid, Spain
| | - Jaime Masjuan
- Departamento de Medicina, Facultad de Medicina, Servicio de Neurología, H Universitario Ramón y Cajal, Universidad de Alcalá, IRYCIS, Madrid, Spain
| | - Rodrigo Álvarez Velasco
- Departamento de Medicina, Facultad de Medicina, Servicio de Neurología, H Universitario Ramón y Cajal, Universidad de Alcalá, IRYCIS, Madrid, Spain
| | - Inmaculada Navas
- Neurology Department, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | | | - José Fernández-Ferro
- Neurology Department and Stroke Unit, Hospital Universitario Rey Juan Carlos, Madrid, Spain
| | - Jorge Rodríguez-Pardo
- Neurology Department and Stroke Centre, Hospital La Paz Institute for Heath Research-IdiPAZ, La Paz Univerisity Hospital, Universidad Autónoma de Madrid, Madrid, Spain
| | - Gerardo Ruiz-Ares
- Neurology Department and Stroke Centre, Hospital La Paz Institute for Heath Research-IdiPAZ, La Paz Univerisity Hospital, Universidad Autónoma de Madrid, Madrid, Spain
| | | | - Blanca Fuentes
- Neurology Department and Stroke Centre, Hospital La Paz Institute for Heath Research-IdiPAZ, La Paz Univerisity Hospital, Universidad Autónoma de Madrid, Madrid, Spain
| | - Exuperio Díez-Tejedor
- Neurology Department and Stroke Centre, Hospital La Paz Institute for Heath Research-IdiPAZ, La Paz Univerisity Hospital, Universidad Autónoma de Madrid, Madrid, Spain
| |
Collapse
|
10
|
Tafur AJ, Clark NP, Spyropoulos AC, Li N, Kaplovitch E, MacDougall K, Schulman S, Caprini JA, Douketis J. Predictors of Bleeding in the Perioperative Anticoagulant Use for Surgery Evaluation Study. J Am Heart Assoc 2020; 9:e017316. [PMID: 32969288 PMCID: PMC7792425 DOI: 10.1161/jaha.120.017316] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background In the PAUSE (Perioperative Anticoagulant Use for Surgery Evaluation) Study, a simple, standardized, perioperative interruption strategy was provided for patients with nonvalvular atrial fibrillation taking direct oral anticoagulants (DOACs). Our objective was to define the factors associated with perioperative bleeding. Methods and Results We analyzed bleeding as the composite of major and clinically relevant nonmajor bleeding. Putative predictors of bleeding, and preoperative DOAC level were prospectively collected during recruitment. We used stratified logistic regression models for analysis. All statistical analyses were performed in R version 3.6.0. There were 3007 patients requiring perioperative DOAC interruption. More than one third of the included patients underwent a high bleeding risk procedure. The 30‐day rates of major and clinically relevant nonmajor bleeding were 3.02% in apixaban (n=1257), 2.84% in dabigatran (n=668), and 4.16% for rivaroxaban (n=1082). Multivariate analysis stratified by region found more bleeding for hypertension (odds ratio [OR], 1.79; 95% CI 1.07‐2.99; P=0.027), and prior bleeding (OR, 1.71; 95% CI, 1.08‐2.71; P=0.021). Surgical bleed risk classification (high‐ versus low‐risk) as a predictor of bleeding was only significant in the univariate analysis. The prediction model for major and clinically relevant nonmajor bleeding had an area under the curve of 0.71, and the preoperative DOAC level did not improve the area under the curve of the model. Conclusions In patients treated with DOACs who required an elective surgery/procedure and were managed with standardized DOAC interruption and resumption, there we did not find reversible risk factors for bleeding, suggesting that adjustment of the PAUSE management protocol to mitigate against bleeding is not needed.
Collapse
Affiliation(s)
- Alfonso J Tafur
- Northshore University HealthSystem Evanston IL.,University of Chicago Pritzker School of Medicine Chicago IL
| | | | - Alex C Spyropoulos
- Zucker School of Medicine at Hofstra/Northwell Northwell Health at Lenox Hill Hospital New York NY
| | - Na Li
- McMaster University Hamilton ON Canada
| | | | - Kira MacDougall
- Zucker School of Medicine at Hofstra/Northwell Northwell Health at Lenox Hill Hospital New York NY
| | - Sam Schulman
- McMaster University Hamilton ON Canada.,Department of Obstetrics and Gynecology The First I.M. Sechenov Moscow State Medical University Moscow Russia
| | - Joseph A Caprini
- Northshore University HealthSystem Evanston IL.,University of Chicago Pritzker School of Medicine Chicago IL
| | | |
Collapse
|
11
|
Mullier F, Paridaens M, Evrard J, Baudar J, Guldenpfennig M, Devroye C, Miller L, Chatelain B, Lessire S, Jacqmin H. Evaluation of a new thromboplastin reagent STA‐NeoPTimal on a STA R Max analyzer for the measurement of prothrombin time, international normalized ratio and extrinsic factor levels. Int J Lab Hematol 2020; 42:650-660. [DOI: 10.1111/ijlh.13236] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/17/2020] [Accepted: 04/21/2020] [Indexed: 11/28/2022]
Affiliation(s)
- François Mullier
- Department of Laboratory Medicine Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS) Yvoir Belgium
| | | | | | - Justine Baudar
- Department of Laboratory Medicine Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS) Yvoir Belgium
| | - Maité Guldenpfennig
- Department of Laboratory Medicine Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS) Yvoir Belgium
| | - Celia Devroye
- Department of Laboratory Medicine Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS) Yvoir Belgium
| | - Laurence Miller
- Department of Laboratory Medicine Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS) Yvoir Belgium
| | - Bernard Chatelain
- Department of Laboratory Medicine Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS) Yvoir Belgium
| | - Sarah Lessire
- Department of Anesthesiology Université catholique de LouvainCHU UCL NamurNamur Thrombosis and Hemostasis Center (NTHC)Namur Research Institute for Life Sciences (NARILIS) Yvoir Belgium
| | - Hugues Jacqmin
- Department of Laboratory Medicine Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS) Yvoir Belgium
| |
Collapse
|
12
|
Ćelap I, Margetić S, Brčić M, Mihić R. Analytical verification and comparison of chromogenic assays for dabigatran, rivaroxaban and apixaban determination on BCSXP and STA Compact Max analysers. Biochem Med (Zagreb) 2020; 30:010706. [PMID: 32063729 PMCID: PMC6999186 DOI: 10.11613/bm.2020.010706] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Accepted: 12/03/2019] [Indexed: 11/01/2022] Open
Abstract
Introduction The aim of the study was to perform analytical verification and comparison of chromogenic assays for determination of dabigatran, rivaroxaban and apixaban concentration on BCSXP and STA Compact Max analysers. Materials and methods Precision, linearity, measurement uncertainty estimation and determination of limit of blank, limit of determination and limit of quantification were calculated. Analytical performance specifications were set according to manufacturer specifications and literature data on between laboratory variability. Comparison of the methods was done using Bland-Altman and Passing-Bablok regression analysis. Results Obtained results have shown acceptable precision on STA Compact Max only for dabigatran (CV = 3.5%) at lower concentration level comparing to manufacturer declaration (CV = 3.6%). On BCSXP, the highest coefficient of variation has been shown for apixaban (6.1%) at lower concentration level. Within laboratory precision was not met on STA Compact Max for all assays. Bland-Altman analysis has shown statistically significant bias for dabigatran (23.2%, 95%CI 11.2 - 35.3; P < 0.001) and apixaban (8.4%, 95%CI 1.2 - 15.6; P = 0.023). Passing-Bablok regression analysis has shown systematic and proportional deviation between methods for rivaroxaban (y = 6.52 (2.94 to 11.83) + 0.84 (0.80 to 0.89) x. Conclusion Chromogenic assays for dabigatran, rivaroxaban and apixaban on BCSXP and STA Compact Max analysers are shown as methods with satisfactory long-term analytical performance specifications for determination of direct oral anticoagulants in clinical laboratories. However, we cannot recommend interchangeable use because of the significant bias between assays.
Collapse
Affiliation(s)
- Ivana Ćelap
- Department of Clinical Chemistry, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Sandra Margetić
- Department of Clinical Chemistry, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Marija Brčić
- Department of Clinical Chemistry, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Roman Mihić
- Department of Clinical Chemistry, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| |
Collapse
|
13
|
Scalambrino E, Padovan L, Chantarangkul V, Clerici M, Artoni A, Peyvandi F, Tripodi A. Responsiveness of the activated partial thromboplastin time and dilute thrombin time to argatroban: Results of an in vitro study. Int J Lab Hematol 2020; 42:e128-e131. [PMID: 32086868 DOI: 10.1111/ijlh.13165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 01/27/2020] [Accepted: 01/29/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Erica Scalambrino
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milano, Italy.,Università degli Studi di Milano Department of Pathophysiology and Transplantation, Milano, Italy
| | - Lidia Padovan
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milano, Italy
| | - Veena Chantarangkul
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milano, Italy
| | - Marigrazia Clerici
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milano, Italy
| | - Andrea Artoni
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milano, Italy
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milano, Italy.,Università degli Studi di Milano Department of Pathophysiology and Transplantation, Milano, Italy
| | - Armando Tripodi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milano, Italy
| |
Collapse
|
14
|
Ofek F, Barchel D, Perets N, Ziv-Baran T, Mahajna A, Filipovich-Rimon T, Garach-Jehoshua O, Berlin M, Berkovitch M. International Normalized Ratio as a Screening Test for Assessment of Anticoagulant Activity for Patients Treated With Rivaroxaban or Apixaban: A Pilot Study. Front Pharmacol 2019; 10:1177. [PMID: 31649541 PMCID: PMC6792346 DOI: 10.3389/fphar.2019.01177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 09/13/2019] [Indexed: 12/29/2022] Open
Abstract
Introduction: In patients treated with direct oral anti activated factor X (anti-FXa) anticoagulants such as apixaban and rivaroxaban, there are several emergency and non-emergency conditions in which anticoagulation activity should be measured. The validity of the common global clotting tests, prothrombin time and international normalized ratio (PT/INR) for determination of blood levels of these drugs, has been widely investigated. As the anticoagulation activity evaluation “calibrated anti-FXa” of these drugs is relatively more expensive and less available, we aimed to build a prediction model for anticoagulation activity assessment based on INR values. Methods and Findings: One hundred sixty samples from 80 hospitalized patients treated with apixaban or rivaroxaban were tested using PT/INR and Anti-FXa chromogenic assay. Two blood samples, trough and peak, were collected from each subject. Participants were randomly divided into two equal groups. One group (n = 40) was used to build the model, which was validated by the second group (n = 40). There was a strong correlation between anti-FXa concentrations and INR in rivaroxaban treated patients (r = 0.899, p < 0.001). Therefore, we were able to build a formula for rivaroxaban patient group which reliably represent the relationship between these two parameters. The correlation in apixaban treated patients was less predictive (r = 0.798, p < 0.001) and the formula suggested could not be validated. Conclusions: In our study, we developed a formula that estimates the anticoagulant activity of rivaroxaban by obtaining INR values. Where anti-FXa assay is unavailable, our proposed formula may be considered as a screening test for rivaroxaban.
Collapse
Affiliation(s)
- Fanny Ofek
- Pharmacy Department, Assaf Harofeh Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dana Barchel
- Internal Department, Assaf Harofeh Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nofar Perets
- Institute for Drug Research, School of Pharmacy, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Tomer Ziv-Baran
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ahmad Mahajna
- Internal Department, Assaf Harofeh Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Talia Filipovich-Rimon
- Division of Hematology, Assaf Harofeh Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Osnat Garach-Jehoshua
- Division of Hematology, Assaf Harofeh Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Maya Berlin
- Clinical Pharmacology and Toxicology Unit, Assaf Harofeh Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Matitiahu Berkovitch
- Clinical Pharmacology and Toxicology Unit, Assaf Harofeh Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| |
Collapse
|
15
|
Culbreth SE, Sylvester KW, Rimsans J, Connors JM. Coordinating emergent procedures after andexanet alfa. Am J Hematol 2019; 94:E278-E282. [PMID: 31342554 DOI: 10.1002/ajh.25587] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 07/20/2019] [Indexed: 01/13/2023]
Affiliation(s)
- Sarah E. Culbreth
- Department of Pharmacy ServicesBrigham and Women's Hospital Boston Massachusetts
| | - Katelyn W. Sylvester
- Department of Pharmacy ServicesBrigham and Women's Hospital Boston Massachusetts
| | - Jessica Rimsans
- Department of Pharmacy ServicesBrigham and Women's Hospital Boston Massachusetts
| | - Jean M. Connors
- Department of Medicine, Division of HematologyBrigham and Women's Hospital Boston Massachusetts
| |
Collapse
|
16
|
Hollestelle MJ, Meijer P. International external quality assessment for measurements of direct oral anticoagulants: results and recommendations. Br J Haematol 2019; 188:460-464. [DOI: 10.1111/bjh.16179] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 07/01/2019] [Accepted: 07/08/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Martine J. Hollestelle
- External quality Control for Assays and Tests (ECAT) Foundation Voorschoten The Netherlands
| | - Piet Meijer
- External quality Control for Assays and Tests (ECAT) Foundation Voorschoten The Netherlands
| |
Collapse
|
17
|
Paciaroni M, Agnelli G, Caso V, Silvestrelli G, Seiffge DJ, Engelter S, De Marchis GM, Polymeris A, Zedde ML, Yaghi S, Michel P, Eskandari A, Antonenko K, Sohn SI, Cappellari M, Tassinari T, Tassi R, Masotti L, Katsanos AH, Giannopoulos S, Acciarresi M, Alberti A, Venti M, Mosconi MG, Vedovati MC, Pierini P, Giustozzi M, Lotti EM, Ntaios G, Kargiotis O, Monaco S, Lochner P, Bandini F, Liantinioti C, Palaiodimou L, Abdul-Rahim AH, Lees K, Mancuso M, Pantoni L, Rosa S, Bertora P, Galliazzo S, Ageno W, Toso E, Angelini F, Chiti A, Orlandi G, Denti L, Flomin Y, Marcheselli S, Mumoli N, Rimoldi A, Verrengia E, Schirinzi E, Del Sette M, Papamichalis P, Komnos A, Popovic N, Zarkov M, Rocco A, Diomedi M, Giorli E, Ciccone A, Mac Grory BC, Furie KL, Bonetti B, Saia V, Guideri F, Acampa M, Martini G, Grifoni E, Padroni M, Karagkiozi E, Perlepe K, Makaritsis K, Mannino M, Maccarrone M, Ulivi L, Giannini N, Ferrari E, Pezzini A, Doronin B, Volodina V, Baldi A, D’Amore C, Deleu D, Corea F, Putaala J, Santalucia P, Nardi K, Risitano A, Toni D, Tsivgoulis G. Causes and Risk Factors of Cerebral Ischemic Events in Patients With Atrial Fibrillation Treated With Non–Vitamin K Antagonist Oral Anticoagulants for Stroke Prevention. Stroke 2019; 50:2168-2174. [PMID: 31234756 DOI: 10.1161/strokeaha.119.025350] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background and Purpose—
Despite treatment with oral anticoagulants, patients with nonvalvular atrial fibrillation (AF) may experience ischemic cerebrovascular events. The aims of this case-control study in patients with AF were to identify the pathogenesis of and the risk factors for cerebrovascular ischemic events occurring during non–vitamin K antagonist oral anticoagulants (NOACs) therapy for stroke prevention.
Methods—
Cases were consecutive patients with AF who had acute cerebrovascular ischemic events during NOAC treatment. Controls were consecutive patients with AF who did not have cerebrovascular events during NOACs treatment.
Results—
Overall, 713 cases (641 ischemic strokes and 72 transient ischemic attacks; median age, 80.0 years; interquartile range, 12; median National Institutes of Health Stroke Scale on admission, 6.0; interquartile range, 10) and 700 controls (median age, 72.0 years; interquartile range, 8) were included in the study. Recurrent stroke was classified as cardioembolic in 455 cases (63.9%) according to the A-S-C-O-D (A, atherosclerosis; S, small vessel disease; C, cardiac pathology; O, other causes; D, dissection) classification. On multivariable analysis, off-label low dose of NOACs (odds ratio [OR], 3.18; 95% CI, 1.95–5.85), atrial enlargement (OR, 6.64; 95% CI, 4.63–9.52), hyperlipidemia (OR, 2.40; 95% CI, 1.83–3.16), and CHA
2
DS
2
-VASc score (OR, 1.72 for each point increase; 95% CI, 1.58–1.88) were associated with ischemic events. Among the CHA
2
DS
2
-VASc components, age was older and presence of diabetes mellitus, congestive heart failure, and history of stroke or transient ischemic attack more common in patients who had acute cerebrovascular ischemic events. Paroxysmal AF was inversely associated with ischemic events (OR, 0.45; 95% CI, 0.33–0.61).
Conclusions—
In patients with AF treated with NOACs who had a cerebrovascular event, mostly but not exclusively of cardioembolic pathogenesis, off-label low dose, atrial enlargement, hyperlipidemia, and high CHA
2
DS
2
-VASc score were associated with increased risk of cerebrovascular events.
Collapse
Affiliation(s)
- Maurizio Paciaroni
- From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Paciaroni, G.A., V.C., M.A., A.A., M.V., M.G.M., M.C.V., P.P., M.G.)
| | - Giancarlo Agnelli
- From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Paciaroni, G.A., V.C., M.A., A.A., M.V., M.G.M., M.C.V., P.P., M.G.)
| | - Valeria Caso
- From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Paciaroni, G.A., V.C., M.A., A.A., M.V., M.G.M., M.C.V., P.P., M.G.)
| | | | - David Julian Seiffge
- University Center for Medicine of Aging and Rehabilitation, University of Basel, Felix-Platter Hospital, Switzerland (D.J.S., S.E., G.M.D.M., A. Polymeris)
| | - Stefan Engelter
- University Center for Medicine of Aging and Rehabilitation, University of Basel, Felix-Platter Hospital, Switzerland (D.J.S., S.E., G.M.D.M., A. Polymeris)
| | - Gian Marco De Marchis
- University Center for Medicine of Aging and Rehabilitation, University of Basel, Felix-Platter Hospital, Switzerland (D.J.S., S.E., G.M.D.M., A. Polymeris)
| | - Alexandros Polymeris
- University Center for Medicine of Aging and Rehabilitation, University of Basel, Felix-Platter Hospital, Switzerland (D.J.S., S.E., G.M.D.M., A. Polymeris)
| | - Maria Luisa Zedde
- Neurology Unit, Stroke Unit, Istituto di Ricovero e Cura a Carattere Scientifico, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy (M.L.Z.)
| | | | - Patrik Michel
- Département des Neurosciences Cliniques Centre Hopitalier Universitaire Vaudois, Centre Cérébrovasculaire, Service de Neurologie, Lausanne, Switzerland (P.M., A.E.)
| | - Ashraf Eskandari
- Département des Neurosciences Cliniques Centre Hopitalier Universitaire Vaudois, Centre Cérébrovasculaire, Service de Neurologie, Lausanne, Switzerland (P.M., A.E.)
| | - Kateryna Antonenko
- Department of Neurology, Bogomolets National Medical University, Kyiv, Ukraine (K.A.)
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University School of Medicine, Daegu, South Korea (S.I.S.)
| | - Manuel Cappellari
- Struttura Semplice Ospedaliera Stroke Unit, Unità Organica Neurologia, DAI di Neuroscienze, Azienda Ospedaliera Universitaria Integrata, Verona, Italy (M.C., B.B.)
| | - Tiziana Tassinari
- Stroke Unit, Department of Neurology, Santa Corona Hospital, Pietra Ligure, Savona, Italy (T.T., V.S.)
| | - Rossana Tassi
- Stroke Unit, AOU Senese, Siena, Italy (R.T., F.G., M.A., G.M.)
| | - Luca Masotti
- Internal Medicine, San Giuseppe Hospital, Empoli, Italy (L.M., E. Grifoni)
| | | | | | - Monica Acciarresi
- From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Paciaroni, G.A., V.C., M.A., A.A., M.V., M.G.M., M.C.V., P.P., M.G.)
| | - Andrea Alberti
- From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Paciaroni, G.A., V.C., M.A., A.A., M.V., M.G.M., M.C.V., P.P., M.G.)
| | - Michele Venti
- From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Paciaroni, G.A., V.C., M.A., A.A., M.V., M.G.M., M.C.V., P.P., M.G.)
| | - Maria Giulia Mosconi
- From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Paciaroni, G.A., V.C., M.A., A.A., M.V., M.G.M., M.C.V., P.P., M.G.)
| | - Maria Cristina Vedovati
- From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Paciaroni, G.A., V.C., M.A., A.A., M.V., M.G.M., M.C.V., P.P., M.G.)
| | - Patrizia Pierini
- From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Paciaroni, G.A., V.C., M.A., A.A., M.V., M.G.M., M.C.V., P.P., M.G.)
| | - Michela Giustozzi
- From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Paciaroni, G.A., V.C., M.A., A.A., M.V., M.G.M., M.C.V., P.P., M.G.)
| | - Enrico Maria Lotti
- U.O. Neurologia Presidio Ospedaliero di Ravenna Azienda USL della Romagna, Italy (E.M.L., M. Padroni)
| | - George Ntaios
- Department of Medicine, University of Thessaly, Larissa, Greece (G.N., E.K., K.P., K.M.)
| | | | - Serena Monaco
- Stroke Unit, Ospedale Civico, Palermo, Italy (S.M., M. Mannino)
| | - Piergiorgio Lochner
- Department of Neurology, Saarland University Medical Center, Homburg, Germany (P.L.)
| | - Fabio Bandini
- Department of Neurology, Ospedale San Paolo, Savona, Italy (F.B.)
| | - Chrysoula Liantinioti
- Second Department of Neurology, Attikon Hospital, National and Kapodistrian University of Athens, School of Medicine, Greece (C.L., L.P., G.T.)
| | - Lina Palaiodimou
- Second Department of Neurology, Attikon Hospital, National and Kapodistrian University of Athens, School of Medicine, Greece (C.L., L.P., G.T.)
| | - Azmil H. Abdul-Rahim
- Medical School and Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (A.H.A.-R., K.L.)
| | - Kennedy Lees
- Medical School and Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (A.H.A.-R., K.L.)
| | - Michelangelo Mancuso
- Clinica Neurologica–Azienda Ospedaliero-Universitaria, Pisa, Italy (M. Mancuso, M. Maccarrone, L.U., N.G., E.F.)
| | - Leonardo Pantoni
- Neurology, L. Sacco Department of Biomedical and Clinical Sciences, University of Milan, Italy (L.P., S.R., P.B.)
| | - Silvia Rosa
- Neurology, L. Sacco Department of Biomedical and Clinical Sciences, University of Milan, Italy (L.P., S.R., P.B.)
| | - Pierluigi Bertora
- Neurology, L. Sacco Department of Biomedical and Clinical Sciences, University of Milan, Italy (L.P., S.R., P.B.)
| | - Silvia Galliazzo
- Department of Medicine and Surgery, University of Insubria, Ospedale di Circolo Varese, Italy (S.G., W.A.)
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Ospedale di Circolo Varese, Italy (S.G., W.A.)
| | - Elisabetta Toso
- Division of Cardiology, University of Torino, Città della Salute e della Scienza Hospital, Italy (E.T., F.A.)
| | - Filippo Angelini
- Division of Cardiology, University of Torino, Città della Salute e della Scienza Hospital, Italy (E.T., F.A.)
| | - Alberto Chiti
- S.C. di Neurologia e S.S. di Stroke Unit, ASST di Mantova, Italy (G.S., A.C.)
| | | | - Licia Denti
- Stroke Unit, Dipartimento Geriatrico Riabilitativo, University of Parma, Italy (L.D.)
| | - Yuriy Flomin
- Stroke and Neurorehabilitation Unit, MC Universal Clinic Oberig, Kyiv, Ukraine (Y.F.)
| | - Simona Marcheselli
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece (O.K.)
- Neurologia d’urgenza e Stroke Unit, Istituto Clinico Humanitas, Rozzano, Milano, Italy (S.M.)
| | - Nicola Mumoli
- Department of Internal Medicine, Magenta Hospital, Italy (N.M., A.R., E.V.)
| | - Alexandra Rimoldi
- Department of Internal Medicine, Magenta Hospital, Italy (N.M., A.R., E.V.)
| | - Elena Verrengia
- Department of Internal Medicine, Magenta Hospital, Italy (N.M., A.R., E.V.)
| | - Erika Schirinzi
- Struttura Complessa di Neurologia, Ente Ospedaliero Ospedali Galliera, Genoa, Italy (E.S., M.D.S.)
| | - Massimo Del Sette
- Struttura Complessa di Neurologia, Ente Ospedaliero Ospedali Galliera, Genoa, Italy (E.S., M.D.S.)
| | - Panagiotis Papamichalis
- Internist-Intensive Care Specialist, Intensive Care Unit, General Hospital of Larissa, Greece (P.P., A.K.)
| | - Apostolos Komnos
- Internist-Intensive Care Specialist, Intensive Care Unit, General Hospital of Larissa, Greece (P.P., A.K.)
| | - Nemanja Popovic
- Clinic of Neurology, Clinical Center Vojvodina, University of Novi Sad, Serbia (N.P., M.Z.)
| | - Marija Zarkov
- Clinic of Neurology, Clinical Center Vojvodina, University of Novi Sad, Serbia (N.P., M.Z.)
| | - Alessandro Rocco
- Stroke Unit, Department of Systems Medicine, University of Tor Vergata, Rome, Italy (A.R., M.D.)
| | - Marina Diomedi
- Stroke Unit, Department of Systems Medicine, University of Tor Vergata, Rome, Italy (A.R., M.D.)
| | - Elisa Giorli
- Stroke Unit, Department of Neurology, Sant’Andrea Hospital, La Spezia, Italy (E. Giorli)
| | - Alfonso Ciccone
- Neurologia, Ospedale Apuano, Massa Carrara, Italy (A.C., G.O.)
| | - Brian C. Mac Grory
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (B.C.M.G., K.L.F.)
| | - Karen L. Furie
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (B.C.M.G., K.L.F.)
| | - Bruno Bonetti
- Struttura Semplice Ospedaliera Stroke Unit, Unità Organica Neurologia, DAI di Neuroscienze, Azienda Ospedaliera Universitaria Integrata, Verona, Italy (M.C., B.B.)
| | - Valentina Saia
- Stroke Unit, Department of Neurology, Santa Corona Hospital, Pietra Ligure, Savona, Italy (T.T., V.S.)
| | | | - Maurizio Acampa
- Stroke Unit, AOU Senese, Siena, Italy (R.T., F.G., M.A., G.M.)
| | | | - Elisa Grifoni
- Internal Medicine, San Giuseppe Hospital, Empoli, Italy (L.M., E. Grifoni)
| | - Marina Padroni
- U.O. Neurologia Presidio Ospedaliero di Ravenna Azienda USL della Romagna, Italy (E.M.L., M. Padroni)
| | - Efstathia Karagkiozi
- Department of Medicine, University of Thessaly, Larissa, Greece (G.N., E.K., K.P., K.M.)
| | - Kalliopi Perlepe
- Department of Medicine, University of Thessaly, Larissa, Greece (G.N., E.K., K.P., K.M.)
| | | | - Marina Mannino
- Stroke Unit, Ospedale Civico, Palermo, Italy (S.M., M. Mannino)
| | - Miriam Maccarrone
- Clinica Neurologica–Azienda Ospedaliero-Universitaria, Pisa, Italy (M. Mancuso, M. Maccarrone, L.U., N.G., E.F.)
| | - Leonardo Ulivi
- Clinica Neurologica–Azienda Ospedaliero-Universitaria, Pisa, Italy (M. Mancuso, M. Maccarrone, L.U., N.G., E.F.)
| | - Nicola Giannini
- Clinica Neurologica–Azienda Ospedaliero-Universitaria, Pisa, Italy (M. Mancuso, M. Maccarrone, L.U., N.G., E.F.)
| | - Elena Ferrari
- Clinica Neurologica–Azienda Ospedaliero-Universitaria, Pisa, Italy (M. Mancuso, M. Maccarrone, L.U., N.G., E.F.)
| | - Alessandro Pezzini
- Department of Clinical and Experimental Sciences, Neurology Clinic, University of Brescia, Italy (A. Pezzini)
| | - Boris Doronin
- Municipal Budgetary Healthcare Institution of Novosibirsk, City Clinical Hospital No. 1, Novosibirsk State Medical University, Russia (B.D., V.V.)
| | - Vera Volodina
- Municipal Budgetary Healthcare Institution of Novosibirsk, City Clinical Hospital No. 1, Novosibirsk State Medical University, Russia (B.D., V.V.)
| | - Antonio Baldi
- Stroke Unit, Ospedale di Portogruaro, Venice, Italy (A.B., C.D.)
| | - Cataldo D’Amore
- Stroke Unit, Ospedale di Portogruaro, Venice, Italy (A.B., C.D.)
| | - Dirk Deleu
- Neurology, Hamad Medical Corporation, Doha, Qatar (D.D.)
| | - Francesco Corea
- Unità Organica Gravi Cerebrolesioni, San Giovanni Battista Hospital, Foligno, Italy (F.C.)
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital, Finland (J.P.)
| | - Paola Santalucia
- Neurologia, Ospedale Piemonte, Istituto di Ricovero e Cura a Carattere Scientifico Bonino Pulejo, Messina, Italy (P.S.)
| | | | - Angela Risitano
- Department of Neurology and Psychiatry, Sapienza University of Rome, Italy (A.R., D.T.)
| | - Danilo Toni
- Department of Neurology and Psychiatry, Sapienza University of Rome, Italy (A.R., D.T.)
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon Hospital, National and Kapodistrian University of Athens, School of Medicine, Greece (C.L., L.P., G.T.)
- Department of Neurology, Democritus University of Thrace, University Hospital of Alexandroupolis, Greece (G.T.)
- Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T.)
| |
Collapse
|
18
|
Smock KJ, Moser KA. What have we learned from coagulation laboratory participation in external quality programs? Int J Lab Hematol 2019; 41 Suppl 1:49-55. [DOI: 10.1111/ijlh.12998] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/02/2019] [Accepted: 02/07/2019] [Indexed: 02/04/2023]
Affiliation(s)
- Kristi J. Smock
- Department of PathologyUniversity of Utah Health Sciences Center and ARUP Laboratories Salt Lake City Utah
| | - Karen A. Moser
- Department of PathologyUniversity of Utah Health Sciences Center and ARUP Laboratories Salt Lake City Utah
| |
Collapse
|
19
|
Cinnella G, Pavesi M, De Gasperi A, Ranucci M, Mirabella L. Clinical standards for patient blood management and perioperative hemostasis and coagulation management. Position Paper of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI). Minerva Anestesiol 2019; 85:635-664. [PMID: 30762323 DOI: 10.23736/s0375-9393.19.12151-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Patient blood management is currently defined as the application of evidence based medical and surgical concepts designed to maintain hemoglobin (Hb), optimize hemostasis and minimize blood loss to improve patient outcome. Blood management focus on the perioperative management of patients undergoing surgery or other invasive procedures in which significant blood loss occurs or is expected. Preventive strategies are emphasized to identify and manage anemia, reduce iatrogenic blood losses, optimize hemostasis (e.g. pharmacologic therapy, and point of care testing); establish decision thresholds for the appropriate administration of blood therapy. This goal was motivated historically by known blood risks including transmissible infectious disease, transfusion reactions, and potential effects of immunomodulation. Patient blood management has been recognized by the World Health Organization (WHO) as the new standard of care and has urged all 193-member countries of WHO to implement this concept. There is a pressing need for this new "standard of care" so as to reduce blood transfusion and promote the availability of transfusion alternatives. Patient blood management therefore encompasses an evidence-based medical and surgical approach that is multidisciplinary (transfusion medicine specialists, surgeons, anesthesiologists, and critical care specialists) and multiprofessional (physicians, nurses, pump technologists and pharmacists). The Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) organized a consensus project involving a Task Force of expert anesthesiologists that reviewing literature provide appropriate levels of care and good clinical practices. Hence, this article focuses on achieving goals of PBM in the perioperative period.
Collapse
Affiliation(s)
- Gilda Cinnella
- Unit of Anesthesia and Resuscitation, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy
| | - Marco Pavesi
- Division of Multispecialty Anesthesia Service of Polispecialistic Anesthesia, San Donato IRCCS Polyclinic, San Donato Milanese, Milan, Italy
| | - Andrea De Gasperi
- Division of Anesthesia and Resuscitation, Niguarda Hospital, Milan, Italy
| | - Marco Ranucci
- Division of Anesthesia and Cardio-Thoraco-Vascular Therapy, San Donato IRCCS Polyclinic, San Donato Milanese, Milan, Italy
| | - Lucia Mirabella
- Unit of Anesthesia and Resuscitation, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy -
| |
Collapse
|
20
|
Huang JH, Lin YK, Chung CC, Hsieh MH, Chiu WC, Chen YJ. Factors That Determine the Prothrombin Time in Patients With Atrial Fibrillation Receiving Rivaroxaban. Clin Appl Thromb Hemost 2018; 24:188S-193S. [PMID: 30244598 PMCID: PMC6714846 DOI: 10.1177/1076029618800830] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Rivaroxaban, a direct factor Xa inhibitor, is widely used to reduce the chance of stroke
in patients with atrial fibrillation (AF). It is not clear why the prothrombin time (PT)
of the international normalized ratio (INR) fails to correlate with treatment using
rivaroxaban in patients with AF. In this study, patient characteristics, the rivaroxaban
dosage, AF type, drug history, biochemical properties, and hematological profiles were
assessed in patients treated with rivaroxaban. In 69 patients with AF receiving
rivaroxaban, 27 (39.1%) patients had a normal INR (≤1.1, group 1), 27 (39.1%) patients had
a slightly prolonged INR (1.1∼1.5, group 2), and 15 (21.7%) patients had a significantly
prolonged INR (>1.5, group 3). Group 1 patients had a higher incidence of a stroke
history than did patients in group 2 (P = .026) and group 3
(P = .032). We scored patients with a persistent AF pattern (1 point),
paroxysmal AF pattern (0 point), renal function (ie, the creatinine clearance rate in
mL/min/1.73 m2 of >60 as 0 points, of 30∼60 as 1 point, and of <30 as 2
points), and no history of stroke (1 point), and we found that group 3 had a higher score
than groups 2 or 1 (2.9 ± 0.8, 2.4 ± 0.7, and 2 ± 0.7, respectively; P
< .05). There were similar incidences of bleeding, stroke, and unexpected
hospitalizations among the 3 groups. The PT of the INR is determined by multiple variables
in patients with AF receiving rivaroxaban. Rivaroxaban-treated patients with AF having
different INR values may have similar clinical outcomes.
Collapse
Affiliation(s)
- Jen-Hung Huang
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yung-Kuo Lin
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Cheng-Chih Chung
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Ming-Hsiung Hsieh
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Wan-Chun Chiu
- School of Nutrition and Health Sciences, College of Nutrition, Taipei Medical University, Taipei, Taiwan
| | - Yi-Jen Chen
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| |
Collapse
|
21
|
Testing and monitoring direct oral anticoagulants. Blood 2018; 132:2009-2015. [DOI: 10.1182/blood-2018-04-791541] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 09/06/2018] [Indexed: 12/19/2022] Open
Abstract
Abstract
Direct oral anticoagulants (DOACs) have significantly improved the care of patients requiring anticoagulation. With similar or better efficacy and safety outcomes and easier use in the outpatient setting compared with the standard-of-care vitamin K antagonists and low molecular weight heparin, DOACs are now endorsed as first-line treatment of indications including prevention of stroke and systemic embolism in nonvalvular atrial fibrillation and treatment of venous thromboembolism. DOACs are easy-to-use oral agents that offer simple dosing and short half-lives, with no need to test levels because of the wide therapeutic window and limited drug-drug interactions. After almost a decade of DOAC use, the question of testing DOAC levels in certain clinical situations has become the focus of debate. Although guidance for using routine coagulation tests is available, these tests are inadequate for optimal care. DOAC-specific tests have been developed but have limited availability in Europe and less availability in the United States. None are licensed. DOAC testing may be useful in the setting of critical clinical situations such as life-threatening bleeding or need for emergent surgery, especially with the availability of DOAC reversal agents. Patients with characteristics that fall outside the normal range may benefit from the guidance that DOAC testing could offer. Obstacles to adopting DOAC testing have been raised, such as test reliability and staffing costs; however, these problems are rapidly being resolved. Further investigation of the role of DOAC testing is needed to explore its full potential and role in clinical practice.
Collapse
|
22
|
Tripodi A, Marongiu F, Moia M, Palareti G, Pengo V, Poli D, Prisco D, Testa S, Zanazzi M. The vexed question of whether or not to measure levels of direct oral anticoagulants before surgery or invasive procedures. Intern Emerg Med 2018; 13:1029-1036. [PMID: 29700696 DOI: 10.1007/s11739-018-1854-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 04/08/2018] [Indexed: 12/12/2022]
Abstract
Direct oral anticoagulants (DOAC) possess high bioavailability, and their anticoagulant effect is more predictable than that of vitamin K antagonists, hence they do not require routine dose adjustment based on laboratory testing. However, there are circumstances when laboratory testing may be useful, including patients who need to undergo surgery or invasive procedures. Most guidelines state that patients on DOAC may safely undergo surgery/invasive procedures by stopping anticoagulation for a few days before intervention without testing if renal function is within normal limits. This review article discusses the pros and cons of measuring (or not measuring) DOAC levels before surgery/invasive procedures by a multidisciplinary team of experts with different background, including the thrombosis laboratory, clinical thrombosis, internal medicine, cardiology and nephrology. The conclusion is that measuring DOAC with dedicated tests before surgical or invasive procedures is important for patient safety. It provides the best and most direct evidence to rule in (or to rule out) clinically relevant concentrations of residual drugs. Regulatory agencies should urgently approve their use in clinical practice. Hospital administrators should make them available, and clinical laboratories should set up the relative methods and make them available to clinicians.
Collapse
Affiliation(s)
- Armando Tripodi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, IRCCS Cà Granda Maggiore Hospital Foundation, Via Pace 9, 20122, Milan, Italy.
| | - Francesco Marongiu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Marco Moia
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, IRCCS Cà Granda Maggiore Hospital Foundation, Via Pace 9, 20122, Milan, Italy
| | - Gualtiero Palareti
- Arianna Anticoagulation Foundation-START Register Section, Bologna, Italy
| | - Vittorio Pengo
- Cardiology Clinic, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Daniela Poli
- Thrombosis Centre, Careggi University Hospital, Florence, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Sophie Testa
- Department of Laboratory Medicine, Hemostasis and Thrombosis Centre, District Hospital, Cremona, Italy
| | - Maria Zanazzi
- Renal Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| |
Collapse
|