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Basu Roy P, Tejani VN, Dhillon SS, Damarlapally N, Winson T, Usman NUB, Panjiyar BK. Efficacy and Safety of Novel Oral Anticoagulants in Atrial Fibrillation: A Systematic Review. Cureus 2023; 15:e46385. [PMID: 37927673 PMCID: PMC10620341 DOI: 10.7759/cureus.46385] [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] [Accepted: 10/02/2023] [Indexed: 11/07/2023] Open
Abstract
In recent times, novel oral anticoagulants (NOACs)/direct oral anticoagulants (DOACs) have emerged as an alternative to the traditionally used Vitamin K oral antagonists (VKA) like warfarin for the treatment of atrial fibrillation (AF). This systematic review and meta-analysis aims to evaluate the efficacy and safety of NOACs in patients with AF and, thus, the related thromboembolic risks and sequelae. Of the 131 published articles we examined, 11 were included in an in-depth systematic review. The articles we reviewed were from the past ten years, from 2013 onward. The analysis derived the efficacy and safety of NOACs in patients with AF and also included different patients' baseline characteristics and subgroups. This systematic review reiterates previous research findings of superior efficacy and safety of the use of NOACs in the AF population and also illuminates certain head-to-head comparisons of individual NOACs with warfarin. It digressed into subgroups of patients with different baseline characteristics to provide evidence and support the existing guidelines for the use of NOACs in the treatment of AF. Overall, there is marked efficacy and safety of NOACs in patients with AF, be they elderly or Asian, with decreased renal function, or with other comorbidities. Adherence to NOACs was also satisfactory. Despite such a review, there needs to be more research on vast subgroups and also on reversal antidotes like andexanet alfa and idarucizumab, as well as more head-to-head analysis between NOACs over a long duration of study, which would provide more answers and pinpoint reasons as to the differences that exist between demographics and subgroups in the usage of NOACs.
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Affiliation(s)
- Prithvi Basu Roy
- Medicine, KPC (Kali Pradip Chaudhuri) Medical College and Hospital, Kolkata, West Bengal, India, Kolkata, IND
| | - Vitrag N Tejani
- Medicine, Parul Institute of Medical Sciences and Research, Vadodara, IND
| | - Sukhmeet S Dhillon
- Internal Medicine, Baba Farid University of Health Sciences, Faridkot, IND
| | - Nanush Damarlapally
- Health Sciences, Houston Community College - Coleman College for Health Sciences, Houston, USA
| | | | | | - Binay K Panjiyar
- Global Clinical Scholars Research Training, Harvard Medical School, Boston, USA
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Xu W, Lv M, Wu S, Jiang S, Zeng Z, Fang Z, Qian J, Chen M, Chen J, Zhang J. Severe Bleeding Risk of Direct Oral Anticoagulants Versus Vitamin K Antagonists for Stroke Prevention and Treatment in Patients with Atrial Fibrillation: A Systematic Review and Network Meta-Analysis. Cardiovasc Drugs Ther 2023; 37:363-377. [PMID: 34436708 DOI: 10.1007/s10557-021-07232-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/18/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE We aimed to determine the safety of direct oral anticoagulants (DOACs) for stroke prevention and treatment in patients with atrial fibrillation (AF). METHODS A systematic search of four databases (PubMed, EMBASE, Web of Science, and Cochrane Library) was performed to identify randomized controlled trials (RCTs) reporting severe bleeding events in patients taking DOACs or vitamin K antagonists (VKAs). In this frequency-based network meta-analysis, odds ratios and 95% confidence intervals were used for reporting. Based on the surface under the cumulative ranking curves (SUCRA), the relative ranking probability of each group was generated. RESULTS Twenty-three RCTs met the inclusion criteria, and a total of 87,616 patients were enrolled. The bleeding safety of DOACs for stroke prevention and treatment in patients with AF was ranked from highest to lowest as follows: fatal bleeding: edoxaban (SUCRA,80.2), rivaroxaban (SUCRA,68.3), apixaban (SUCRA,48.5), dabigatran (SUCRA,40.0), VKAs (SUCRA,12.9); major bleeding: dabigatran (SUCRA,74.0), apixaban (SUCRA,71.5), edoxaban (SUCRA,66.5), rivaroxaban (SUCRA,22.7), VKAs (SUCRA,15.4); gastrointestinal bleeding: apixaban (SUCRA,55.9), VKAs (SUCRA,53.7), edoxaban (SUCRA,50.5), rivaroxaban (SUCRA,50.4), dabigatran (SUCRA,39.5); intracranial hemorrhage: dabigatran (SUCRA,84.6), edoxaban (SUCRA,74.1), apixaban (SUCRA,65.8), rivaroxaban (SUCRA,24.4), VKAs (SUCRA,1.1). CONCLUSION Based on current evidence, for stroke prevention and treatment in patients with AF, the most safe DOAC is edoxaban in terms of fatal bleeding; dabigatran in terms of major bleeding and intracranial hemorrhage and apixaban in terms of gastrointestinal bleeding. However, given the nature of indirect comparisons, more high-quality evidence from head-to-head comparisons is still needed to confirm them.
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Affiliation(s)
- Wenlin Xu
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, China
| | - Meina Lv
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, China
| | - Shuyi Wu
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, China
| | - Shaojun Jiang
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, China
| | - Zhiwei Zeng
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, China
| | - Zongwei Fang
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, China
| | - Jiafen Qian
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, China
| | - Mingrong Chen
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, China
| | - Jiana Chen
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, China
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Medical University Union Hospital, #29 Xinquan Road, Fuzhou, 350001, China.
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Alejandre-Altamirano RM, Castro-Rodríguez J, Pleguezuelo-Navarro M, Casáis-Juanena LL, Serrano-Ruiz FJ, Martínez-Rodríguez AM, Hervás-Molina AJ. Risk of thromboembolic events in relation to the management of anticoagulant and antiagregant therapy in patients subjected to endoscopic retrograde cholangiopancreatography. GASTROENTEROLOGIA Y HEPATOLOGIA 2023; 46:83-91. [PMID: 35278503 DOI: 10.1016/j.gastrohep.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 02/15/2022] [Accepted: 03/01/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND OBJECTIVES The main clinical practice guidelines recommend adequate periprocedural withdrawal and reintroduction of antithrombotic drugs in case of invasive techniques. The main objective of this study was to assess whether, in patients receiving anticoagulant or antiplatelet therapy, the suppression or reduction of the pharmacological dose for the performance of endoscopic retrograde cholangiopancreatography (ERCP) implies a greater risk of thromboembolic events. PATIENTS AND METHODS A prospective observational study was carried out, which included 644ERCP performed with therapeutic intention during 2019 at the Reina Sofía University Hospital with follow-up during the 30days after the endoscopic intervention. RESULTS Six patients presented a thromboembolic event, finding no differences between the incorrect withdrawal/reintroduction of antithrombotic treatment and a higher proportion of thromboembolic or hemorrhagic events after the procedure (P>.05). The incidence of thrombotic events was significantly higher in patients treated with heparin or apixaban (P=.001), as well as with a history of atrial fibrillation (P=.05), rheumatic valve disease (P=.037) and recurrent pulmonary embolism (P=.035), this being also an independent risk factor. Likewise, the incidence of hemorrhage in the 30days post-sphincterotomy was significantly lower in those with implantation of a biliary prosthesis (P=.04). CONCLUSIONS Inadequate periprocedural management of antithrombotic therapy is not associated with a significant increase in the incidence of thromboembolic events in the 30days after ERCP. However, close follow-up and surveillance during the days after this is essential in those patients with a condition that significantly increases the risk of thrombosis.
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Lv M, Wu T, Jiang S, Chen W, Zhang J. Risk of Intracranial Hemorrhage Caused by Direct Oral Anticoagulants for Stroke Prevention in Patients With Atrial Fibrillation (from a Network Meta-Analysis of Randomized Controlled Trials). Am J Cardiol 2022; 162:92-99. [PMID: 34756593 DOI: 10.1016/j.amjcard.2021.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 09/01/2021] [Accepted: 09/07/2021] [Indexed: 11/25/2022]
Abstract
Patients with atrial fibrillation (AF) who take direct oral anticoagulants (DOACs) face the risk of intracranial hemorrhage (ICH), which can be serious and even life threatening, but the risk of ICH of anticoagulants is still controversial. In this meta-analysis, we compared the risk of ICH between vitamin K antagonists (VKAs) and DOACs. Furthermore, we also compared the risk of ICH in different DOACs. PubMed, Embase, Web of Science, and the Cochrane Library were searched for relevant randomized controlled trials. The outcome was ICH, shown as the odds ratio (OR) with a 95% confidence interval (CI). DOACs were ranked by calculating the surface under the cumulative ranking curve (SUCRA). We included a total of 82,404 patients with AF. DOACs reduced the ICH risk by nearly half compared with VKAs (OR 0.47, 95% CI 0.40 to 0.54, p <0.001). VKAs were the least safe among all oral anticoagulants (SUCRA 1.7). Dabigatran 110 mg was the safest DOAC (SUCRA 87.3) for ICH risk, whereas rivaroxaban 20 mg was a relatively unsafe DOAC (SUCRA 27.5). Compared with rivaroxaban 20 mg, dabigatran 110 mg presented 53% (OR 0.47, 95% CI 0.27 to 0.82) lower relative risk for ICH. In conclusion, DOACs present less ICH risk than VKAs in patients with AF. For patients with AF who are at high risk of ICH, dabigatran 110 mg may be the safest choice among the DOACs.
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Carballo Álvarez F, Albillos Martínez A, Llamas Silero P, Orive Calzada A, Redondo-Cerezo E, Rodríguez de Santiago E, Crespo García J. Consensus document of the Sociedad Española de Patología Digestiva on massive nonvariceal gastrointestinal bleeding and direct-acting oral anticoagulants. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2022; 114:375-389. [DOI: 10.17235/reed.2022.8920/2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Zhu H, Li F, Tao K, Liu M, Xu H. Bleeding after endoscopic resection between direct oral anticoagulants or warfarin: Systematic review and meta-analysis. J Gastroenterol Hepatol 2021; 36:2363-2374. [PMID: 33893748 DOI: 10.1111/jgh.15527] [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: 11/23/2020] [Revised: 02/15/2021] [Accepted: 04/16/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Oral anticoagulants are risk factors for post-endoscopic resection bleeding. We aimed to conduct a systematic review and meta-analysis for the risks of post-procedural bleeding (PPB) for direct oral anticoagulants (DOACs) and warfarin following endoscopic resection. METHODS Two independent reviewers searched PubMed, Web of Science, Embase, and Cochrane Library. The Newcastle-Ottawa Scale score was used to assess the quality of the studies, the pooled odds ratio (OR) to present PPB results, and the funnel plots to assess publication bias. The Higgins I2 statistic was employed to determine the variation across studies due to heterogeneity. RESULTS We reviewed 30 articles. PPB occurred in 586 patients on DOACs and 1782 on warfarin. The patients on DOACs had a significantly lower overall risk of PPB compared with those on warfarin (OR, 0.867, 95% confidence interval, 0.771-0.975; P = 0.017, I2 = 1.6%). Cumulative meta-analysis showed that the PPB rate of DOACs has the trend to be lower than that of warfarin with publication year and sample size. For the subgroup of endoscopic submucosal dissection, the PPB of DOACs was significantly lower than that of warfarin (OR, 0.786; 95% confidence interval, 0.633-0.976; P = 0.029, I2 = 0%). No significant difference was observed between DOACs and warfarin for anticoagulant strategies, endoscopic procedures, and lesion location. CONCLUSIONS Compared with warfarin, DOACs have the possibility to significantly decrease the risk of PPB following endoscopic resection, especially for endoscopic submucosal dissection.
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Affiliation(s)
- He Zhu
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun, China
| | - Fudong Li
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun, China
| | - Ke Tao
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun, China
| | - Mingqing Liu
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun, China
| | - Hong Xu
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun, China
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Factor Xa inhibitors in patients with continuous-flow left ventricular assist devices. Gen Thorac Cardiovasc Surg 2020; 68:1278-1284. [DOI: 10.1007/s11748-020-01371-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 04/17/2020] [Indexed: 10/24/2022]
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Turcato G, Bonora A, Zorzi E, Zaboli A, Zannoni M, Ricci G, Pfeifer N, Maccagnani A, Tenci A. Thirty-day mortality in atrial fibrillation patients with gastrointestinal bleeding in the emergency department: differences between direct oral anticoagulant and warfarin users. Intern Emerg Med 2020; 15:311-318. [PMID: 31754969 DOI: 10.1007/s11739-019-02229-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 11/02/2019] [Indexed: 02/07/2023]
Abstract
More clinical data are required on the safety of direct oral anticoagulants (DOACs). Although patients treated with warfarin and DOACs have a similar risk of bleeding, short-term mortality after a gastrointestinal bleeding (GIB) episode in DOAC-treated patients has not been clarified. The objective of this study was to assess differences in 30-day mortality in patients treated with DOACs or warfarin admitted to the emergency department (ED) for GIB. This was a multicentre retrospective study conducted over 2 years. The study included patients evaluated at three different EDs for GIB. The baseline characteristics were included. Subsequently, we assessed the differences in past medical history and clinical data between the two study groups (DOAC and warfarin users). Differences between the two groups were evaluated using Kaplan-Meier curves. Among the 284 patients presenting GIB enrolled in the study period, 39.4% (112/284) were treated with DOACs and 60.6% (172/284) were treated with warfarin. Overall, 8.1% (23/284) of patients died within 30 days. Among the 172 warfarin-treated patients, 8.7% (15/172) died within 30 days from ED evaluation. In the 112 DOAC-treated patients, the mortality rate was 7.1% (8/112). The Cox regression analysis, adjusted for possible clinical confounders, and the Kaplan-Meier curves did not outline differences between the two treatment groups. The present study shows no differences between DOACs and warfarin in short-term mortality after GIB.
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Affiliation(s)
- Gianni Turcato
- Department of Emergency Medicine, Franz Tappeiner Hospital of Merano, Azienda Sanitaria Dell'Alto Adige, Merano, Bolzano, Italy.
| | - Antonio Bonora
- Department of Emergency Medicine, University of Verona, Verona, Italy
| | - Elisabetta Zorzi
- Department of Cardiology and Intensive Care Cardiology, Girolamo Fracastoro Hospital of San Bonifacio, Azienda Ospedaliera Scaligera, San Bonifacio, Verona, Italy
| | - Arian Zaboli
- Department of Emergency Medicine, Franz Tappeiner Hospital of Merano, Azienda Sanitaria Dell'Alto Adige, Merano, Bolzano, Italy
| | - Massimo Zannoni
- Department of Emergency Medicine, University of Verona, Verona, Italy
| | - Giorgio Ricci
- Department of Cardiology and Intensive Care Cardiology, Girolamo Fracastoro Hospital of San Bonifacio, Azienda Ospedaliera Scaligera, San Bonifacio, Verona, Italy
| | - Norbert Pfeifer
- Department of Emergency Medicine, Franz Tappeiner Hospital of Merano, Azienda Sanitaria Dell'Alto Adige, Merano, Bolzano, Italy
| | | | - Andrea Tenci
- Department of Emergency Medicine, Girolamo Fracastoro Hospital of San Bonifacio, Azienda Ospedaliera Scaligera, San Bonifacio, Verona, Italy
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Ntaios G, Perlepe K, Lambrou D, Sirimarco G, Strambo D, Eskandari A, Karagkiozi E, Vemmou A, Koroboki E, Manios E, Makaritsis K, Vemmos K, Michel P. Prevalence and Overlap of Potential Embolic Sources in Patients With Embolic Stroke of Undetermined Source. J Am Heart Assoc 2019; 8:e012858. [PMID: 31364451 PMCID: PMC6761628 DOI: 10.1161/jaha.119.012858] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background We aimed to assess the prevalence and degree of overlap of potential embolic sources (PES) in patients with embolic stroke of undetermined source (ESUS). Methods and Results In a pooled data set derived from 3 prospective stroke registries, patients were categorized in ≥1 groups according to the PES that was/were identified. We categorized PES as follows: atrial cardiopathy, atrial fibrillation diagnosed during follow‐up, arterial disease, left ventricular disease, cardiac valvular disease, patent foramen ovale, and cancer. In 800 patients with ESUS (43.1% women; median age, 67.0 years), 3 most prevalent PES were left ventricular disease, arterial disease, and atrial cardiopathy, which were present in 54.4%, 48.5%, and 45.0% of patients, respectively. Most patients (65.5%) had >1 PES, whereas only 29.7% and 4.8% of patients had a single or no PES, respectively. In 31.1% of patients, there were ≥3 PES present. On average, each patient had 2 PES (median, 2). During a median follow‐up of 3.7 years, stroke recurrence occurred in 101 (12.6%) of patients (23.3 recurrences per 100 patient‐years). In multivariate analysis, the risk of stroke recurrence was higher in the atrial fibrillation group compared with other PES, but not statistically different between patients with 0 to 1, 2, or ≥3 PES. Conclusions There is major overlap of PES in patients with ESUS. This may possibly explain the negative results of the recent large randomized controlled trials of secondary prevention in patients with ESUS and offer a rationale for a randomized controlled trial of combination of anticoagulation and aspirin for the prevention of stroke recurrence in patients with ESUS. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02766205.
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Affiliation(s)
- George Ntaios
- Department of Internal Medicine School of Medicine Larissa University Hospital University of Thessaly Larissa Greece
| | - Kalliopi Perlepe
- Department of Internal Medicine School of Medicine Larissa University Hospital University of Thessaly Larissa Greece
| | - Dimitrios Lambrou
- Department of Internal Medicine School of Medicine Larissa University Hospital University of Thessaly Larissa Greece
| | - Gaia Sirimarco
- Stroke Center and Neurology Service Department of Clinical Neurosciences Centre Hospitalier Universitaire Vaudois and University of Lausanne Switzerland
| | - Davide Strambo
- Stroke Center and Neurology Service Department of Clinical Neurosciences Centre Hospitalier Universitaire Vaudois and University of Lausanne Switzerland
| | - Ashraf Eskandari
- Stroke Center and Neurology Service Department of Clinical Neurosciences Centre Hospitalier Universitaire Vaudois and University of Lausanne Switzerland
| | - Efstathia Karagkiozi
- Department of Internal Medicine School of Medicine Larissa University Hospital University of Thessaly Larissa Greece
| | - Anastasia Vemmou
- Department of Clinical Therapeutics Medical School of Athens Alexandra Hospital Athens Greece
| | - Eleni Koroboki
- Department of Clinical Therapeutics Medical School of Athens Alexandra Hospital Athens Greece
| | - Efstathios Manios
- Department of Clinical Therapeutics Medical School of Athens Alexandra Hospital Athens Greece
| | - Konstantinos Makaritsis
- Department of Internal Medicine School of Medicine Larissa University Hospital University of Thessaly Larissa Greece
| | - Konstantinos Vemmos
- Department of Clinical Therapeutics Medical School of Athens Alexandra Hospital Athens Greece
| | - Patrik Michel
- Stroke Center and Neurology Service Department of Clinical Neurosciences Centre Hospitalier Universitaire Vaudois and University of Lausanne Switzerland
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Vedin T, Karlsson M, Edelhamre M, Clausen L, Svensson S, Bergenheim M, Larsson PA. A proposed amendment to the current guidelines for mild traumatic brain injury: reducing computerized tomographies while maintaining safety. Eur J Trauma Emerg Surg 2019; 47:1451-1459. [PMID: 31089789 PMCID: PMC8476398 DOI: 10.1007/s00068-019-01145-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 04/29/2019] [Indexed: 12/21/2022]
Abstract
PURPOSE Head trauma is a common complaint in emergency departments. Identifying patients with serious injuries can be difficult and generates many computerized tomographies. Reducing the number of computerized tomographies decreases both cost and radiation exposure. The aim of this study was to evaluate whether the current Scandinavian Neurotrauma Committee guidelines could be revised in such a way that would enable hospitals to perform fewer computerized tomographies while maintaining the ability to identify all patients requiring neurological intervention. METHODS A retrospective study of the medical records of adult patients suffering a traumatic brain injury was performed. A total of 1671 patients over a period of 365 days were included, and 25 parameters were extracted. Multitrauma patients managed with ATLS™ were excluded. The Scandinavian Neurotrauma Committee guidelines were amended with the previously derived "low-risk proposal" and applied retrospectively to the cohort. RESULTS Incidence of intracranial hemorrhage was 5.6% (93/1671). Application of the current Scandinavian Neurotrauma Committee guidelines would have resulted in 860 computerized tomographies and would have missed 11 intracranial hemorrhages. The proposed amendment with the low-risk proposal would have resulted in 748 CT scans and would have missed 19 intracranial hemorrhages (a relative reduction of 13%). None of the missed intracranial hemorrhages required neurological intervention. CONCLUSION For patients with mild and moderate traumatic brain injuries, application of the Scandinavian Neurotrauma Committee guidelines amended with the low-risk proposal may result in a significant reduction of computerized tomographies without missing any patients in need of neurological intervention.
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Affiliation(s)
- Tomas Vedin
- Clinical Sciences, Helsingborg, Lund University, Svartbrödragränden 3-5, 251 87, Helsingborg, Sweden.
| | - Mathias Karlsson
- Department of Clinical Chemistry, Center for Clinical Research, Centralsjukhuset, Karlstad, Sweden
| | - Marcus Edelhamre
- Clinical Sciences, Helsingborg, Lund University, Svartbrödragränden 3-5, 251 87, Helsingborg, Sweden
| | - Linus Clausen
- Clinical Sciences, Helsingborg, Lund University, Svartbrödragränden 3-5, 251 87, Helsingborg, Sweden
| | - Sebastian Svensson
- Clinical Sciences, Helsingborg, Lund University, Svartbrödragränden 3-5, 251 87, Helsingborg, Sweden
| | - Mikael Bergenheim
- Centralsjukhuset i Karlstad, Rosenborgsgatan 9, 652 30, Karlstad, Sweden
| | - Per-Anders Larsson
- Clinical Sciences, Helsingborg, Lund University, Svartbrödragränden 3-5, 251 87, Helsingborg, Sweden
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Bleeding risk assessment for stroke patients on antithrombotic therapy. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS 2019; 31:282-288. [PMID: 31005341 DOI: 10.1016/j.arteri.2019.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 01/04/2019] [Accepted: 01/27/2019] [Indexed: 11/21/2022]
Abstract
INTRODUCTION After an ischemic cerebrovascular event the risk of new ischemic events is high, therefore antithrombotic therapy are indicated to prevent stroke recurrence. DISCUSSION Despite its clear benefit, these therapies increase the risk of bleeding. Therefore, it is essential to identify high hemorrhagic risk patients. There are different predictive models of hemorrhage, in particular of intracranial hemorrhage, associated with the use of antiaggregants in patients who have presented an ischemic stroke or TIA, such as the CCSC, intracranial scales -B2LEED3S score or S2TOP-BLEED. However, though main international guidelines recommend the use of scales, in particular, the HAS-BLED score, to assess the risk of bleeding in anticoagulated patients, there is no specific recommendation in the case of the use of antiplatelet drugs. CONCLUSIONS In this review we present the main models currently available for the prediction of bleeding of antithrombotic therapy in patients who have had a stroke or TIA.
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Cerdá M, Cerezo-Manchado JJ, Johansson E, Martínez F, Fernández M, Varela A, Rodríguez S, Bosch F, Santamaría A. Facing real-life with direct oral anticoagulants in patients with nonvalvular atrial fibrillation: outcomes from the first observational and prospective study in a Spanish population. J Comp Eff Res 2019; 8:165-178. [DOI: 10.2217/cer-2018-0134] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Aim: To analyze the effectiveness and safety of direct oral anticoagulants (DOACs) in atrial fibrillation (AF) patients attended in clinical practice. Methods: Observational and prospective study of AF patients that started treatment with DOACs. Results: 1443 patients (age 77.2 ± 9.7 years, CHA2DS2-VASc = 4.1 ± 1.5) were included. 46.0% were taking rivaroxaban, 24.4% dabigatran, 22.5% apixaban and 7.1% edoxaban. Patients taking dabigatran were younger, had lower CHA2DS2-VASc and lesser renal insufficiency. Patients taking apixaban had higher CHA2DS2-VASc and more renal insufficiency. Rates of stroke/major bleeding/intracranial bleeding were 0.7/1.3/0.2 events/100 patient-years, respectively. Conclusion: This was the first prospective study that analyzed the use of all DOACs in AF patients in Spain, showing a good profile in terms of safety and effectiveness in accordance with pivotal studies.
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Affiliation(s)
- María Cerdá
- Servicio de Hematología, Hospital Vall d'Hebron, Barcelona, Spain
| | | | - Erik Johansson
- Servicio de Hematología, Hospital Vall d'Hebron, Barcelona, Spain
| | | | | | - Ana Varela
- Servicio de Hematología, Hospital Vall d'Hebron, Barcelona, Spain
| | - Saray Rodríguez
- Servicio de Hematología, Hospital Vall d'Hebron, Barcelona, Spain
| | - Francesc Bosch
- Servicio de Hematología, Hospital Vall d'Hebron, Barcelona, Spain
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Chizhova OY, Belousova LN, Bakulin IG. Risk Controlling of Gastrointestinal Bleeding in Comorbid Patients with Cardiovascular Diseases. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2018. [DOI: 10.20996/1819-6446-2018-14-4-583-590] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The issues of prevention of thromboembolic complications (TE) in the management of patients with atrial fibrillation (AF) are of leading importance. Recently, non-vitamin K antagonist oral anticoagulants (NOACs), previously known as new oral anticoagulants are used in the treatment and prevention of TE in patients with AF. A lot of data has been accumulated, in which the NOACs indications have been revised. As a result, the updating has been done in the Recommendations of European Society of Cardiology (2016), the project of Russian Society of Cardiology Guidelines (2017), as well as in the new Recommendations of the European Heart Rhythm Association (2018). At the same time, the issues of prevention ща hemorrhagic complications, especially gastrointestinal bleeding, remain unresolved. Currently, there are no clinical guidelines on the use of NOACs from the standpoint of prevention of gastrointestinal bleeding, as well as definition of the risk of gastrointestinal bleeding in the treatment of NOACs. The authors analyze the recommended algorithms for the evaluation of the risk of gastrointestinal bleeding in NOACs using.
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Ioannou A, Tsappa I, Metaxa S, Missouris CG. Non-valvular atrial fibrillation: impact of apixaban on patient outcomes. PATIENT-RELATED OUTCOME MEASURES 2017; 8:121-131. [PMID: 29138609 PMCID: PMC5680948 DOI: 10.2147/prom.s117549] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Atrial fibrillation is the most common arrhythmia worldwide, and carries a significantly increased risk of thromboembolic stroke. Initially, vitamin K antagonists were used as stroke prophylaxis; but more recently, a group of drugs known as novel oral anticoagulants have been developed. Apixaban belongs to this group of drugs, and is a factor Xa inhibitor that has emerged as a popular pharmacological agent worldwide. In this review, we will provide an overview of the pivotal trials in the development of apixaban, while also critically evaluating the new emerging real-world data, and discussing the effectiveness, safety, economic viability and future prospects of apixaban and how it impacts on patient outcomes in those with non-valvular atrial fibrillation.
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Affiliation(s)
- Adam Ioannou
- Cardiology Department, Royal Free NHS Foundation Trust, London, UK
| | - Irene Tsappa
- Cardiology Department, Medical School, University of Cyprus, Nicosia, Cyprus
| | - Sofia Metaxa
- Cardiology Department, Frimley Health NHS Foundation Trust, London, UK
| | - Constantinos G Missouris
- Cardiology Department, Medical School, University of Cyprus, Nicosia, Cyprus.,Cardiology Department, Frimley Health NHS Foundation Trust, London, UK
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