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Buchner L, Park EJ, Bendz P, Englert A, von der Groeben C, Vo L, Schmitt E, Zacharowski K, Börm P, Stauber D, Bingold T, Booke M, Gerth M, Greim C, Mersmann J, Muellenbach RM, Mutlak H, Ott B, Pape A, Sander M, Teßmann R, Welte M, Wermelt J, Wulf H, Choorapoikayil S, Füllenbach C, Meybohm P. Evaluation of a Clinical Decision Support System for the most evidence-based approach to managing perioperative anticoagulation. J Clin Anesth 2022; 80:110877. [DOI: 10.1016/j.jclinane.2022.110877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 03/29/2022] [Accepted: 04/28/2022] [Indexed: 11/18/2022]
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Huang HK, Liu PPS, Hsu JY, Lin SM, Peng CCH, Wang JH, Loh CH. Fracture risks among patients with atrial fibrillation receiving different oral anticoagulants: a real-world nationwide cohort study. Eur Heart J 2021; 41:1100-1108. [PMID: 32006423 DOI: 10.1093/eurheartj/ehz952] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 10/17/2019] [Accepted: 12/24/2019] [Indexed: 02/06/2023] Open
Abstract
AIMS To evaluate the fracture risk among patients with atrial fibrillation (AF) treated with non-vitamin K antagonist oral anticoagulants (NOACs) or warfarin. METHODS AND RESULTS We conducted a real-world nationwide retrospective cohort study using Taiwan's National Health Insurance Research Database. All adult patients in Taiwan newly diagnosed with AF between 2012 and 2016 who received NOACs or warfarin were enrolled and followed up until 2017. Patients treated with NOACs were sub-grouped according to the NOAC used (dabigatran, rivaroxaban, and apixaban). Propensity score matching was performed for each head-to-head comparison. Cox regression analysis, with a shared frailty model, was used to calculate the adjusted hazard ratios (aHRs) for hip, vertebral, and humerus/forearm/wrist fractures. After matching, 19 414 patients were included (9707 in each NOAC and warfarin groups). The median follow-up time was 2.4 years. Compared with warfarin, NOACs were associated with a reduced fracture risk [aHR = 0.84, 95% confidence interval (CI) = 0.77-0.93; P < 0.001]. Sub-analyses revealed that each NOAC, namely dabigatran (aHR = 0.88, 95% CI = 0.78-0.99; P = 0.027), rivaroxaban (aHR = 0.81, 95% CI = 0.72-0.90; P < 0.001), and apixaban (aHR = 0.67, 95% CI = 0.52-0.87; P = 0.003), had a reduced fracture risk. Analyses including all eligible patients, without propensity score matching, generated similar results. CONCLUSION Compared with warfarin, NOAC was associated with a reduced fracture risk among AF patients. Therefore, if oral anticoagulants are indicated, NOACs rather than warfarin should be considered to lower the risk of fractures. However, further studies are needed to investigate the underlying mechanisms and elucidate causality.
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Affiliation(s)
- Huei-Kai Huang
- Department of Family Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 707, Sec. 3, Zhongyang Rd., Hualien 97002, Taiwan.,School of Medicine, Tzu Chi University, No. 701, Sec. 3, Zhongyang Rd., Hualien 97004, Taiwan.,Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 707, Sec. 3, Zhongyang Rd., Hualien 97002, Taiwan
| | - Peter Pin-Sung Liu
- Center for Aging and Health, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 707, Sec. 3, Zhongyang Rd., Hualien 97002, Taiwan
| | - Jin-Yi Hsu
- School of Medicine, Tzu Chi University, No. 701, Sec. 3, Zhongyang Rd., Hualien 97004, Taiwan.,Center for Aging and Health, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 707, Sec. 3, Zhongyang Rd., Hualien 97002, Taiwan
| | - Shu-Man Lin
- School of Medicine, Tzu Chi University, No. 701, Sec. 3, Zhongyang Rd., Hualien 97004, Taiwan.,Department of Physical Medicine and Rehabilitation, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 707, Sec. 3, Zhongyang Rd., Hualien 97002, Taiwan
| | - Carol Chiung-Hui Peng
- Department of Internal Medicine, University of Maryland Medical Center Midtown Campus, 827 Linden Ave, Baltimore, MD 21201, USA
| | - Jen-Hung Wang
- Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 707, Sec. 3, Zhongyang Rd., Hualien 97002, Taiwan
| | - Ching-Hui Loh
- School of Medicine, Tzu Chi University, No. 701, Sec. 3, Zhongyang Rd., Hualien 97004, Taiwan.,Center for Aging and Health, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 707, Sec. 3, Zhongyang Rd., Hualien 97002, Taiwan
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Galhardo C, Yamauchi LHI, Dantas H, Guerra JCDC. Clinical protocols for oral anticoagulant reversal during high risk of bleeding for emergency surgical and nonsurgical settings: a narrative review. Braz J Anesthesiol 2021; 71:429-442. [PMID: 33887335 PMCID: PMC9373671 DOI: 10.1016/j.bjane.2021.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 02/23/2021] [Accepted: 03/13/2021] [Indexed: 11/29/2022] Open
Abstract
Background and objectives Oral anticoagulants prevent thromboembolic events but expose patients to a significant risk of bleeding due to the treatment itself, after trauma, or during surgery. Any physician working in the emergency department or involved in the perioperative care of a patient should be aware of the best reversal approach according to the type of drug and the patient’s clinical condition. This paper presents a concise review and proposes clinical protocols for the reversal of oral anticoagulants in emergency settings, such as bleeding or surgery. Contents The authors searched for relevant studies in PubMed, LILACS, and the Cochrane Library database and identified 82 articles published up to September 2020 to generate a review and algorithms as clinical protocols for practical use. Hemodynamic status and the implementation of general supportive measures should be the first approach under emergency conditions. The drug type, dose, time of last intake, and laboratory evaluations of anticoagulant activity and renal function provide an estimation of drug clearance and should be taken into consideration. The reversal agents for vitamin K antagonists are 4-factor prothrombin complex concentrate and vitamin K, followed by fresh frozen plasma as a second-line treatment. Direct oral anticoagulants have specific reversal agents, such as andexanet alfa and idarucizumab, but are not widely available. Another possibility in this situation, but with less evidence, is prothrombin complex concentrates. Conclusion The present algorithms propose a tool to help healthcare providers in the best decision making for patients under emergency conditions.
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Affiliation(s)
- Carlos Galhardo
- Hospital São Lucas Copacabana, Departamento de Anestesia, Rio de Janeiro, RJ, Brazil; Instituto Nacional de Cardiologia, Rio de Janeiro, RJ, Brazil.
| | | | - Hugo Dantas
- Clínica de Anestesiologia, Departamento de Anestesia, Salvador, BA, Brazil
| | - João Carlos de Campos Guerra
- Hospital Israelita Albert Einstein, Centro de Oncologia e Hematologia, Setor de Hematologia e Coagulação, Departamento de Patologia Clínica, São Paulo, SP, Brazil
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Huang HK, Peng CCH, Lin SM, Munir KM, Chang RHE, Wu BBC, Liu PPS, Hsu JY, Loh CH, Tu YK. Fracture Risks in Patients Treated With Different Oral Anticoagulants: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2021; 10:e019618. [PMID: 33759542 PMCID: PMC8174313 DOI: 10.1161/jaha.120.019618] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Evidence on the differences in fracture risk associated with non-vitamin K antagonist oral anticoagulants (NOAC) and warfarin is inconsistent and inconclusive. We conducted a systematic review and meta-analysis to assess the fracture risk associated with NOACs and warfarin. Methods and Results We searched PubMed, Embase, Cochrane Library, Scopus, Web of Science, and ClinicalTrials.gov from inception until May 19, 2020. We included studies presenting measurements (regardless of primary/secondary/tertiary/safety outcomes) for any fracture in both NOAC and warfarin users. Two or more reviewers independently screened relevant articles, extracted data, and performed quality assessments. Data were retrieved to synthesize the pooled relative risk (RR) of fractures associated with NOACs versus warfarin. Random-effects models were used for data synthesis. We included 29 studies (5 cohort studies and 24 randomized controlled trials) with 388 209 patients. Patients treated with NOACs had lower risks of fracture than those treated with warfarin (pooled RR, 0.84; 95% CI, 0.77-0.91; P<0.001) with low heterogeneity (I2=38.9%). NOACs were also associated with significantly lower risks of hip fracture than warfarin (pooled RR, 0.89; 95% CI, 0.81-0.98; P=0.023). A nonsignificant trend of lower vertebral fracture risk in NOAC users was also observed (pooled RR, 0.74; 95% CI, 0.54-1.01; P=0.061). Subgroup analyses for individual NOACs demonstrated that dabigatran, rivaroxaban, and apixaban were significantly associated with lower fracture risks. Furthermore, the data synthesis results from randomized controlled trials and real-world cohort studies were quite consistent, indicating the robustness of our findings. Conclusions Compared with warfarin, NOACs are associated with lower risks of bone fracture.
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Affiliation(s)
- Huei-Kai Huang
- Institute of Epidemiology and Preventive Medicine College of Public Health National Taiwan University Taipei Taiwan.,Departments of Family Medicine and Medical Research Hualien Tzu Chi HospitalBuddhist Tzu Chi Medical Foundation Hualien Taiwan
| | - Carol Chiung-Hui Peng
- Department of Internal Medicine University of Maryland Medical Center Midtown Campus Baltimore MD
| | - Shu-Man Lin
- Department of Physical Medicine and Rehabilitation Hualien Tzu Chi HospitalBuddhist Tzu Chi Medical Foundation Hualien Taiwan.,School of Medicine Tzu Chi University Hualien Taiwan
| | - Kashif M Munir
- Division of Endocrinology, Diabetes and Nutrition University of Maryland School of Medicine Baltimore MD
| | | | - Brian Bo-Chang Wu
- School of Medicine College of Medicine Fu-Jen Catholic University New Taipei City Taiwan
| | - Peter Pin-Sung Liu
- Center for Aging and Health Hualien Tzu Chi HospitalBuddhist Tzu Chi Medical Foundation Hualien Taiwan
| | - Jin-Yi Hsu
- School of Medicine Tzu Chi University Hualien Taiwan.,Center for Aging and Health Hualien Tzu Chi HospitalBuddhist Tzu Chi Medical Foundation Hualien Taiwan
| | - Ching-Hui Loh
- School of Medicine Tzu Chi University Hualien Taiwan.,Center for Aging and Health Hualien Tzu Chi HospitalBuddhist Tzu Chi Medical Foundation Hualien Taiwan
| | - Yu-Kang Tu
- Institute of Epidemiology and Preventive Medicine College of Public Health National Taiwan University Taipei Taiwan.,Department of Dentistry National Taiwan University Hospital and School of DentistryNational Taiwan University Taipei Taiwan.,Research Center of Big Data and Meta-analysis Wan Fang HospitalTaipei Medical University Taipei Taiwan
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Pose R, Langer F, Tennstedt P, Graefen M, Isbarn H. Management of Patients Receiving Direct Oral Anticoagulants Scheduled for Radical Prostatectomy: An Update of a Prospective Assessment. Eur Urol Focus 2021; 8:128-133. [PMID: 33518509 DOI: 10.1016/j.euf.2021.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/26/2020] [Accepted: 01/11/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND In the perioperative setting, temporary interruption of direct oral anticoagulants (DOACs) is mandatory. However, the safety of these recommendations is largely based on nonurological surgical experiences. OBJECTIVE To verify the safety of these recommendations in patients undergoing radical prostatectomy (RP). DESIGN, SETTING, AND PARTICIPANTS A total of 5317 patients underwent RP in our tertiary care centre between December 2017 and February 2020. Of them, 107 consecutive patients had DOACs in standard preoperative medication. DOAC intake was stopped 2-3 d before RP. Postoperatively, patients received weight- and risk-adapted low-molecular-weight heparin (LMWH). DOAC intake was restarted, and administration of LMWH was stopped the 3rd day after surgery. For comparison, we performed 1:2 propensity-score matching (DOAC:non-DOAC), which resulted in 321 consecutive patients. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Perioperative outcomes and 30-d morbidity were compared between both cohorts. The Wilcoxon rank sum test and the Pearson's chi-square test were used. RESULTS AND LIMITATIONS The median age of patients with DOACs was 68 yr. Sixty-six patients (61.7%) stopped DOAC intake 48 h and 41 patients (38.3%) 72 h before RP. In comparison with the matching cohort, the median blood loss during RP, median duration of surgery, and median duration of hospitalisation did not differ in a statistically significant fashion. Similarly, there was no significant difference in 30-d morbidity between groups. Importantly, the rate of bleeding and thromboembolic complications did likewise not differ significantly, though it is a nonrandomised and retrospective study. CONCLUSIONS Standardised perioperative management of DOACs is important to minimise bleeding and thromboembolic complications. RP can be performed with a low perioperative complication risk if patients are adherent to our presented algorithm. PATIENT SUMMARY We looked at peri- and postoperative complications and compared direct oral anticoagulant (DOAC) and non-DOAC patients. We found no significant difference in thromboembolic and bleeding complications between the groups. We conclude that our regime is safe.
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Affiliation(s)
- Randi Pose
- Martini-Klinik Prostate Cancer Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
| | - Florian Langer
- Department of Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Pierre Tennstedt
- Martini-Klinik Prostate Cancer Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Markus Graefen
- Martini-Klinik Prostate Cancer Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Hendrik Isbarn
- Martini-Klinik Prostate Cancer Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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Rahi MS, Jindal V, Reyes SP, Gunasekaran K, Gupta R, Jaiyesimi I. Hematologic disorders associated with COVID-19: a review. Ann Hematol 2021; 100:309-320. [PMID: 33415422 PMCID: PMC7789889 DOI: 10.1007/s00277-020-04366-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 11/30/2020] [Indexed: 01/08/2023]
Abstract
Coronavirus disease 2019 is caused by severe acute respiratory syndrome coronavirus 2. Primarily an infection of the lower respiratory tract, it is now well known to cause multisystem abnormalities. Hematologic manifestations constitute a significant area of concern. Severe acute respiratory syndrome coronavirus 2 infects monocytes and endothelial cells leading to a complex downstream cascade, cytokine storm, and eventual intravascular thrombosis. Coronavirus disease 2019 causes lymphopenia, neutrophilia, and thrombocytopenia. Prophylactic anticoagulation is vital in patients with coronavirus disease 2019, as its effect on the coagulation system is associated with significant morbidity and mortality. The disease can cause both arterial and venous thromboses, especially pulmonary embolism and pulmonary microthrombi. A high index of suspicion is indispensable in recognizing these complications, and timely institution of therapeutic anticoagulation is vital in treating them. Virus-induced disseminated intravascular coagulation is uncommon but shares some similarities to sepsis-induced disseminated intravascular coagulation. Marked elevations in hematologic biomarkers such as lactate dehydrogenase, D-dimer, ferritin, and C-reactive protein are associated with worse outcomes. Understanding the pathophysiology and recognizing factors associated with poor prognosis are crucial in improving patient outcomes with coronavirus disease 2019.
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Affiliation(s)
- Mandeep Singh Rahi
- Division of Pulmonary Diseases and Critical Care Medicine, Yale-New Haven Health Bridgeport Hospital, 267 Grant Street, Bridgeport, CT, 06610, USA.
| | - Vishal Jindal
- Division of Hematology and Oncology, William Beaumont Hospital, Oakland University, Royal Oak, MI, USA
| | - Sandra-Patrucco Reyes
- Department of Internal Medicine, Yale-New Haven Health Bridgeport Hospital, Bridgeport, CT, USA
| | - Kulothungan Gunasekaran
- Division of Pulmonary Diseases and Critical Care Medicine, Yale-New Haven Health Bridgeport Hospital, 267 Grant Street, Bridgeport, CT, 06610, USA
| | - Ruby Gupta
- Division of Hematology and Oncology, William Beaumont Hospital, Oakland University, Royal Oak, MI, USA
| | - Ishmael Jaiyesimi
- Division of Hematology and Oncology, William Beaumont Hospital, Oakland University, Royal Oak, MI, USA
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Gunasekaran K, Rajasurya V, Devasahayam J, Singh Rahi M, Chandran A, Elango K, Talari G. A Review of the Incidence Diagnosis and Treatment of Spontaneous Hemorrhage in Patients Treated with Direct Oral Anticoagulants. J Clin Med 2020; 9:jcm9092984. [PMID: 32942757 PMCID: PMC7563837 DOI: 10.3390/jcm9092984] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/08/2020] [Accepted: 09/11/2020] [Indexed: 12/25/2022] Open
Abstract
Anticoagulation carries a tremendous therapeutic advantage in reducing morbidity and mortality with venous thromboembolism and atrial fibrillation. For over six decades, traditional anticoagulants like low molecular weight heparin and vitamin K antagonists like warfarin have been used to achieve therapeutic anticoagulation. In the past decade, multiple new direct oral anticoagulants have emerged and been approved for clinical use. Since their introduction, direct oral anticoagulants have changed the landscape of anticoagulants. With increasing indications and use in various patients, they have become the mainstay of treatment in venous thromboembolic diseases. The safety profile of direct oral anticoagulants is better or at least similar to warfarin, but several recent reports are focusing on spontaneous hemorrhages with direct oral anticoagulants. This narrative review aims to summarize the incidence of spontaneous hemorrhage in patients treated with direct oral anticoagulants and also offers practical management strategies for clinicians when patients receiving direct oral anticoagulants present with bleeding complications.
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Affiliation(s)
- Kulothungan Gunasekaran
- Division of Pulmonary Diseases and Critical Care, Yale-New Haven Health Bridgeport Hospital, Bridgeport, CT 06610, USA;
- Correspondence: ; Tel.: +203-384-5009; Fax: 203-330-7498
| | - Venkat Rajasurya
- Division of Pulmonary Diseases and Critical Care, Multi-Care Pulmonary Specialists, Puyallup, WA 98372, USA;
| | - Joe Devasahayam
- Division of Pulmonary Diseases and Critical Care, Avera Medical Group, Sioux Falls, SD 57105, USA;
| | - Mandeep Singh Rahi
- Division of Pulmonary Diseases and Critical Care, Yale-New Haven Health Bridgeport Hospital, Bridgeport, CT 06610, USA;
| | - Arul Chandran
- Division of Pulmonary Diseases and Critical Care, Hurley Medical Center, Flint, MI 48532, USA;
| | - Kalaimani Elango
- Division of Cardiology, University of Nevada, Las Vegas, NV 89154, USA;
| | - Goutham Talari
- Division of Hospital Medicine, Henry Ford Hospital, Detroit, MI 48202, USA;
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Peled H, Dau NQ, Lau H. Response to Dr. Mahan Regarding Key Points to Consider When Evaluating Andexxa for Formulary Addition. Neurocrit Care 2020; 33:327-329. [DOI: 10.1007/s12028-020-01007-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Talari G, Demertzis ZD, Summey RD, Gill B, Kaatz S. Perioperative management of anticoagulation. Hosp Pract (1995) 2020; 48:231-240. [PMID: 32627607 DOI: 10.1080/21548331.2020.1792138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Periprocedural management of the anticoagulated patient can be as easy as continuing warfarin for a low bleeding risk procedure, holding a direct oral anticoagulant for 1 day prior and resuming 1 day later or as complex as emergent reversal with prothrombin complex concentrate, idarucizumab, or andexanet alfa. Patient-specific factors for thromboembolic risk and procedural bleeding risk determine timing of anticoagulation hold prior to and resumption after invasive procedures. Clinical trials and management studies in recent years have helped inform our approach to these patients, but much of the guidance is still based on expert consensus.
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Affiliation(s)
- Goutham Talari
- Division of Hospital Medicine, Henry Ford Hospital , Detroit, Michigan, USA
| | - Zachary D Demertzis
- Department of Internal Medicine, Henry Ford Hospital , Detroit, Michigan, USA
| | - Robert D Summey
- Division of Hospital Medicine, Henry Ford Hospital , Detroit, Michigan, USA
| | - Baljinder Gill
- Division of Hospital Medicine, Henry Ford Hospital , Detroit, Michigan, USA
| | - Scott Kaatz
- Division of Hospital Medicine, Henry Ford Hospital , Detroit, Michigan, USA
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Dager WE, Ansell J, Barnes GD, Burnett A, Deitelzweig S, Minichiello T, Triller D, Kaatz S. "Reduce the Likelihood of Patient Harm Associated with the Use of Anticoagulant Therapy": Commentary from the Anticoagulation Forum on the Updated Joint Commission NPSG.03.05.01 Elements of Performance. Jt Comm J Qual Patient Saf 2020; 46:173-180. [PMID: 32005512 DOI: 10.1016/j.jcjq.2019.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 11/26/2019] [Accepted: 12/04/2019] [Indexed: 12/18/2022]
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Piran S, Khatib R, Schulman S, Majeed A, Holbrook A, Witt DM, Wiercioch W, Schünemann HJ, Nieuwlaat R. Management of direct factor Xa inhibitor-related major bleeding with prothrombin complex concentrate: a meta-analysis. Blood Adv 2019; 3:158-67. [PMID: 30658963 DOI: 10.1182/bloodadvances.2018024133] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 11/03/2018] [Indexed: 01/12/2023] Open
Abstract
A targeted antidote for reversal of direct factor Xa (FXa) inhibitors is now available for clinical use in the United States, but it is costly and has limited availability. In a systematic review, we evaluated the safety and effectiveness of 4-factor prothrombin complex concentrate (4F-PCC) as an alternative for managing direct FXa inhibitor-related major bleeding. A systematic literature search was conducted using Medline, Embase, and the Cochrane Register of Controlled Trials up to September 2018. No comparative studies were found. Ten case series with 340 patients who received PCC for direct FXa inhibitor-related major bleeding were included. The pooled proportion of patients with effective management of major bleeding was 0.69 (95% confidence interval [CI], 0.61-0.76) in 2 studies using the International Society on Thrombosis and Haemostasis (ISTH) criteria and 0.77 (95% CI, 0.63-0.92) in 8 studies that did not use the ISTH criteria; all-cause mortality was 0.16 (95% CI, 0.07-0.26), and thromboembolism rate was 0.04 (95% CI, 0.01-0.08). On the basis of evidence with very low certainty from single-arm case series, it is difficult to determine whether 4F-PCC in addition to cessation of direct oral FXa inhibitor is more effective than cessation of direct oral FXa inhibitor alone in patients with direct FXa inhibitor-related major bleeding.
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Rubino RT, Dawson DR, Kryscio RJ, Al-Sabbagh M, Miller CS. Postoperative bleeding associated with antiplatelet and anticoagulant drugs: A retrospective study. Oral Surg Oral Med Oral Pathol Oral Radiol 2019; 128:243-249. [DOI: 10.1016/j.oooo.2019.04.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/21/2019] [Accepted: 04/08/2019] [Indexed: 12/22/2022]
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Gibler WB, Racadio JM, Hirsch AL, Roat TW. Management of Severe Bleeding in Patients Treated With Oral Anticoagulants: Proceedings Monograph From the Emergency Medicine Cardiac Research and Education Group-International Multidisciplinary Severe Bleeding Consensus Panel October 20, 2018. Crit Pathw Cardiol 2019; 18:143-166. [PMID: 31348075 DOI: 10.1097/hpc.0000000000000181] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
In this Emergency Medicine Cardiac Research and Education Group (EMCREG)-International Proceedings Monograph from the October 20, 2018, EMCREG-International Multidisciplinary Consensus Panel on Management of Severe Bleeding in Patients Treated With Oral Anticoagulants held in Orlando, FL, you will find a detailed discussion regarding the treatment of patients requiring anticoagulation and the reversal of anticoagulation for patients with severe bleeding. For emergency physicians, critical care physicians, hospitalists, cardiologists, internists, surgeons, and family physicians, the current approach and disease indications for treatment with anticoagulants such as coumadin, factor IIa, and factor Xa inhibitors are particularly relevant. When a patient treated with anticoagulants presents to the emergency department, intensive care unit, or operating room with severe, uncontrollable bleeding, achieving rapid, controlled hemostasis is critically important to save the patient's life. This EMCREG-International Proceedings Monograph contains multiple sections reflecting critical input from experts in Emergency Cardiovascular Care, Prehospital Emergency Medical Services, Emergency Medicine Operations, Hematology, Hospital Medicine, Neurocritical Care, Cardiovascular Critical Care, Cardiac Electrophysiology, Cardiology, Trauma and Acute Care Surgery, and Pharmacy. The first section provides a description of the current indications for the treatment of patients using oral anticoagulants including coumadin, the factor IIa (thrombin) inhibitor dabigatran, and factor Xa inhibitors such as apixaban and rivaroxaban. In the remaining sections, the treatment of patients presenting to the hospital with major bleeding becomes the focus. The replacement of blood components including red blood cells, platelets, and clotting factors is the critically important initial treatment for these individuals. Reversing the anticoagulated state is also necessary. For patients treated with coumadin, infusion of vitamin K helps to initiate the process of protein synthesis for the vitamin K-dependent coagulation proteins II, VII, IX, and X and the antithrombotic protein C and protein S. Repletion of clotting factors for the patient with 4-factor prothrombin complex concentrate, which includes factors II (prothrombin), VII, IX, and X and therapeutically effective concentrations of the regulatory proteins (protein C and S), provides real-time ability to slow bleeding. For patients treated with the thrombin inhibitor dabigatran, treatment using the highly specific, antibody-derived idarucizumab has been demonstrated to reverse the hypocoagulable state of the patient to allow blood clotting. In May 2018, andexanet alfa was approved by the US Food and Drug Administration to reverse the factor Xa anticoagulants apixaban and rivaroxaban in patients with major bleeding. Before the availability of this highly specific agent, therapy for patients treated with factor Xa inhibitors presenting with severe bleeding usually included replacement of lost blood components including red blood cells, platelets, and clotting factors and 4-factor prothrombin complex concentrate, or if not available, fresh frozen plasma. The evaluation and treatment of the patient with severe bleeding as a complication of oral anticoagulant therapy are discussed from the viewpoint of the emergency physician, neurocritical and cardiovascular critical care intensivist, hematologist, trauma and acute care surgeon, hospitalist, cardiologist, electrophysiologist, and pharmacist in an approach we hope that the reader will find extremely practical and clinically useful. The clinician learner will also find the discussion of the resumption of oral anticoagulation for the patient with severe bleeding after effective treatment important because returning the patient to an anticoagulated state as soon as feasible and safe prevents thrombotic complications. Finally, an EMCREG-International Severe Bleeding Consensus Panel algorithm for the approach to management of patients with life-threatening oral anticoagulant-associated bleeding is provided for the clinician and can be expanded in size for use in a treatment area such as the emergency department or critical care unit.
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Piegeler T, Stehr SN, Pfirrmann D, Knödler M, Lordick F, Mehnert A, Selig L, Weimann A, Mehdorn M, Gockel I, Simon P. [Special situations of preconditioning and prehabilitation in oncological visceral surgery]. Chirurg 2019; 89:903-908. [PMID: 30377726 DOI: 10.1007/s00104-018-0708-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Prehabilitation prior to complex visceral oncological surgery is playing an increasingly important role. OBJECTIVE The aim of this review article is to present special situations of preconditioning in visceral oncological patient cohorts. The following conditions were defined as special situations with subsequently increased risk profile: cardiopulmonary comorbidities, geriatric patients, neoadjuvant therapy and simultaneous fatigue. MATERIAL AND METHODS A selective literature review based on a search in the electronic databases MEDLINE, PubMed, Cochrane Library and the International Standard Randomization Controlled Trial Number (ISRCTN) was performed. RESULTS The identification of high-risk patients is an essential part of the preoperative evaluation conducted by the anesthesiologist prior to surgery. The cardiovascular and the pulmonary risk profile are determined by means of prediction indices evaluating patient-specific and surgery-related risk factors. The increased use of new oral anticoagulants and dual platelet aggregation inhibition requires individualized treatment strategies. Numerous studies have shown clinically relevant effects of exercise therapy interventions throughout all phases of oncological treatment. In addition to positive effects on therapy-associated side effects, sport can also counteract the effects of sedentary behavior in cancer patients and improve the health-related quality of life. The effectiveness of sport and exercise therapies as well as psychological interventions in oncological patients with fatigue (CRF) is broad, with important components being motivation and compliance. DISCUSSION In high-risk patients an interdisciplinary approach to planning and conduction of prehabilitation is essential for the early detection and optimization of perioperative risk factors and potential complications. The aim is faster recovery, reduced morbidity and mortality and the possibility to improve long-term survival and quality of life.
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Affiliation(s)
- T Piegeler
- Klinik und Poliklinik für Anästhesiologie und Intensivmedizin (KAI), Universitätsklinikum Leipzig, AöR, Leipzig, Deutschland
| | - S N Stehr
- Klinik und Poliklinik für Anästhesiologie und Intensivmedizin (KAI), Universitätsklinikum Leipzig, AöR, Leipzig, Deutschland
| | - D Pfirrmann
- Abteilung Sportmedizin, Prävention und Rehabilitation am Institut für Sportwissenschaft, Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - M Knödler
- Universitäres Krebszentrum Leipzig (UCCL), Universitätsklinikum Leipzig, AöR, Leipzig, Deutschland
| | - F Lordick
- Universitäres Krebszentrum Leipzig (UCCL), Universitätsklinikum Leipzig, AöR, Leipzig, Deutschland
| | - A Mehnert
- Abteilung für Medizinische Psychologie und Medizinische Soziologie, Sektion Psychosoziale Onkologie, Universitätsklinikum Leipzig, AöR, Leipzig, Deutschland
| | - L Selig
- Klinik und Poliklinik für Gastroenterologie und Rheumatologie; Ernährungsteam, Universitätsklinikum Leipzig, AöR, Leipzig, Deutschland
| | - A Weimann
- Klinik und Poliklinik für Allgemein‑, Viszeral- und Onkologische Chirurgie, Klinikum St. Georg gGmbH, Leipzig, Deutschland
| | - M Mehdorn
- Klinik und Poliklinik für Viszeral‑, Transplantations‑, Thorax‑ und Gefäßchirurgie, Universitätsklinikum Leipzig, AöR, Liebigstr. 20, 04103, Leipzig, Deutschland
| | - I Gockel
- Klinik und Poliklinik für Viszeral‑, Transplantations‑, Thorax‑ und Gefäßchirurgie, Universitätsklinikum Leipzig, AöR, Liebigstr. 20, 04103, Leipzig, Deutschland.
| | - P Simon
- Abteilung Sportmedizin, Prävention und Rehabilitation am Institut für Sportwissenschaft, Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
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Beckmann A, Spalteholz J, Langer F, Heinzer H, Budäus L, Tilki D, Michl U, Soave A, Steuber T, Veleva V, Salomon G, Haese A, Huland H, Graefen M, Isbarn H. Perioperative management of direct oral anticoagulants in patients undergoing radical prostatectomy: results of a prospective assessment. World J Urol 2019; 37:2657-2662. [DOI: 10.1007/s00345-019-02668-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 02/01/2019] [Indexed: 01/11/2023] Open
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Affiliation(s)
- Kalaimani Elango
- Internal Medicine, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Swetha Murthi
- Internal Medicine, Sinai Grace Hospital, Detroit, Michigan, USA
| | - Joe Devasahayam
- Pulmonary and Critical Care, Avera Health, Sioux Falls, South Dakota, USA
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17
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Affiliation(s)
- A'drianne Dorsey
- Department of Biochemistry and Molecular Biology, LSU Health Science Center, New Orleans, LA-70112
| | - Vijaya Satish Pilli
- Department of Biochemistry and Molecular Biology, LSU Health Science Center, New Orleans, LA-70112
| | - Howard Fried
- Department of Biochemistry and Molecular Biology, LSU Health Science Center, New Orleans, LA-70112
| | - Rinku Majumder
- Department of Biochemistry and Molecular Biology, LSU Health Science Center, New Orleans, LA-70112
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