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Lester W, Bent C, Alikhan R, Roberts L, Gordon-Walker T, Trenfield S, White R, Forde C, Arachchillage DJ. A British Society for Haematology guideline on the assessment and management of bleeding risk prior to invasive procedures. Br J Haematol 2024. [PMID: 38517351 DOI: 10.1111/bjh.19360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 02/12/2024] [Accepted: 02/13/2024] [Indexed: 03/23/2024]
Affiliation(s)
- Will Lester
- Department of Haematology, University Hospitals Birmingham, Birmingham, UK
| | - Clare Bent
- Department of Radiology, University Hospitals Dorset, Dorset, UK
| | - Raza Alikhan
- Department of Haematology, University Hospitals of Cardiff, Cardiff, UK
| | - Laura Roberts
- Department of Haematology, King College London, London, UK
| | - Tim Gordon-Walker
- Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Sarah Trenfield
- Department of Anaesthesia and Critical Care, Royal Brompton Hospital, London, UK
| | - Richard White
- Department of Radiology, Cardiff and Vale UHB, Cardiff, UK
| | - Colm Forde
- Department of Radiology, University Hospitals Birmingham, Birmingham, UK
| | - Deepa J Arachchillage
- Department of Immunology and Inflammation, Centre for Haematology, Imperial College London, London, UK
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
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Cohen AT, Creeper KJ, Alikhan R, Er C, Connors JM, Huisman MV, Munoz A, Vescovo G, Bauersachs R, Ageno W, Agnelli G, Becattini C. Early Time Courses of Recurrent Venous Thromboembolism and Bleeding during Apixaban or Dalteparin Therapy for Patients with Cancer. Thromb Haemost 2024. [PMID: 38196077 DOI: 10.1055/s-0043-1778642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
BACKGROUND In patients with acute venous thromboembolism (VTE), the rates of recurrence and major bleeding are highest during the first weeks of anticoagulation. The CARAVAGGIO trial demonstrated noninferiority of apixaban to dalteparin for treatment of cancer-associated VTE without an increased risk of major bleeding. We compared the early time course of VTE recurrence and major bleeding events of apixaban compared with dalteparin at 7, 30, and 90 days of treatment in patients with cancer-associated VTE. METHODS The study design of the CARAVAGGIO trial has been described. Eligible patients were randomly assigned to receive monotherapy with either apixaban or dalteparin for 6 months. The primary efficacy outcome was the incidence of objectively confirmed recurrent VTE. The primary safety outcome was major bleeding. RESULTS In 1,155 patients, recurrent VTE after 7, 30, and 90 days occurred in 6 (1%), 15 (2.6%), and 27 (4.7%) patients in the apixaban arm versus 5 (0.9%), 20 (3.5%), and 36 (6.2%) patients respectively in the dalteparin arm. By day 7, 30, and 90, major bleeding events had occurred in 3 (0.5%), 9 (1.6%), and 16 (2.8%) patients in the apixaban group versus 5 (0.9%), 11 (1.9%), and 17 (2.9%) patients in the dalteparin group. CONCLUSION The frequencies of recurrent VTE and major bleeding events at 7, 30, and 90 days of apixaban compared with dalteparin were similar in patients with cancer-associated VTE. This supports the use of apixaban for the initiation and early phase of anticoagulant therapy in cancer-associated VTE.
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Affiliation(s)
- Alexander T Cohen
- Department of Haemostasis and Thrombosis, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Katherine J Creeper
- Department of Haemostasis and Thrombosis, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- Haematology Department, Sir Charles Gairdner Hospital, Perth, Australia
- Haematology Department, PathWest Laboratory Medicine, Nedlands, Australia
| | - Raza Alikhan
- Haematology Department, University Hospital Wales, Cardiff, United Kingdom
| | - Chaozer Er
- Department of General Medicine, Woodlands Health, Singapore, Singapore
| | - Jean M Connors
- Heart and Vascular Center, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden and Dutch Thrombosis Network, The Netherlands
| | - Andres Munoz
- Department of Medical Oncology, Gregorio Marañón Health Research Institute, Complutense University, Madrid, Spain
| | - Giorgio Vescovo
- Department of internal medicine, Ospedale sant Antonio, Padua, Italy
| | - Rupert Bauersachs
- Cardioangiologic Center Bethanien, CCB, Frankfurt, Germany
- Center of Thrombosis and Hemostasis, University Mainz, Mainz, Germany
| | - Walter Ageno
- Dipartimento di Medicina e Chirurgia, Università degli Studi dell'Insubria, Varese, Italy
| | - Giancarlo Agnelli
- Department of internal medicine, Ospedale sant Antonio, Padua, Italy
| | - Cecilia Becattini
- Department of internal medicine, Ospedale sant Antonio, Padua, Italy
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Hutchings HA, Lanyon KJ, Holland G, Alikhan R, Jenkins R, Laing H, Hughes A, Lobban T, Pollock K, Tod D, Lister S. Can we collect health-related quality of life information from anticoagulated atrial fibrillation participants who have recently experienced a bleed? An observational feasibility study in primary and secondary care in Wales and through a UK online forum. BMJ Open 2023; 13:e075335. [PMID: 37802619 PMCID: PMC10565208 DOI: 10.1136/bmjopen-2023-075335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 09/13/2023] [Indexed: 10/10/2023] Open
Abstract
OBJECTIVE To evaluate the feasibility of recruiting participants diagnosed with atrial fibrillation (AF) taking oral anticoagulation therapies (OATs) and recently experiencing a bleed to collect health-related quality of life (HRQoL) information. DESIGN Observational feasibility study. The study aimed to determine the feasibility of recruiting participants with minor and major bleeds, the most appropriate route for recruitment and the appropriateness of the patient-reported outcome measures (PROMs) selected for collecting HRQoL information in AF patients, and the preferred format of the surveys. SETTING Primary care, secondary care and via an online patient forum. PARTICIPANTS The study population was adult patients (≥18) with AF taking OATs who had experienced a recent major or minor bleed within the last 4 weeks. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcomes - PROMs: EuroQol 5 Dimensions-5 Levels, Perception of Anticoagulant Treatment Questionnaire, part 2 only (part 2), atrial fibrillation effect on quality of life. Secondary outcomes - Location of bleed, bleed severity, current treatment, patient perceptions of HRQoL in relation to bleeding events. RESULTS We received initial expressions of interest from 103 participants. We subsequently recruited 32 participants to the study-14 from primary care and 18 through the AF forum. No participants were recruited through secondary care. Despite 32 participants consenting, only 26 initial surveys were completed. We received follow-up surveys from 11 participants (8 primary care and 3 AF forum). COVID-19 had a major impact on the study. CONCLUSIONS Primary care was the most successful route for recruitment. Most participants recruited to the study experienced a minor bleed. Further ways to recruit in secondary care should be explored, especially to capture more serious bleeds. TRIAL REGISTRATION NUMBER The study is registered in the Clinicaltrials.gov database, NCT04921176.
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Affiliation(s)
| | - Kirsty J Lanyon
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Gail Holland
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Raza Alikhan
- Department of Haematology, University Hospital of Wales, Cardiff, UK
| | | | - Hamish Laing
- VBHC Academy, School of Management, Swansea University, Swansea, UK
| | | | | | - Kevin Pollock
- Bristol-Myers Squibb Pharmaceuticals Ltd, Uxbridge, UK
| | - Daniel Tod
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Steven Lister
- Bristol-Myers Squibb Pharmaceuticals Ltd, Uxbridge, UK
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Kitson T, Osborne E, Noble S, Pease N, Alikhan R, Bryant C, Groves T, Wallace R, Walker S, Seddon K, Smith D, Raisanen L, Smith J, Thomas I, Upton L, Casbard A. HIDDEN2: Study protocol for the hospital deep vein thrombosis detection study in patients with cancer receiving palliative care. BMJ Open 2023; 13:e073049. [PMID: 37669841 PMCID: PMC10481726 DOI: 10.1136/bmjopen-2023-073049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 07/27/2023] [Indexed: 09/07/2023] Open
Abstract
INTRODUCTION Medical patients, admitted acutely to hospital, are at risk of venous thromboembolism (VTE). Clinical guidelines advise thromboprophylaxis prophylaxis for those at high risk of VTE. VTE is a common sequela of cancer, but guidelines take little consideration of cancer as an independent risk factor and their utility in palliative care patients is unclear. The hospice inpatient deep vein thrombosis (DVT) detection study (HIDDen) reported a 28% prevalence of asymptomatic iliofemoral DVT in hospice patients of poor performance status (PS) and prognosis, calling into question the utility of thromboprophylaxis in the palliative care setting. However, the majority of cancer inpatients receiving palliative care are admitted to hospital through the acute medical setting, yet their risk factors for VTE may differ from those admitted to hospices. OBJECTIVE To better understand the prevalence and behaviours of VTE in patients with cancer receiving palliative care who are admitted as an acute medical emergency. DESIGN Multicentre, observational cohort study. SETTING Secondary care acute hospitals in South Wales, UK. PATIENTS We plan to recruit 232 patients≥18 years old with a diagnosis of incurable cancer, and/or receiving palliative or best supportive care who are admitted acutely to hospital. Patients will be followed up for a maximum of 6 months following registration. PRIMARY OUTCOME Presence of lower extremity DVT. SECONDARY OUTCOMES Symptom burden attributed to DVT or pulmonary embolism, patient PS, patient demographics and development of new VTE within 90 days of registration. ANALYSIS The study statistical analysis plan will document analysis, methodology and procedures. ETHICS AND DISSEMINATION Ethical approval was obtained from the Wales Research Ethics Committee, reference 22/WA/0037 (IRAS 306352)-the main trial results will be analysed as soon as practically possible and the publication shared with investigators and on sponsor website; applications to access trial data will be subject to sponsor review process.
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Affiliation(s)
- Terri Kitson
- College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Emma Osborne
- College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Simon Noble
- Population Medicine, Cardiff University, Cardiff, UK
| | | | - Raza Alikhan
- University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, UK
| | - Catherine Bryant
- University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, UK
| | - Tristan Groves
- University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, UK
| | | | | | - Kathy Seddon
- Public Involvement, Health and Care Research Wales, Cardiff, UK
| | - Deb Smith
- Public Involvement, Health and Care Research Wales, Cardiff, UK
| | - Lawrence Raisanen
- College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Joanna Smith
- College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Ian Thomas
- College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Laura Upton
- College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Angela Casbard
- College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
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Harris DE, Torabi F, Mallory D, Akbari A, Thayer D, Wang T, Grundy S, Gravenor M, Alikhan R, Lister S, Halcox J. SAIL study of stroke, systemic embolism and bleeding outcomes with warfarin anticoagulation in non-valvular atrial fibrillation (S 4-BOW-AF). Eur Heart J Open 2023; 3:oead037. [PMID: 37143610 PMCID: PMC10153743 DOI: 10.1093/ehjopen/oead037] [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] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 03/29/2023] [Accepted: 04/12/2023] [Indexed: 05/06/2023]
Abstract
Aims In patients with non-valvular atrial fibrillation (NVAF) prescribed warfarin, the association between guideline defined international normalised ratio (INR) control and adverse outcomes in unknown. We aimed to (i) determine stroke and systemic embolism (SSE) and bleeding events in NVAF patients prescribed warfarin; and (ii) estimate the increased risk of these adverse events associated with poor INR control in this population. Methods and results Individual-level population-scale linked patient data were used to investigate the association between INR control and both SSE and bleeding events using (i) the National Institute for Health and Care Excellence (NICE) criteria of poor INR control [time in therapeutic range (TTR) <65%, two INRs <1.5 or two INRs >5 in a 6-month period or any INR >8]. A total of 35 891 patients were included for SSE and 35 035 for bleeding outcome analyses. Mean CHA2DS2-VASc score was 3.5 (SD = 1.7), and the mean follow up was 4.3 years for both analyses. Mean TTR was 71.9%, with 34% of time spent in poor INR control according to NICE criteria.SSE and bleeding event rates (per 100 patient years) were 1.01 (95%CI 0.95-1.08) and 3.4 (95%CI 3.3-3.5), respectively, during adequate INR control, rising to 1.82 (95%CI 1.70-1.94) and 4.8 (95% CI 4.6-5.0) during poor INR control.Poor INR control was independently associated with increased risk of both SSE [HR = 1.69 (95%CI = 1.54-1.86), P < 0.001] and bleeding [HR = 1.40 (95%CI 1.33-1.48), P < 0.001] in Cox-multivariable models. Conclusion Guideline-defined poor INR control is associated with significantly higher SSE and bleeding event rates, independent of recognised risk factors for stroke or bleeding.
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Affiliation(s)
| | | | - Daniel Mallory
- Population Data Science, Swansea University, Singleton Park, Swansea, SA28PP, UK
| | - Ashley Akbari
- Population Data Science, Swansea University, Singleton Park, Swansea, SA28PP, UK
| | - Daniel Thayer
- Population Data Science, Swansea University, Singleton Park, Swansea, SA28PP, UK
| | - Ting Wang
- Population Data Science, Swansea University, Singleton Park, Swansea, SA28PP, UK
| | - Sarah Grundy
- Medical Department, Bristol-Myers Squibb ltd, ARC Uxbridge, Sanderson Road, Denham, UB8 1DH, UK
| | - Mike Gravenor
- Population Data Science, Swansea University, Singleton Park, Swansea, SA28PP, UK
| | - Raza Alikhan
- Thrombosis Centre, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK
| | - Steven Lister
- Department of Health Economics, Bristol-Myers Squibb ltd, ARC Uxbridge, Sanderson Road, Denham, UB8 1DH, UK
| | - Julian Halcox
- Population Data Science, Swansea University, Singleton Park, Swansea, SA28PP, UK
- Cardiology Department, Swansea Bay University Health Board, Sketty Lane, Swansea, SA28QA, UK
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Cohen AT, Benson G, Bradbury CA, Choudhuri S, Hutchinson Jones N, Maraveyas A, Venugopal B, Young AM, Chapman C, McIntyre S, Burney D, Pollock KG, Morgan AR, Gabb PD, Alikhan R. A consensus viewpoint on the role of direct factor Xa inhibitors in the management of cancer-associated venous thromboembolism in the UK. Curr Med Res Opin 2023; 39:483-495. [PMID: 36629478 DOI: 10.1080/03007995.2023.2167441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Cancer patients are at high risk of venous thromboembolism (VTE), a significant cause of cancer-related death. Historically, low molecular weight heparins (LMWH) were the gold standard therapy for cancer-associated VTE, but recent evidence supports the use of direct factor Xa inhibitors in cancer-associated VTE and this is now reflected in many guidelines. However, uptake of direct factor Xa inhibitors varies and guidance on the use of direct factor Xa inhibitors in specific cancer sub-populations and clinical situations is lacking. This review presents consensus expert opinion alongside evaluation of evidence to support healthcare professionals in the use of direct factor Xa inhibitors in cancer-associated VTE. METHODS Recent guidelines, meta-analyses, reviews and clinical studies on anticoagulation therapy for cancer-associated VTE were used to direct clinically relevant topics and evidence to be systematically discussed using nominal group technique. The consensus manuscript and recommendations were developed based on these discussions. RESULTS Considerations when prescribing anticoagulant therapy for cancer-associated VTE include cancer site and stage, systemic anti-cancer therapy (including vascular access), drug-drug interactions, length of anticoagulation, quality of life and needs during palliative care. Treatment of patients with kidney or liver impairment, gastrointestinal disorders, extremes of bodyweight, elevated bleeding or recurrence risk, VTE recurrence and COVID-19 is discussed. CONCLUSION Anticoagulant therapy for cancer-associated VTE patients should be carefully selected with consideration given to the relative benefits of specific drugs when individualizing care. Direct factor Xa inhibitors are typically the treatment of choice for preventing VTE recurrence in non-cancer patients and should also be considered as such for cancer-associated VTE in most situations.
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Affiliation(s)
- Alexander T Cohen
- Guy's and St Thomas' NHS Foundation Trust, King's College London, London, UK
| | - Gary Benson
- Northern Ireland Haemophilia Comprehensive Care Centre and Thrombosis Unit, Belfast, UK
| | | | | | | | | | - Balaji Venugopal
- The Beatson West of Scotland Cancer Centre, Glasgow, UK
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Annie M Young
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | | | | | | | | | | | - Peter D Gabb
- Health Economics and Outcomes Research Ltd., Cardiff, UK
| | - Raza Alikhan
- Haemophilia and Thrombosis Centre, University Hospital of Wales, Cardiff, UK
- Cardiff University School of Medicine, Cardiff, UK
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Milling TJ, Middeldorp S, Xu L, Koch B, Demchuk A, Eikelboom JW, Verhamme P, Cohen AT, Beyer-Westendorf J, Michael Gibson C, Lopez-Sendon J, Crowther M, Shoamanesh A, Coppens M, Schmidt J, Albaladejo P, Connolly SJ, Bastani A, Clark C, Concha M, Cornell J, Dombrowski K, Fermann G, Fulmer J, Goldstein J, Kereiakes D, Milling T, Pallin D, Patel N, Refaai M, Rehman M, Schmaier A, Schwarz E, Shillinglaw W, Spohn M, Takata T, Venkat A, Welker J, Welsby I, Wilson J, Van Keer L, Verschuren F, Blostein M, Eikelboom J, Althaus K, Berrouschot J, Braun G, Doeppner T, Dziewas R, Genth-Zotz S, Greinacher P, Hamann F, Hanses F, Heide W, Kallmuenzer B, Kermer P, Poli S, Royl G, Schellong S, Schnupp S, Schwarze J, Spies C, Thomalla G, von Mering M, Weissenborn K, Wollenweber F, Gumbinger C, Jaschinski U, Maschke M, Mochmann HC, Pfeilschifter W, Pohlmann C, Zahn R, Bouzat P, Schmidt J, Vallejo C, Floccard B, Coppens M, van Wissen S, Arellano-Rodrigo E, Valles E, Alikhan R, Breen K, Hall R, Crowther M, Albaladejo P, Cohen A, Demchuk A, Schmidt J, Wyse D, Garcia D, Prins M, Nakamya J, Büller H, Mahaffey KW, Alexander JH, Cairns J, Hart R, Joyner C, Raskob G, Schulman S, Veltkamp R, Meeks B, Zotova E, Ahmad S, Pinto T, Baker K, Dykstra A, Holadyk-Gris I, Malvaso A, Demchuk A. Final Study Report of Andexanet Alfa for Major Bleeding With Factor Xa Inhibitors. Circulation 2023; 147:1026-1038. [PMID: 36802876 DOI: 10.1161/circulationaha.121.057844] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [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] [Indexed: 02/22/2023]
Abstract
BACKGROUND Andexanet alfa is a modified recombinant inactive factor Xa (FXa) designed to reverse FXa inhibitors. ANNEXA-4 (Andexanet Alfa, a Novel Antidote to the Anticoagulation Effects of Factor Xa Inhibitors) was a multicenter, prospective, phase-3b/4, single-group cohort study that evaluated andexanet alfa in patients with acute major bleeding. The results of the final analyses are presented. METHODS Patients with acute major bleeding within 18 hours of FXa inhibitor administration were enrolled. Co-primary end points were anti-FXa activity change from baseline during andexanet alfa treatment and excellent or good hemostatic efficacy, defined by a scale used in previous reversal studies, at 12 hours. The efficacy population included patients with baseline anti-FXa activity levels above predefined thresholds (≥75 ng/mL for apixaban and rivaroxaban, ≥40 ng/mL for edoxaban, and ≥0.25 IU/mL for enoxaparin; reported in the same units used for calibrators) who were adjudicated as meeting major bleeding criteria (modified International Society of Thrombosis and Haemostasis definition). The safety population included all patients. Major bleeding criteria, hemostatic efficacy, thrombotic events (stratified by occurring before or after restart of either prophylactic [ie, a lower dose, for prevention rather than treatment] or full-dose oral anticoagulation), and deaths were assessed by an independent adjudication committee. Median endogenous thrombin potential at baseline and across the follow-up period was a secondary outcome. RESULTS There were 479 patients enrolled (mean age, 78 years; 54% male, 86% White; 81% anticoagulated for atrial fibrillation at a median time of 11.4 hours since last dose, with 245 (51%) on apixaban, 176 (37%) on rivaroxaban, 36 (8%) on edoxaban, and 22 (5%) on enoxaparin. Bleeding was predominantly intracranial (n=331 [69%]) or gastrointestinal (n=109 [23%]). In evaluable apixaban patients (n=172), median anti-FXa activity decreased from 146.9 ng/mL to 10.0 ng/mL (reduction, 93% [95% CI, 94-93]); in rivaroxaban patients (n=132), it decreased from 214.6 ng/mL to 10.8 ng/mL (94% [95% CI, 95-93]); in edoxaban patients (n=28), it decreased from 121.1 ng/mL to 24.4 ng/mL (71% [95% CI, 82-65); and in enoxaparin patients (n=17), it decreased from 0.48 IU/mL to 0.11 IU/mL (75% [95% CI, 79-67]). Excellent or good hemostasis occurred in 274 of 342 evaluable patients (80% [95% CI, 75-84]). In the safety population, thrombotic events occurred in 50 patients (10%); in 16 patients, this occurred during treatment with prophylactic anticoagulation that began after the bleeding event. No thrombotic episodes occurred after oral anticoagulation restart. Specific to certain populations, reduction of anti-FXa activity from baseline to nadir significantly predicted hemostatic efficacy in patients with intracranial hemorrhage (area under the receiver operating characteristic curve, 0.62 [95% CI, 0.54-0.70]) and correlated with lower mortality in patients <75 years of age (adjusted P=0.022; unadjusted P=0.003). Median endogenous thrombin potential was within the normal range by the end of andexanet alfa bolus through 24 hours for all FXa inhibitors. CONCLUSIONS In patients with major bleeding associated with the use of FXa inhibitors, treatment with andexanet alfa reduced anti-FXa activity and was associated with good or excellent hemostatic efficacy in 80% of patients. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02329327.
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Affiliation(s)
- Truman J Milling
- Seton Dell Medical School Stroke Institute, Dell Medical School, University of Texas at Austin (T.J.M.)
| | - Saskia Middeldorp
- Department of Internal Medicine and Radboud Institute of Health Sciences, Nijmegenthe Netherlands (S.M.)
| | - Lizhen Xu
- Population Health Research Institute, McMaster University, HamiltonOntario Canada. (L.X., A.S., S.J.C.)
| | - Bruce Koch
- Alexion, AstraZeneca Rare Disease, BostonMA (B.K.)
| | - Andrew Demchuk
- Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, AlbertaCanada (A.D.)
| | - John W Eikelboom
- Department of Medicine, McMaster University, HamiltonOntario Canada. (J.W.E., M. Crowther)
| | - Peter Verhamme
- Center for Molecular and Vascular Biology, University of Leuven, Belgium (P.V.)
| | | | - Jan Beyer-Westendorf
- Department of Medicine I, Division of Hematology and Hemostasis, University Hospital Dresden, Germany (J.B-W.)
| | | | - Jose Lopez-Sendon
- Instituto de Investigación Hospital Universitario, La PazMadridSpain (J. L-S.)
| | - Mark Crowther
- Department of Medicine, McMaster University, HamiltonOntario Canada. (J.W.E., M. Crowther)
| | - Ashkan Shoamanesh
- Population Health Research Institute, McMaster University, HamiltonOntario Canada. (L.X., A.S., S.J.C.)
| | - Michiel Coppens
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, the Netherlands (M. Coppens)
| | - Jeannot Schmidt
- Centre Hospitalier Universitaire de Clermont-Ferrand, France (J.S.)
| | | | - Stuart J Connolly
- Population Health Research Institute, McMaster University, HamiltonOntario Canada. (L.X., A.S., S.J.C.)
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Hutchings HA, Lanyon K, Lister S, Alikhan R, Halcox J, Holland G, Hughes A, Jenkins R, Laing H, Lobban T, Owen D, Pollock KG, Todd C, Wareham K. Investigating the feasibility of recruitment to an observational, quality-of-life study of patients diagnosed with atrial fibrillation (AF) who have experienced a bleed while anticoagulated: EQUAL-AF feasibility study protocol. Pilot Feasibility Stud 2022; 8:180. [PMID: 35962446 PMCID: PMC9372958 DOI: 10.1186/s40814-022-01135-8] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 07/26/2022] [Indexed: 11/10/2022] Open
Abstract
Background Oral anticoagulation therapies (OATs) are often prescribed in conjunction with medications to restore normal heart rate rhythm which can limit the risk of an atrial fibrillation (AF) related stroke and systemic thromboembolism. However, they are associated with the serious side effect of bleeding. Both clinically relevant nonmajor bleeding (CRNMB) and major bleeding while anticoagulated are believed to have a significant impact on patient quality of life (QoL). There is currently limited research into the effect bleeding has on QoL. The aim of this study is to evaluate the feasibility of identifying and recruiting patients diagnosed with AF, who are taking OATs and have recently experienced a bleed and collecting information on their QoL. Methods We will recruit a minimum of 50 patients to this cross-sectional, observational study. We will recruit from general practices, secondary care, and through an online AF forum. We will ask participants to complete three validated patient-reported outcome measures (PROMs), EQ5D, AFEQT, and PACT-Q, approximately 4 weeks following a bleed and again 3 months later. We will randomly select a subset of 10 participants (of those who agree to be interviewed) to undergo a structured interview with a member of the research team to explore the impact of bleeding on their QoL and to gain feedback on the three PROMs used. We will undertake a descriptive analysis of the PROMs and demographic data. We will analyse the qualitative interviews thematically to identify key themes. Discussion We aim to establish if it is possible to recruit patients and use PROMs to collect information regarding how patient QoL is affected when they experience either a clinically relevant non-major bleed (CRNMB) or major bleed while taking OATs for the management of AF. We will also explore the appropriateness, or otherwise, of the three identified PROMs for assessing quality of life following a bleed. PROMs Three PROMs were selected following a literature review of similar QoL studies and using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist for comparison. A review of the current literature produced no suitable validated PROM to record QoL experiences in patients who have been diagnosed with AF and have experienced a bleed while anticoagulated. As such, the EQ5D, AFEQT, and PACT-Q (part 2) were deemed most appropriate for use in this feasibility study. Trial registration The trial has been adopted onto the NIHR Portfolio (ID no. 47771) and registered with www.ClinicalTrials.gov (no. NCT04921176) retrospectively registered in June 2021. Supplementary Information The online version contains supplementary material available at 10.1186/s40814-022-01135-8.
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Affiliation(s)
- Hayley A Hutchings
- Faculty of Medicine, Health and Life Science, Swansea University, Singleton Park, Swansea, SA2 8PP, UK
| | - Kirsty Lanyon
- Faculty of Medicine, Health and Life Science, Swansea University, Singleton Park, Swansea, SA2 8PP, UK.
| | - Steven Lister
- Bristol Myers Squibb, Uxbridge Business Park, Sanderson Road, Uxbridge, Middlesex, UB8 1DH, UK
| | - Raza Alikhan
- Department of Haematology, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, UK
| | - Julian Halcox
- Faculty of Medicine, Health and Life Science, Swansea University, Singleton Park, Swansea, SA2 8PP, UK
| | - Gail Holland
- Faculty of Medicine, Health and Life Science, Swansea University, Singleton Park, Swansea, SA2 8PP, UK
| | | | - Rhys Jenkins
- City Health Cluster, Swansea Bay University Health Board, Swansea, UK
| | - Hamish Laing
- VBHC Academy, School of Management, Swansea University, Swansea, UK
| | - Trudie Lobban
- Arrythmia Alliance and Public and Patient Representative, Stratford Upon Avon, UK
| | - Diane Owen
- Faculty of Medicine, Health and Life Science, Swansea University, Singleton Park, Swansea, SA2 8PP, UK
| | - Kevin G Pollock
- Bristol Myers Squibb, Uxbridge Business Park, Sanderson Road, Uxbridge, Middlesex, UB8 1DH, UK
| | - Ceri Todd
- City Health Cluster, Swansea Bay University Health Board, Swansea, UK
| | - Kathie Wareham
- Joint Clinical Research Facility, Swansea University, Swansea, UK
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9
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Ariëns RA, Hunt BJ, Agbani EO, Ahnström J, Ahrends R, Alikhan R, Assinger A, Bagoly Z, Balduini A, Barbon E, Barrett CD, Batty P, Carneiro JDA, Chan W, de Maat M, de Wit K, Denis C, Ellis MH, Eslick R, Fu H, Hayward CPM, Ho‐Tin‐Noé B, Klok F, Kumar R, Leiderman K, Litvinov RI, Mackman N, McQuilten Z, Neal MD, Parker WAE, Preston RJS, Rayes J, Rezaie AR, Roberts LN, Rocca B, Shapiro S, Siegal DM, Sousa LP, Suzuki‐Inoue K, Zafar T, Zhou J. Illustrated State-of-the-Art Capsules of the ISTH 2022 Congress. Res Pract Thromb Haemost 2022; 6:e12747. [PMID: 35814801 PMCID: PMC9257378 DOI: 10.1002/rth2.12747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 05/27/2022] [Indexed: 11/13/2022] Open
Abstract
The ISTH London 2022 Congress is the first held (mostly) face-to-face again since the COVID-19 pandemic took the world by surprise in 2020. For 2 years we met virtually, but this year's in-person format will allow the ever-so-important and quintessential creativity and networking to flow again. What a pleasure and joy to be able to see everyone! Importantly, all conference proceedings are also streamed (and available recorded) online for those unable to travel on this occasion. This ensures no one misses out. The 2022 scientific program highlights new developments in hemophilia and its treatment, acquired and other inherited bleeding disorders, thromboinflammation, platelets and coagulation, clot structure and composition, fibrinolysis, vascular biology, venous thromboembolism, women's health, arterial thrombosis, pediatrics, COVID-related thrombosis, vaccine-induced thrombocytopenia with thrombosis, and omics and diagnostics. These areas are elegantly reviewed in this Illustrated Review article. The Illustrated Review is a highlight of the ISTH Congress. The format lends itself very well to explaining the science, and the collection of beautiful graphical summaries of recent developments in the field are stunning and self-explanatory. This clever and effective way to communicate research is revolutionary and different from traditional formats. We hope you enjoy this article and will be inspired by its content to generate new research ideas.
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Affiliation(s)
| | | | - Ejaife O. Agbani
- Department of Physiology and Pharmacology, Cumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
| | | | - Robert Ahrends
- Institute of Analytical ChemistryUniversity of ViennaViennaAustria
| | - Raza Alikhan
- Haemostasis & ThrombosisUniversity Hospital of WalesCardiffUK
| | | | - Zsuzsa Bagoly
- Faculty of Medicine, Department of Laboratory Medicine, Division of Clinical Laboratory Sciences and ELKH‐DE Neurodegenerative and Cerebrovascular Research GroupUniversity of DebrecenDebrecenHungary
| | | | - Elena Barbon
- San Raffaele Telethon Institute for Gene TherapyIRCCS San Raffaele Scientific InstituteMilanItaly
| | - Christopher D. Barrett
- Division of Acute Care Surgery and Surgical Critical Care, Department of SurgeryUniversity of Nebraska Medical CenterOmahaNebraskaUSA,Koch Institute, Center for Precision Cancer MedicineMassachusetts Institute of TechnologyCambridgeMassachusettsUSA,Division of Surgical Critical Care, Department of Surgery, Boston University Medical CenterBoston University School of MedicineBostonMassachusettsUSA
| | | | | | - Wee Shian Chan
- University of British ColumbiaVancouverBritish ColumbiaCanada
| | - Moniek de Maat
- Department of HematologyErasmus MCRotterdamThe Netherlands
| | - Kerstin de Wit
- Queen’s University and McMaster UniversityKingstonONCanada
| | | | - Martin H. Ellis
- Hematology Institute and Blood Bank, Meir Medical Center and Sackler School of MedicineTel Aviv UniversityTel AvivIsrael
| | - Renee Eslick
- Haematology DepartmentCanberra HospitalGarranAustralian Capital TerritoryAustralia
| | - Hongxia Fu
- Division of Hematology, Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | | | | | - Frederikus A. Klok
- Department of Medicine – Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Riten Kumar
- Dana Farber/Boston Children’s Cancer and Blood Disorders CenterBostonMassachusettsUSA
| | | | - Rustem I. Litvinov
- Department of Cell and Developmental BiologyUniversity of Pennsylvania School of MedicinePhiladelphiaPennsylvaniaUSA
| | - Nigel Mackman
- UNC Blood Research Center, Division of Hematology, Department of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | | | - Matthew D. Neal
- Trauma and Transfusion Medicine Research Center, Department of SurgeryUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - William A. E. Parker
- Cardiovascular Research Unit, Northern General HospitalUniversity of SheffieldSheffieldUK
| | - Roger J. S. Preston
- Irish Centre for Vascular Biology, Department of Pharmacy & Biomolecular SciencesRoyal College of Surgeons in IrelandDublin 2Ireland
| | | | - Alireza R. Rezaie
- Cardiovascular Biology Research ProgramOklahoma Medical Research FoundationOklahoma CityOklahomaUSA
| | - Lara N. Roberts
- King’s Thrombosis Centre, Department of Haematological MedicineKing’s College Hospital NHS Foundation TrustLondonUK
| | - Bianca Rocca
- Department of Safety and Bioethics, Section of PharmacologyCatholic University School of MedicineRomeItaly
| | - Susan Shapiro
- Oxford University Hospitals NHS Foundation TrustOxfordUK,Radcliffe Department of MedicineOxford UniversityOxfordUK
| | - Deborah M. Siegal
- Ottawa Hospital Research Institute and University of OttawaOttawaOntarioCanada
| | - Lirlândia P. Sousa
- Departamento de Análises Clínicas e Toxicológicas, Faculdade de FarmáciaUniversidade Federal de Minas GeraisBelo HorizonteBrazil
| | - Katsue Suzuki‐Inoue
- Department of Clinical and Laboratory MedicineUniversity of YamanashiYamanashiJapan
| | - Tahira Zafar
- Frontier Medical CollegeAbbotabadPakistan,Hemophilia Treatment CenterRawalpindiPakistan
| | - Jiaxi Zhou
- Institute of Hematology & Blood Diseases HospitalChinese Academy of Medical Sciences & Peking Union Medical CollegeTianjinChina
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10
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Cohen AT, Lewis M, Connor A, Connolly SJ, Yue P, Curnutte J, Alikhan R, MacCallum P, Tan J, Green L. Thirty‐day mortality with andexanet alfa compared with prothrombin complex concentrate therapy for life‐threatening direct oral anticoagulant‐related bleeding. J Am Coll Emerg Physicians Open 2022; 3:e12655. [PMID: 35280921 PMCID: PMC8898077 DOI: 10.1002/emp2.12655] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 12/22/2021] [Accepted: 12/28/2021] [Indexed: 11/10/2022] Open
Affiliation(s)
- Alexander T. Cohen
- Department of Haematological Medicine Guy's and St Thomas’ Hospitals London UK
| | | | | | - Stuart J. Connolly
- Population Health Research Institute McMaster University Hamilton Ontario Canada
| | - Patrick Yue
- Portola Pharmaceuticals, Inc. now Alexion Pharmaceuticals, Inc. South San Francisco California USA
| | - John Curnutte
- Portola Pharmaceuticals, Inc. now Alexion Pharmaceuticals, Inc. South San Francisco California USA
| | - Raza Alikhan
- University Hospital of Wales, Cardiff and Vale University Health Board Cardiff UK
| | - Peter MacCallum
- Haemostasis and Transfusion Barts Health NHS Trust London UK
- Wolfson Institute of Preventive Medicine Queen Mary University of London London UK
| | - Joachim Tan
- Population Health Research Institute St George's, University of London London UK
| | - Laura Green
- Haemostasis and Transfusion Barts Health NHS Trust London UK
- Blizard Institute Queen Mary University of London London UK
- NHS Blood and Transplant London UK
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11
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Arachchillage DJ, Rajakaruna I, Odho Z, Crossette-Thambiah C, Nicolson PLR, Roberts LN, Allan C, Lewis S, Riat R, Mounter P, Lynch C, Langridge A, Oakes R, Aung N, Drebes A, Dutt T, Raheja P, Delaney A, Essex S, Lowe G, Sutton D, Lentaigne C, Sayar Z, Kilner M, Everington T, Shapiro S, Alikhan R, Szydlo R, Makris M, Laffan M. Clinical outcomes and the impact of prior oral anticoagulant use in patients with coronavirus disease 2019 admitted to hospitals in the UK - a multicentre observational study. Br J Haematol 2022; 196:79-94. [PMID: 34500500 DOI: 10.1111/bjh.17787] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 08/07/2021] [Indexed: 12/22/2022]
Abstract
Coagulation dysfunction and thrombosis are major complications in patients with coronavirus disease 2019 (COVID-19). Patients on oral anticoagulants (OAC) prior to diagnosis of COVID-19 may therefore have better outcomes. In this multicentre observational study of 5 883 patients (≥18 years) admitted to 26 UK hospitals between 1 April 2020 and 31 July 2020, overall mortality was 29·2%. Incidences of thrombosis, major bleeding (MB) and multiorgan failure (MOF) were 5·4%, 1·7% and 3·3% respectively. The presence of thrombosis, MB, or MOF was associated with a 1·8, 4·5 or 5·9-fold increased risk of dying, respectively. Of the 5 883 patients studied, 83·6% (n = 4 920) were not on OAC and 16·4% (n = 963) were taking OAC at the time of admission. There was no difference in mortality between patients on OAC vs no OAC prior to admission when compared in an adjusted multivariate analysis [hazard ratio (HR) 1·05, 95% confidence interval (CI) 0·93-1·19; P = 0·15] or in an adjusted propensity score analysis (HR 0·92 95% CI 0·58-1·450; P = 0·18). In multivariate and adjusted propensity score analyses, the only significant association of no anticoagulation prior to diagnosis of COVID-19 was admission to the Intensive-Care Unit (ICU) (HR 1·98, 95% CI 1·37-2·85). Thrombosis, MB, and MOF were associated with higher mortality. Our results indicate that patients may have benefit from prior OAC use, especially reduced admission to ICU, without any increase in bleeding.
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Affiliation(s)
- Deepa J Arachchillage
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, UK
- Department of Haematology, Imperial College Healthcare NHS Trust, UK
| | | | - Zain Odho
- Department of Biochemistry, Royal Brompton Hospital, London, UK
| | | | | | - Lara N Roberts
- King's College Hospital NHS Foundation Trust, London, UK
| | - Caroline Allan
- Department of Emergency Medicine, Aberdeen Royal Infirmary Aberdeen, Aberdeen, UK
| | - Sarah Lewis
- Department of Haematology, Aneurin Bevan Health Board, Abergavenny, UK
| | - Renu Riat
- Department of Haematology, Buckinghamshire Healthcare NHS Trust, Buckinghamshire, UK
| | - Philip Mounter
- Department of Haematology County Durham and Darlington, NHS Foundation Trust, Darlington, UK
| | - Ceri Lynch
- Department of Critical Care, Cwm Taf Morgannwg University Health Board, Cynon Taff, UK
| | - Alexander Langridge
- Department of Haematology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Roderick Oakes
- Department of Haematology, North Cumbria Integrated Care NHS Foundation Trust, Carlisle, UK
| | - Nini Aung
- Department of Haematology, North Tees and Hartlepool NHS Foundation Trust, Hartlepool, UK
| | - Anja Drebes
- Department of Haematology, Royal Free London NHS Foundation Trust, London, UK
| | - Tina Dutt
- Department of Haematology, Royal Liverpool University Hospital, Liverpool, UK
| | - Priyanka Raheja
- Department of Haematology, The Royal London Hospital, London, UK
| | - Alison Delaney
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Sarah Essex
- Department of Haematology, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Gillian Lowe
- Department of Haematology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - David Sutton
- Department of Haematology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Claire Lentaigne
- Department of Haematology, University Hospitals Plymouth NHS Trust Plymouth, UK
| | - Zara Sayar
- Department of Haematology, Whittington Health NHS Trust, London, UK
| | - Mari Kilner
- Department of Haematology, Northumbria Healthcare NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Tamara Everington
- Department of Haematology, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - Susie Shapiro
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Raza Alikhan
- Haemophilia and Thrombosis Centre, University Hospital of Wales, Cardiff, UK
| | - Richard Szydlo
- Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Michael Makris
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Michael Laffan
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, UK
- Department of Haematology, Imperial College Healthcare NHS Trust, UK
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12
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Veitch AM, Radaelli F, Alikhan R, Dumonceau JM, Eaton D, Jerrome J, Lester W, Nylander D, Thoufeeq M, Vanbiervliet G, Wilkinson JR, Van Hooft JE. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Gut 2021; 70:1611-1628. [PMID: 34362780 PMCID: PMC8355884 DOI: 10.1136/gutjnl-2021-325184] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 06/20/2021] [Indexed: 12/17/2022]
Abstract
This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.
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Affiliation(s)
- Andrew M Veitch
- Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | | | - Raza Alikhan
- Haematology, Cardiff and Vale University Health Board, Cardiff, UK
| | | | | | | | - Will Lester
- Department of Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | - David Nylander
- Gastroenterology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Mo Thoufeeq
- Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - James R Wilkinson
- Interventional Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Jeanin E Van Hooft
- Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
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13
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Veitch AM, Radaelli F, Alikhan R, Dumonceau JM, Eaton D, Jerrome J, Lester W, Nylander D, Thoufeeq M, Vanbiervliet G, Wilkinson JR, van Hooft JE. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Endoscopy 2021; 53:947-969. [PMID: 34359080 PMCID: PMC8390296 DOI: 10.1055/a-1547-2282] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles, and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.
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Affiliation(s)
- Andrew M. Veitch
- Department of Gastroenterology, Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom
| | | | - Raza Alikhan
- Department of Haematology Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - Jean-Marc Dumonceau
- Department of Gastroenterology, Charleroi University Hospitals, Charleroi, Belgium
| | | | | | - Will Lester
- Department of Haematology University Hospitals Birmingham NHS Foundation Trust, Birmingham,
| | - David Nylander
- Department of Gastroenterology, The Newcastle-upon-Tyne NHS Foundation Trust, Newcastle-upon-Tyne
| | - Mo Thoufeeq
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield
| | | | - James R. Wilkinson
- Department of Interventional Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Jeanin E. van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, Netherlands
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14
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Besford M, Leahy TP, Sammon C, Ulvestad M, Carroll R, Mehmud F, Alikhan R, Ramagopalan S. CHA 2DS 2-VASc and HAS-BLED risk scores and real-world oral anticoagulant prescribing decisions in atrial fibrillation. Future Cardiol 2021; 17:855-864. [PMID: 33890499 DOI: 10.2217/fca-2020-0175] [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: 11/21/2022] Open
Abstract
Background: Guidelines indicate that oral anticoagulant (OAC) treatment decisions in atrial fibrillation should be based on a balanced consideration of thromboembolic and bleeding risk. Materials & methods: A retrospective cohort of nonvalvular atrial fibrillation patients were identified. Univariate logistic regression and conditional inference trees were used to quantify the importance of the CHA2DS2-VASc and modified HAS-BLED scores and their individual components on OAC treatment decisions. Results: The individual components of these risk scores provided more distinguishability between treated and untreated patients than the risk scores themselves, with bleeding risk factors strongly associated with nontreatment. Conclusion: While individual components of risk scores drive OAC treatment decisions according to guidelines, the relationship between bleeding risk factors and nontreatment warrants further consideration.
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Affiliation(s)
| | | | | | | | - Robert Carroll
- Centre for Observational Research & Data Sciences, Bristol Myers Squibb, Uxbridge, UK
| | | | - Raza Alikhan
- University Hospital of Wales, Cardiff & Vale University Health Board, UK
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15
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Shah A, Donovan K, McHugh A, Pandey M, Aaron L, Bradbury CA, Stanworth SJ, Alikhan R, Von Kier S, Maher K, Curry N, Shapiro S, Rowland MJ, Thomas M, Mason R, Holland M, Holmes T, Ware M, Gurney S, McKechnie SR. Thrombotic and haemorrhagic complications in critically ill patients with COVID-19: a multicentre observational study. Crit Care 2020; 24:561. [PMID: 32948243 PMCID: PMC7499016 DOI: 10.1186/s13054-020-03260-3] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 08/23/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Optimal prophylactic and therapeutic management of thromboembolic disease in patients with COVID-19 remains a major challenge for clinicians. The aim of this study was to define the incidence of thrombotic and haemorrhagic complications in critically ill patients with COVID-19. In addition, we sought to characterise coagulation profiles using thromboelastography and explore possible biological differences between patients with and without thrombotic complications. METHODS We conducted a multicentre retrospective observational study evaluating all the COVID-19 patients received in four intensive care units (ICUs) of four tertiary hospitals in the UK between March 15, 2020, and May 05, 2020. Clinical characteristics, laboratory data, thromboelastography profiles and clinical outcome data were evaluated between patients with and without thrombotic complications. RESULTS A total of 187 patients were included. Their median (interquartile (IQR)) age was 57 (49-64) years and 124 (66.3%) patients were male. Eighty-one (43.3%) patients experienced one or more clinically relevant thrombotic complications, which were mainly pulmonary emboli (n = 42 (22.5%)). Arterial embolic complications were reported in 25 (13.3%) patients. ICU length of stay was longer in patients with thrombotic complications when compared with those without. Fifteen (8.0%) patients experienced haemorrhagic complications, of which nine (4.8%) were classified as major bleeding. Thromboelastography demonstrated a hypercoagulable profile in patients tested but lacked discriminatory value between those with and without thrombotic complications. Patients who experienced thrombotic complications had higher D-dimer, ferritin, troponin and white cell count levels at ICU admission compared with those that did not. CONCLUSION Critically ill patients with COVID-19 experience high rates of venous and arterial thrombotic complications. The rates of bleeding may be higher than previously reported and re-iterate the need for randomised trials to better understand the risk-benefit ratio of different anticoagulation strategies.
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Affiliation(s)
- Akshay Shah
- Radcliffe Department of Medicine, Level 4 Academic Block, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.
- Adult Intensive Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Killian Donovan
- Adult Intensive Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Anna McHugh
- Intensive Care Unit, North Bristol NHS Trust, Bristol, UK
| | - Manish Pandey
- Adult Intensive Care Unit, University Hospital of Wales, Cardiff, Wales, UK
| | - Louise Aaron
- Adult Intensive Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Simon J Stanworth
- Radcliffe Department of Medicine, Level 4 Academic Block, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK
- Haematology Theme, NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Raza Alikhan
- Haemostasis and Thrombosis, Department of Haematology, University Hospital of Wales, Cardiff, UK
| | - Stephen Von Kier
- Blood Management and Conservation Service, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Keith Maher
- Blood Management and Conservation Service, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nicola Curry
- Haematology Theme, NIHR Oxford Biomedical Research Centre, Oxford, UK
- Oxford Haemophilia & Thrombosis Centre, Department of Haematology, Churchill Hospital, Oxford University Hospitals NHS Foundation, Oxford, UK
| | - Susan Shapiro
- Haematology Theme, NIHR Oxford Biomedical Research Centre, Oxford, UK
- Oxford Haemophilia & Thrombosis Centre, Department of Haematology, Churchill Hospital, Oxford University Hospitals NHS Foundation, Oxford, UK
| | - Matthew J Rowland
- Adult Intensive Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Kadoorie Centre for Critical Care Research, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Matt Thomas
- Intensive Care Unit, North Bristol NHS Trust, Bristol, UK
| | - Richard Mason
- Intensive Care Unit, North Bristol NHS Trust, Bristol, UK
| | | | - Tom Holmes
- Adult Intensive Care Unit, University Hospital of Wales, Cardiff, Wales, UK
| | - Michael Ware
- Adult Intensive Care Unit, University Hospital of Wales, Cardiff, Wales, UK
| | - Stefan Gurney
- Intensive Care Unit, Bristol Royal Infirmary, University Hospitals Bristol NHS Trust, Bristol, UK
| | - Stuart R McKechnie
- Adult Intensive Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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16
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Condliffe R, Albert P, Alikhan R, Gee E, Horner D, Hunter L, Jacobs P, Limbrey R, Newnham M, Preston W, Patel S, Smith LJ, Suntharalingam J. British Thoracic Society Quality Standards for outpatient management of pulmonary embolism. BMJ Open Respir Res 2020; 7:7/1/e000636. [PMID: 32816797 PMCID: PMC7437715 DOI: 10.1136/bmjresp-2020-000636] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION The purpose of the quality standards document is to provide healthcare professionals, commissioners, service providers and patients with a guide to standards of care that should be met for outpatient management of pulmonary embolism in the UK, together with measurable markers of good practice. Quality statements are based on the British Thoracic Society (BTS) Guideline for the Initial Outpatient Management of Pulmonary Embolism. METHODS Development of BTS Quality Standards follows the BTS process of quality standard production based on the National Institute for Health and Care Excellence process manual for the development of quality standards. RESULTS Six quality statements have been developed, each describing a standard of care for the outpatient management of pulmonary embolism in the UK, together with measurable markers of good practice. DISCUSSION BTS Quality Standards for Outpatient Management of Pulmonary Embolism form a key part of the range of supporting materials that the society produces to assist in the dissemination and implementation of a guideline's recommendations.
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Affiliation(s)
- Robin Condliffe
- Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Paul Albert
- Respiratory Medicine, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Raza Alikhan
- Haematology, University Hospital of Wales, Cardiff, UK
| | - Emma Gee
- Thrombosis and Coagulation, King's College Hospital, London, UK
| | - Daniel Horner
- Emergency Medicine, Salford Royal NHS Foundation Trust, Salford, UK
| | - Laura Hunter
- Emergency Medicine, St Thomas' Hospital, London, UK
| | | | - Rachel Limbrey
- Respiratory Medicine, Southampton General Hospital, Southampton, UK
| | - Michael Newnham
- Respiratory Medicine, Papworth Hospital NHS Foundation Trust, Cambridge, Cambridgeshire, UK
| | - Wendy Preston
- Respiratory Medicine, George Eliot Hospital NHS Trust, Nuneaton, Warwickshire, UK
| | - Sheena Patel
- Anticoagulation and Medication Safety/Clinical Governance, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
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17
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Besford M, Graham S, Sammon C, Mehmud F, Allan V, Alikhan R, Ramagopalan S. Factors associated with non-prescription of oral anticoagulant treatment in non-valvular atrial fibrillation patients with dementia: a CPRD-HES study. Age Ageing 2020; 49:679-682. [PMID: 32242616 DOI: 10.1093/ageing/afaa045] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Indexed: 01/22/2023] Open
Abstract
Dementia is a common comorbidity in patients with atrial fibrillation (AF) and treatment guidelines recommend oral anticoagulant (OAC) therapy for AF patients with dementia unless concordance cannot be ensured by the caregiver. Despite this, the literature reports a low prescribing of OAC treatment in these patients. This study investigated possible factors associated with non-prescribing of OAC treatment in dementia patients newly diagnosed with non-valvular atrial fibrillation (NVAF) at age ≥ 65 years between 2013 and 2017 using the Clinical Practice Research Datalink and Hospital Episodes Statistics databases. Of 1090 dementia patients newly diagnosed with NVAF, 693 (63.6%) patients did not have a prescription for an OAC in the year following their diagnosis. The likelihood of experiencing a thromboembolic event was high, with 97% of the population having a CHA2DS2-VASc score > 2; however, little difference in the presence of stroke risk factors was observed between the prescribed and non-prescribed groups. The presence of bleeding risk factors was high; only 28 (2.6%) of patients did not have a previous fall or a HAS-BLED bleeding risk factor. A history of falls [OR = 0.76, 95% confidence intervals (CIs) (0.58, 0.98)], previous major bleed [OR = 0.56, 95% CI (0.43, 0.73)] and care home residence [OR = 0.47, 95% CI (0.30, 0.74)] were associated with not having an OAC prescription. The results suggest that dementia patients with NVAF and certain risk bleeding risk factors are less likely to be prescribed an OAC. Further work is needed to establish possible relationships between bleeding risk factors and other potential drivers of OAC prescribing.
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Affiliation(s)
| | | | | | - Faisal Mehmud
- Centre for Observational Research and Data Sciences, Bristol-Myers Squibb, Uxbridge, UK
| | - Victoria Allan
- Centre for Observational Research and Data Sciences, Bristol-Myers Squibb, Uxbridge, UK
| | - Raza Alikhan
- Haemophilia and Thrombosis Centre, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, UK
| | - Sreeram Ramagopalan
- Centre for Observational Research and Data Sciences, Bristol-Myers Squibb, Uxbridge, UK
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18
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Arachchillage DRJ, Gomez K, Alikhan R, Anderson JAM, Lester W, Laffan M. Addendum to British Society for Haematology Guidelines on Investigation and Management of Antiphospholipid syndrome, 2012 (
Br. J.
Haematol
.
2012; 157: 47–58): use of direct acting oral anticoagulants. Br J Haematol 2020; 189:212-215. [DOI: 10.1111/bjh.16308] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 09/26/2019] [Indexed: 12/31/2022]
Affiliation(s)
- Deepa R. J. Arachchillage
- Department of Haematology Imperial College Healthcare NHS Trust London UK
- Centre for Haematology Imperial College London London UK
| | - Keith Gomez
- Katherine Dormandy Haemophilia Centre and Thrombosis Unit Royal Free London NHS Foundation Trust London UK
| | - Raza Alikhan
- Haemophilia and Thrombosis Centre University Hospital of Wales Cardiff UK
| | | | - Will Lester
- Centre for Clinical Haematology University Hospitals Birmingham NHS Foundation Trust Birmingham UK
| | - Mike Laffan
- Department of Haematology Imperial College Healthcare NHS Trust London UK
- Centre for Haematology Imperial College London London UK
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19
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McDonald L, Carroll R, Harish A, Tanna N, Mehmud F, Alikhan R, Ramagopalan SV. Suspected cancer symptoms and blood test results in primary care before a diagnosis of lung cancer: a case-control study. Future Oncol 2019; 15:3755-3762. [PMID: 31668096 DOI: 10.2217/fon-2019-0442] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Aim: To compare symptoms and blood test results prior to cancer diagnosis in individuals who developed lung cancer and those who did not. Patients & methods: Nested case-control study, lung cancer patients were matched to up four controls with no record of cancer. Differences in symptoms and blood test results were investigated in the 2-year period prior to diagnosis. Results: 26,379 lung cancer patients were matched to 92,125 controls. Elevated C-reactive protein (CRP) was independently predictive of lung cancer at every 2-month interval 12 months prior to diagnosis. Elevated CRP in conjunction with at least one symptom was associated with greater than fourfold higher odds of lung cancer. Conclusion: CRP may be a prediagnostic marker for lung cancer, and when present with other symptoms could facilitate the investigation of high-risk individuals.
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Affiliation(s)
- Laura McDonald
- Centre for Observational Research & Data Sciences, Bristol-Myers Squibb, Uxbridge, UB8 1DH, United Kingdom
| | - Robert Carroll
- Centre for Observational Research & Data Sciences, Bristol-Myers Squibb, Uxbridge, UB8 1DH, United Kingdom
| | | | - Nikhil Tanna
- Bristol-Myers Squibb, Uxbridge, UB8 1DH, United Kingdom
| | - Faisal Mehmud
- Bristol-Myers Squibb, Uxbridge, UB8 1DH, United Kingdom
| | - Raza Alikhan
- University Hospital of Wales, Cardiff & Vale University Health Board, CF14 4XW, United Kingdom
| | - Sreeram V Ramagopalan
- Centre for Observational Research & Data Sciences, Bristol-Myers Squibb, Uxbridge, UB8 1DH, United Kingdom
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20
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Alikhan R, Lefevre C, Menown I, Lister S, Bird A, You M, Evans D, Sammon C. Risk of Recurrent Bleeding Events in Nonvalvular Atrial Fibrillation Treated with Vitamin K Antagonists: A Clinical Practice Research Datalink Study. TH Open 2019; 3:e316-e324. [PMID: 31592518 PMCID: PMC6777986 DOI: 10.1055/s-0039-1698413] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 07/29/2019] [Indexed: 01/23/2023] Open
Abstract
Background
There is little evidence on how the occurrence of a bleed in individuals on vitamin K antagonists (VKAs) impacts the risk of subsequent bleeds, and thromboembolic and ischemic events. Such information would help to inform treatment decisions following bleeds.
Objective
To estimate the impact of bleeding events on the risk of subsequent bleeds, venous thromboembolism (VTE), stroke, and myocardial infarction (MI) among patients initiating VKA treatment for new-onset nonvalvular atrial fibrillation (NVAF).
Methods
We conducted an observational cohort study using a linked Clinical Practice Research Datalink—Hospital Episode Statistics dataset. Among a cohort of individuals with NVAF, the risk of clinically relevant bleeding, VTE, stroke, and MI was compared between the period prior to the first bleed and the periods following each subsequent bleed. The rate and cost of general practitioner (GP) consultations, prescriptions, and hospitalizations were also compared across these periods.
Results
The risk of clinically relevant bleeding events was observed to be elevated at least twofold in all periods following the first bleeding event. The risk of VTE, stroke, and MI was not found to differ according to the number of clinically relevant bleeding events. The rate and cost of GP consultations, GP prescriptions, and hospitalizations were increased in all periods relative to the period prior to the first bleed.
Conclusions
The doubling in the risk of bleeding following the first bleed, taken alongside the stable risk of MI, VTE, and stroke, suggests that the risk–benefit balance for VKA treatment should be reconsidered following the first clinically relevant bleed.
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Affiliation(s)
- Raza Alikhan
- Haemophilia and Thrombosis Centre, University Hospital of Wales, Cardiff, United Kingdom
| | - Cinira Lefevre
- Center of Observational Research and Data Sciences, Bristol-Myers Squibb, Rueil-Malmaison, France
| | - Ian Menown
- Craigavon Cardiac Centre, Craigavon, United Kingdom
| | - Steven Lister
- UK Health Economics and Outcomes Research, Bristol-Myers Squibb, Uxbridge, United Kingdom
| | - Alex Bird
- Health Economics and Outcomes Research, Pfizer, Surrey, United Kingdom
| | - Min You
- Center of Observational Research and Data Sciences, Bristol-Myers Squibb, Plainsboro, New Jersey, United States
| | - David Evans
- Center of Observational Research and Data Sciences, Bristol-Myers Squibb, Rueil-Malmaison, France
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21
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Ramagopalan SV, Samnaliev M, Weir S, Sammon CJ, Carroll R, Alikhan R. Costs of gastrointestinal bleeding events in atrial fibrillation: a UK Clinical Practice Research Datalink study. Future Cardiol 2019; 15:367-375. [DOI: 10.2217/fca-2019-0033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To estimate the healthcare costs attributable to gastrointestinal (GI) bleeds in nonvalvular atrial fibrillation (NVAF) patients. Material & methods: A difference-in-differences approach was used in which NVAF patients suffering a (GI) bleed were propensity score matched to those not suffering a GI bleed, and the difference in healthcare costs in the year prior to the GI bleed and the subsequent 3 years was compared between the two groups. Results: The mean cost attributable to GI bleeds was £3989 (p < 0.0001) in the year of the bleed and £1816 (p = 0.001) in the subsequent year. Attributable costs arose primarily from inpatient visits. Conclusion: GI bleeds among NVAF patients are associated with significant healthcare costs up to 2 years following the bleed.
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Affiliation(s)
- Sreeram V Ramagopalan
- Centre for Observational Research & Data Sciences, Bristol-Myers Squibb, Uxbridge, UB8 1DH, UK
| | - Mihail Samnaliev
- PHMR Ltd, Berkeley Works, Berkley Grove, London, NW1 8XY, UK
- Harvard Medical School, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA
| | - Sharada Weir
- PHMR Ltd, Berkeley Works, Berkley Grove, London, NW1 8XY, UK
| | - Cormac J Sammon
- PHMR Ltd, Berkeley Works, Berkley Grove, London, NW1 8XY, UK
| | - Robert Carroll
- Centre for Observational Research & Data Sciences, Bristol-Myers Squibb, Uxbridge, UB8 1DH, UK
| | - Raza Alikhan
- Haemophilia & Thrombosis Centre, University Hospital of Wales, Cardiff, CF14 4XW, UK
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22
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Slade R, Alikhan R, Wise MP, Germain L, Stanworth S, Morgan M. Impact of blood group on survival following critical illness: a single-centre retrospective observational study. BMJ Open Respir Res 2019; 6:e000426. [PMID: 31321058 PMCID: PMC6606056 DOI: 10.1136/bmjresp-2019-000426] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 03/08/2019] [Revised: 06/13/2019] [Accepted: 06/17/2019] [Indexed: 01/28/2023] Open
Abstract
Background Predicting patient outcomes following critical illness is challenging. Recent evidence has suggested that patients with blood group AB are more likely to survive following major cardiac surgery, and this is associated with a reduced number of blood transfusions. However, there are no current data to indicate whether a patient’s blood group affects general intensive care outcomes. Objective The objective of this study was to determine if ABO blood group affects survival in intensive care. The primary outcome measure was 90-day mortality with a secondary outcome measure of the percentage of patients receiving a blood transfusion. Design Retrospective analysis of electronically collected intensive care data, blood group and transfusion data. Setting General intensive care unit (ICU) of a major tertiary hospital with both medical and surgical patients. Patients All patients admitted to ICU between 2006 and 2016 who had blood group data available. Intervention None. Measurements and main results 7340 patients were included in the study, blood group AB accounted for 3% (221), A 41% (3008), B 10.6% (775) and O 45.4% (3336). These values are similar to UK averages. Baseline characteristics between the groups were similar. Blood group AB had the greatest survival benefit (blood group AB 90-day survival estimate 76.75, 95% CI 72.89 to 80.61 with the overall estimate 72.07, 95% CI 71.31 to 72.82) (log-rank χ2 16.128, p=0.001). Transfusion requirements were similar in all groups with no significant difference between the percentages of patients transfused (AB 23.1%, A 21.5%, B 18.7%, O 19.9%, Pearson χ2 5.060 p=0.167). Conclusion Although this is primarily a hypothesis generating study, intensive care patients with blood group AB appeared to have a higher 90-day survival compared with other blood groups. There was no correlation between blood group and percentage of patients receiving transfusion.
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Affiliation(s)
- Robert Slade
- Adult Critical Care, University Hospital of Wales, Cardiff and Vale University Healthcare NHS Trust, Cardiff, UK
| | - Raza Alikhan
- Department of Haematology, University Hospital of Wales, Cardiff and Vale University Healthcare NHS Trust, Cardiff, UK
| | - Matt P Wise
- Adult Critical Care, University Hospital of Wales, Cardiff and Vale University Healthcare NHS Trust, Cardiff, UK
| | - Lam Germain
- Adult Critical Care, University Hospital of Wales, Cardiff and Vale University Healthcare NHS Trust, Cardiff, UK
| | - Simon Stanworth
- Departement of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Matt Morgan
- Adult Critical Care, University Hospital of Wales, Cardiff and Vale University Healthcare NHS Trust, Cardiff, UK
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23
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Allan V, Sammon CJ, McDonald L, Mehmud F, Alikhan R, Ramagopalan SV. Impact of atrial fibrillation awareness campaigns: interrupted time series using the Clinical Practice Research Datalink. Future Cardiol 2019; 15:311-318. [PMID: 31241353 DOI: 10.2217/fca-2019-0025] [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: 11/21/2022] Open
Abstract
Aim: This study investigated whether the rates of atrial fibrillation (AF) consultations changed following AF awareness campaigns in England. Materials & methods: Among adults in the Clinical Practice Research Datalink, Poisson regression was used to model weekly rates of AF-related consultations over time. The models were used to assess whether rates changed in the 8 weeks following World Heart Rhythm Week (WHRW) and Global AF aware week. Results: A higher incidence of pulse checks was observed following WHRW (IRR 1.16 [95% CI 1.08-1.24]). No difference in the incidence of AF diagnoses was noted following WHRW (IRR: 1.03 [95% CI: 0.97-1.09]) or Global AF aware week (IRR: 0.94 [95% CI: 0.88-1.00]). Conclusion: The results suggest AF campaigns may increase awareness but do not bring about short-term increases in the rates of AF diagnoses.
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Affiliation(s)
- Victoria Allan
- Centre for Observational Research & Data Sciences, Bristol-Myers Squibb, Uxbridge, UB8 1DH, UK
| | - Cormac J Sammon
- PHMR Ltd, Berkeley Works, Berkley Grove, London, NW1 8XY, UK
| | - Laura McDonald
- Centre for Observational Research & Data Sciences, Bristol-Myers Squibb, Uxbridge, UB8 1DH, UK
| | | | - Raza Alikhan
- Department of Haematology, Cardiff & Vale University Health Board, University Hospital of Wales, Cardiff, Wales, UK
| | - Sreeram V Ramagopalan
- Centre for Observational Research & Data Sciences, Bristol-Myers Squibb, Uxbridge, UB8 1DH, UK
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24
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Ramagopalan SV, Stamp E, Sammon CJ, Besford M, Carroll R, Mehmud F, Alikhan R. Renal function and oral anticoagulant treatment of incident non-valvular atrial fibrillation: a retrospective study. Future Cardiol 2019; 15:301-309. [PMID: 31140872 DOI: 10.2217/fca-2019-0012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To describe the renal function of individuals newly diagnosed with non-valvular atrial fibrillation in England, and describe how oral anticoagulant (OAC) treatment varies according to renal function. Patients & methods: We identified a cohort of individuals with non-valvular atrial fibrillation (n = 18,419) and described their renal function at diagnosis and the prevalence of OAC treatment initiation by renal function. Results: 79% of individuals had some evidence of renal dysfunction with 12% having a glomerular filtration rate <30 ml/min/1.73 m2. OAC treatment initiation in the 6 months following diagnosis was lower in individuals with severe renal dysfunction than in those with normal renal function. Conclusion: The high prevalence of renal dysfunction and low OAC treatment prevalence highlights the need for additional evidence regarding OACs in individuals with severe renal dysfunction.
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Affiliation(s)
- Sreeram V Ramagopalan
- Centre for Observational Research & Data Sciences, Bristol-Myers Squibb, UB8 1DH, UK
| | | | | | | | - Robert Carroll
- Centre for Observational Research & Data Sciences, Bristol-Myers Squibb, UB8 1DH, UK
| | | | - Raza Alikhan
- Department of Haematology, University Hospital of Wales, Cardiff & Vale University Health Board, Cardiff, CF14 4XW, UK
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25
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Ramagopalan SV, Carroll R, Ulvestad M, Mehmud F, Alikhan R. The changing face of venous thromboembolism management in England. Future Cardiol 2019; 15:183-185. [DOI: 10.2217/fca-2019-0003] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Aim: Venous thromboembolism (VTE), which comprises deep vein thrombosis and pulmonary embolism, poses a global disease burden. Vitamin K antagonists have traditionally been the mainstay of treatment; however, the non-vitamin K oral anticoagulants (NOACs) are emerging as an alternative. The relative use of these treatment classes in the real world is unknown. Patients & methods: We performed a retrospective study using data from the UK Clinical Practice Research Datalink to understand VTE treatment patterns. Results: NOACs have unseated vitamin K antagonist as the main form of VTE patient treatment in England. Conclusion: The data highlight how comfortable physicians have become in using NOACs to treat VTE in England and it is likely that the increasing use of NOACs will continue.
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Affiliation(s)
- Sreeram V Ramagopalan
- Centre for Observational Research & Data Sciences, Bristol-Myers Squibb, Uxbridge UB8 1DH, UK
| | - Robert Carroll
- Centre for Observational Research & Data Sciences, Bristol-Myers Squibb, Uxbridge UB8 1DH, UK
| | - Maria Ulvestad
- Medical Department, Bristol-Myers Squibb, 1366 Lysaker, Norway
| | - Faisal Mehmud
- Medical Department, Bristol-Myers Squibb, Uxbridge UB8 1DH, UK
| | - Raza Alikhan
- Haemophilia & Thrombosis Centre, University Hospital Wales, Cardiff, UK
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26
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Ramagopalan SV, Graham S, Carroll R, Raluy-Callado M, Nordstrom BL, Donaldson R, Colby C, Mehmud F, Alikhan R. Discontinuation and primary care visits in nonvalvular atrial fibrillation patients treated with apixaban or warfarin. J Comp Eff Res 2019; 8:371-379. [DOI: 10.2217/cer-2019-0005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Aim: Nonvalvular atrial fibrillation (NVAF) requires long-term anticoagulation treatment, which may necessitate frequent primary care visits. Materials & methods: NVAF patients initiating warfarin or apixaban in 2012–2017 were identified from linked primary (Clinical Practice Research Datalink) and secondary care (Hospital Episode Statistics) data. A propensity score matched Cox regression model compared discontinuation risk. Primary care visits were compared via negative binomial regression. Results: A total of 2695 apixaban users were matched to warfarin patients. Discontinuation risk was lower with apixaban than warfarin (hazard ratio: 0.40; 95% CI: 0.35–0.46). Apixaban patients averaged 12.2 annual primary care visits, versus 17.1 for warfarin users (p < 0.001). Conclusion: Apixaban was associated with reduced rates of discontinuation and primary care visits compared with warfarin.
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Affiliation(s)
- Sreeram V Ramagopalan
- Centre for Observational Research & Data Sciences, Bristol-Myers Squibb, Uxbridge, UB8 1DH, UK
| | | | - Robert Carroll
- Centre for Observational Research & Data Sciences, Bristol-Myers Squibb, Uxbridge, UB8 1DH, UK
| | | | | | | | - Chris Colby
- Evidera, Real-World Evidence, San Francisco, CA 94111, USA
| | | | - Raza Alikhan
- Department of Haematology, University Hospital of Wales, Cardiff, CF14 4XW, UK
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27
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Green L, Tan J, Antoniou S, Alikhan R, Curry N, Everington T, Saja K, Stanworth S, Tait C, Morris JK, MacCallum P. Haematological management of major bleeding associated with direct oral anticoagulants –
UK
experience. Br J Haematol 2019; 185:514-522. [DOI: 10.1111/bjh.15808] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 12/26/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Laura Green
- Barts and the London School of Medicine and Dentistry Queen Mary University of LondonLondonUK
- Barts Health NHS Trust London UK
- NHS Blood and Transplant, Colindale LondonUK
| | - Joachim Tan
- Barts and the London School of Medicine and Dentistry Queen Mary University of LondonLondonUK
| | - Sotiris Antoniou
- Barts and the London School of Medicine and Dentistry Queen Mary University of LondonLondonUK
| | - Raza Alikhan
- University Hospital of Wales Cardiff and Vale University Health Board CardiffUK
| | - Nicola Curry
- Department of Haematology Oxford University Hospitals NHS Foundation TrustOxfordUK
- Radcliffe Department of Medicine University of Oxford Oxford BRC Haematology Theme OxfordUK
| | - Tamara Everington
- Hampshire Hospitals NHS Foundation Trust BasingstokeUK
- Salisbury NHS Foundation Trust SalisburyUK
| | - Khalid Saja
- Barking, Havering and Redbridge University Hospitals NHS Trust RomfordUK
| | - Simon Stanworth
- Department of Haematology Oxford University Hospitals NHS Foundation TrustOxfordUK
- Radcliffe Department of Medicine University of Oxford Oxford BRC Haematology Theme OxfordUK
- Transfusion Medicine NHS Blood and Transplant Oxford UK
| | - Campbell Tait
- Glasgow Royal Infirmary NHS Greater Glasgow and Clyde Glasgow UK
| | - Joan K. Morris
- Barts and the London School of Medicine and Dentistry Queen Mary University of LondonLondonUK
| | - Peter MacCallum
- Barts and the London School of Medicine and Dentistry Queen Mary University of LondonLondonUK
- Barts Health NHS Trust London UK
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28
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Hickey BA, Cleves A, Alikhan R, Pugh N, Nokes L, Perera A. Can we use biomarkers of coagulation to predict which patients with foot and ankle injury will develop deep vein thrombosis? Foot Ankle Surg 2019; 25:59-62. [PMID: 29409258 DOI: 10.1016/j.fas.2017.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 07/11/2017] [Accepted: 08/04/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Our aim was to determine whether plasma levels of Tissue Factor (TF), Vascular Cell Adhesion Molecule 1 (VCAM-1), Interleukin 6 (IL-6) or D-dimer after foot and ankle injury could predict which patients would develop deep vein thrombosis (DVT). METHODS Patients aged 18-60 years with acute foot and ankle injury had venous blood sample to measure TF, VCAM-1, IL-6 and D-dimer within 3 days of injury. Patients had bilateral lower limb venous ultrasound to assess for DVT on discharge from clinic. RESULTS 21 of 77 patients were found to have DVT (27%). There was no statistically significant association between levels of TF, VCAM-1, IL-6 or D-dimer and subsequent development of DVT. CONCLUSION Tissue Factor (TF), Vascular Cell Adhesion Molecule-1 (VCAM-1), Interleukin-6 (IL-6) and D-dimer levels were not associated with development deep vein thrombosis in patients with acute foot and ankle injury.
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Affiliation(s)
- Ben A Hickey
- University Hospital of Wales, Heath Park, Cardiff CF14 4XW, Wales, UK.
| | - Andrew Cleves
- University Hospital of Wales, Heath Park, Cardiff CF14 4XW, Wales, UK
| | - Raza Alikhan
- University Hospital of Wales, Heath Park, Cardiff CF14 4XW, Wales, UK
| | - Neil Pugh
- University Hospital of Wales, Heath Park, Cardiff CF14 4XW, Wales, UK
| | - Len Nokes
- Cardiff University, Cardiff, Wales, UK
| | - Anthony Perera
- University Hospital of Wales, Heath Park, Cardiff CF14 4XW, Wales, UK
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Alikhan R, Roberts H. Diagnosis of pulmonary embolism: should we wait YEARS? Br J Haematol 2018; 183:165-167. [DOI: 10.1111/bjh.15555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Raza Alikhan
- Thrombosis and Haemostasis Centre; University Hospital of Wales; Cardiff UK
| | - Heledd Roberts
- Thrombosis and Haemostasis Centre; University Hospital of Wales; Cardiff UK
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Jennings I, Perry D, Watson H, Alikhan R, Laffan M, Gomez K, Kitchen S, Walker I. Quality assurance and tests of platelet function. Br J Haematol 2018; 181:560-561. [PMID: 28653330 DOI: 10.1111/bjh.14668] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | - David Perry
- Cambridge Haemophilia & Thrombophilia Centre, Cambridge University Hospital NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Henry Watson
- Department of Haematology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Raza Alikhan
- Haemophilia and Thrombosis Centre, University Hospital of Wales, Cardiff, UK
| | - Mike Laffan
- Department of Haematology, Hammersmith Hospital, London, UK
| | - Keith Gomez
- Haemophilia Centre and Thrombosis Unit Royal Free Hospital, London, UK
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Hickey BA, Watson U, Cleves A, Alikhan R, Pugh N, Nokes L, Perera A. Does thromboprophylaxis reduce symptomatic venous thromboembolism in patients with below knee cast treatment for foot and ankle trauma? A systematic review and meta-analysis. Foot Ankle Surg 2018; 24:19-27. [PMID: 29413769 DOI: 10.1016/j.fas.2016.06.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 06/24/2016] [Accepted: 06/29/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Our aim was to determine the evidence for thromboprophylaxis for prevention of symptomatic venous thromboembolism (VTE) in adults with foot or ankle trauma treated with below knee cast or splint. Our secondary aim was to report major bleeding events. METHODS MEDLINE and EMBASE databases were searched for randomized controlled trials from inception to 1st June 2015. RESULTS Seven studies were included. All focused on low molecular weight heparin (LMWH). None found a statistically significant symptomatic DVT reduction individually. At meta-analysis LMWH was protective against symptomatic DVT (OR 0.29, 95% CI 0.09-0.95). Symptomatic pulmonary embolism affected 3/692 (0.43%). None were fatal. 86 patients required LMWH thromboprophylaxis to prevent one symptomatic DVT event. The overall incidence of major bleeding was 1 in 886 (0.11%). CONCLUSIONS Low molecular weight heparin reduces the incidence of symptomatic VTE in adult patients with foot or ankle trauma treated with below knee cast or splint.
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Affiliation(s)
- Ben A Hickey
- University Hospital of Wales, Heath Park, Cardiff CF14 4XW, Wales, UK.
| | - Ultan Watson
- University Hospital of Wales, Heath Park, Cardiff CF14 4XW, Wales, UK
| | - Andrew Cleves
- University Hospital of Wales, Heath Park, Cardiff CF14 4XW, Wales, UK
| | - Raza Alikhan
- University Hospital of Wales, Heath Park, Cardiff CF14 4XW, Wales, UK
| | - Neil Pugh
- University Hospital of Wales, Heath Park, Cardiff CF14 4XW, Wales, UK
| | - Len Nokes
- Cardiff University, Cardiff, Wales, UK
| | - Anthony Perera
- University Hospital of Wales, Heath Park, Cardiff CF14 4XW, Wales, UK
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32
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Green L, Tan J, Morris JK, Alikhan R, Curry N, Everington T, Maclean R, Saja K, Stanworth S, Tait C, MacCallum P. A three-year prospective study of the presentation and clinical outcomes of major bleeding episodes associated with oral anticoagulant use in the UK (ORANGE study). Haematologica 2018; 103:738-745. [PMID: 29371325 PMCID: PMC5865412 DOI: 10.3324/haematol.2017.182220] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 01/22/2018] [Indexed: 12/15/2022] Open
Abstract
The outcomes of patients developing major bleeding while on oral anticoagulants remain largely unquantified. The objectives of this study were to: (i) describe the burden of major hemorrhage associated with all available oral anticoagulants in terms of proportion of bleeds which are intracranial hemorrhages, in-hospital mortality and duration of hospitalization following major bleeding; (ii) identify risk factors for mortality; and (iii) compare the characteristics of major hemorrhage between cases treated with warfarin and direct oral anticoagulants for the subgroups of patients with atrial fibrillation or venous thromboembolism. This was a multicenter, 3-year prospective cohort study of patients aged ≥18 years on oral anticoagulants who developed major hemorrhage leading to hospitalization. The patients were followed up for 30 days or until discharge or death, whichever occurred first. In total 2,192 patients (47% female, 81% on warfarin, median age 80 years) were reported between October 2013 and August 2016 from 32 hospitals in the UK. Bleeding sites were intracranial (44%), gastrointestinal (33%), and other (24%). The in-hospital mortality was 21% (95% CI: 19%-23%) overall, and 33% (95% CI: 30%-36%) for patients with intracranial hemorrhage. Intracranial hemorrhage, advanced age, spontaneous bleeding, liver failure and cancer were risk factors for death. Compared to warfarin-treated patients, patients treated with direct oral anticoagulants were older and had lower odds of subdural/epidural, subarachnoid and intracerebral bleeding. The mortality rate due to major bleeding was not different between patients being treated with warfarin or direct oral anticoagulants. Major bleeding while on oral anticoagulant therapy leads to considerable hospital stays and short-term mortality.
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Affiliation(s)
- Laura Green
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK .,Barts Health NHS Trust, London, UK.,NHS Blood and Transplant, Colindale, UK
| | - Joachim Tan
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK
| | - Joan K Morris
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK
| | - Raza Alikhan
- University Hospital of Wales, Cardiff and Vale University Health Board, UK
| | - Nicola Curry
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, and Oxford BRC Haematology Theme, UK
| | - Tamara Everington
- Hampshire Hospitals NHS Foundation Trust, UK.,Salisbury NHS Foundation Trust, UK
| | - Rhona Maclean
- Sheffield Teaching Hospitals NHS Foundation Trust, UK
| | - Khalid Saja
- Barking, Havering and Redbridge University Hospitals NHS Trust, UK
| | - Simon Stanworth
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, and Oxford BRC Haematology Theme, UK.,Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
| | - Campbell Tait
- Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, UK
| | - Peter MacCallum
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK.,Barts Health NHS Trust, London, UK
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Bailey CS, Alikhan R, Cooper DJ, Cohen AT. Extended Thromboprophylaxis with Low Molecular Weight Heparin Reduces Symptomatic Venous Thromboembolism following Lower Limb Arthroplasty - a Meta-analysis. Thromb Haemost 2017. [DOI: 10.1055/s-0037-1615775] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Noble S, Alikhan R, Robbins A, Macbeth F, Hood K. Predictors of active cancer thromboembolic outcomes: validation of the Khorana score among patients with lung cancer: comment. J Thromb Haemost 2017; 15:590-591. [PMID: 27992116 DOI: 10.1111/jth.13594] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 12/02/2016] [Indexed: 11/30/2022]
Affiliation(s)
- S Noble
- Cardiff University, Cardiff, UK
| | - R Alikhan
- University Hospital of Wales, Cardiff, UK
| | | | | | - K Hood
- Cardiff University, Cardiff, UK
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Noble S, Pease N, Sui J, Davies J, Lewis S, Malik U, Alikhan R, Prout H, Nelson A. Impact of a dedicated cancer-associated thrombosis service on clinical outcomes: a mixed-methods evaluation of a clinical improvement exercise. BMJ Open 2016; 6:e013321. [PMID: 27895068 PMCID: PMC5168504 DOI: 10.1136/bmjopen-2016-013321] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 08/17/2016] [Accepted: 10/12/2016] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES Cancer-associated thrombosis (CAT) complex condition, which may present to any healthcare professional and at any point during the cancer journey. As such, patients may be managed by a number of specialties, resulting in inconsistent practice and suboptimal care. We describe the development of a dedicated CAT service and its evaluation. SETTING Specialist cancer centre, district general hospital and primary care. PARTICIPANTS Patients with CAT and their referring clinicians. INTERVENTION A cross specialty team developed a dedicated CAT service , including clear referral pathways, consistent access to medicines, patient's information and a specialist clinic. PRIMARY AND SECONDARY OUTCOME MEASURES The service was evaluated using a mixed-methods evaluation , including audits of clinical practice, clinical outcomes, staff surveys and qualitative interviewing of patients and healthcare professionals. RESULTS Data from 457 consecutive referrals over an 18-month period were evaluated. The CAT service has led to an 88% increase in safe and consistent community prescribing of low-molecular-weight heparin, with improved access to specialist advice and information. Patients reported improved understanding of their condition, enabling better self-management as well as better access to support and information. Referring clinicians reported better care standards for their patients with improved access to expertise and appropriate management. CONCLUSIONS A dedicated CAT service improves overall standards of care and is viewed positively by patients and clinicians alike. Further health economic evaluation would enhance the case for establishing this as the standard model of care.
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Affiliation(s)
- Simon Noble
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | | | | | | | - Sarah Lewis
- Department of Haematology, Neville Hall Hospital, Abergavenny, UK
| | | | - Raza Alikhan
- Haemophilia and Thrombosis Centre, University Hospital of Wales, Cardiff, UK
| | - Hayley Prout
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - Annmarie Nelson
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
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Biss T, Alikhan R, Payne J, Alamelu J, Williams M, Richards M, Mathias M, Tunstall O, Chalmers E. Venous thromboembolism occurring during adolescence. Arch Dis Child 2016; 101:427-32. [PMID: 26787610 DOI: 10.1136/archdischild-2015-309875] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [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: 10/16/2015] [Accepted: 12/17/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Risk assessment for venous thromboembolism (VTE) and thromboprophylaxis in those with risk factors is established in adult practice. Evidence to support efficacy and safety of this approach in adolescents is lacking. We aimed to describe thrombotic risk factors and to determine the proportion of potentially preventable events in a retrospective cohort study of adolescents with VTE. DESIGN, SETTING AND PATIENTS Data were collected between 2008 and 2014 from eight tertiary UK centres. Qualifying events were radiologically confirmed VTE in subjects aged 12-17 years. Central venous line-related upper venous system events were excluded. RESULTS 76 cases were identified, 41 males, median age 15 years. Frequent risk factors were: reduced mobility, 45%; thrombophilia, 24%; malignancy, 20%; surgery, 18%; combined oral contraceptive pill, 12%; congenital venous anomaly, 5%. 28 (37%) had no significant underlying diagnosis and no provoking event/hospitalisation, presenting as outpatients with VTE which was considered 'unpreventable'. Of 48 where there had been opportunity for risk assessment, chemical thromboprophylaxis was not indicated in 26 and was contraindicated in 8. 14/76 (18%) had an indication to consider thromboprophylaxis and no contraindication. Of these, four had cerebral palsy, five malignancy and two inflammatory bowel disease. All had reduced mobility with recent surgery in eight. Four received chemical thromboprophylaxis prior to presentation. CONCLUSIONS Among a cohort of adolescents with VTE, a small proportion (13%) had an indication to consider chemical thromboprophylaxis but did not receive it. VTE risk assessment and prevention should focus on adolescents with immobility or surgery, particularly in those with malignancy.
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Affiliation(s)
- Tina Biss
- Department of Haematology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Raza Alikhan
- Haemophilia and Thrombosis Centre, University Hospital of Wales, Cardiff, UK
| | - Jeanette Payne
- Department of Haematology, Sheffield Children's Hospital, Sheffield, UK
| | - Jayanthi Alamelu
- Department of Haematology, Evelina London Children's Hospital, London, UK
| | - Michael Williams
- Department of Haematology, Birmingham Children's Hospital NHS Trust, Birmingham, UK
| | - Michael Richards
- Department of Paediatric Haematology, Leeds Children's Hospital, Leeds, UK
| | - Mary Mathias
- Haematology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Oliver Tunstall
- Department of Haematology, The University Hospitals Bristol NHS Trust, Bristol, UK
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Obaji S, Alikhan R, Rayment R, Carter P, Macartney N, Collins P. Unclassified bleeding disorders: outcome of haemostatic challenges following tranexamic acid and/or desmopressin. Haemophilia 2015; 22:285-291. [PMID: 26422253 DOI: 10.1111/hae.12811] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2015] [Indexed: 11/29/2022]
Abstract
INTRODUCTION In a minority of patients with a significant bleeding history no cause is found despite extensive testing and we diagnose such cases as unclassified bleeding disorders (UBD). UBDs may have diverse underlying causes and currently no standard management strategy exists in the event of a haemorrhage or to cover surgery. AIM To document the clinical characteristics and response to treatment of UBDs. METHODS We performed a retrospective chart review of all patients with UBDs who had an invasive procedure at our centre between 1998 and 2014. RESULTS The commonest symptoms were menorrhagia (89%) and bleeding at the time of surgery (88%) or dental extraction (85%). A total of 33 patients underwent 78 minor and major haemostatic challenges. Haemostatic cover was provided in 28 procedures with tranexamic acid alone, two with desmopressin and 45 with both agents in combination. A successful haemostatic outcome was observed in 70/78 (90%) cases. No patient required additional surgical intervention to achieve haemostasis, but one patient required a platelet transfusion to control postoperative bleeding. CONCLUSIONS This is the first study to report on the investigation and treatment of UBD. Future studies are needed to further our understanding of the bleeding phenotype and identify any underlying causes.
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Affiliation(s)
- S Obaji
- Department of Haematology, School of Medicine, Cardiff University, Cardiff, UK
| | - R Alikhan
- Arthur Bloom Haemophilia Centre, University Hospital of Wales, Cardiff, UK
| | - R Rayment
- Arthur Bloom Haemophilia Centre, University Hospital of Wales, Cardiff, UK
| | - P Carter
- Arthur Bloom Haemophilia Centre, University Hospital of Wales, Cardiff, UK
| | - N Macartney
- Arthur Bloom Haemophilia Centre, University Hospital of Wales, Cardiff, UK
| | - P Collins
- Arthur Bloom Haemophilia Centre, University Hospital of Wales, Cardiff, UK
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Aawar N, Alikhan R, Bruynseels D, Cannings-John R, Collis R, Dick J, Elton C, Fernando R, Hall J, Hood K, Lack N, Mallaiah S, Maybury H, Nuttall J, Paranjothy S, Rayment R, Rees A, Sanders J, Townson J, Weeks A, Collins P. Fibrinogen concentrate versus placebo for treatment of postpartum haemorrhage: study protocol for a randomised controlled trial. Trials 2015; 16:169. [PMID: 25906770 PMCID: PMC4408576 DOI: 10.1186/s13063-015-0670-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 03/24/2015] [Indexed: 11/28/2022] Open
Abstract
Background Postpartum haemorrhage (PPH) is a major cause of maternal morbidity. Bleeding is caused by a combination of physical causes, such as failure of the uterus to contract or operations, and is made worse by impairment of the blood clotting system. A number of studies have shown that low levels of the blood clotting factor fibrinogen are associated with progression of bleeding, the need for invasive interventions and transfusions of red blood cells and fresh frozen plasma (FFP). This trial will investigate whether early infusion of fibrinogen concentrate during a major PPH, with the aim of correcting a low fibrinogen to a level that is normal for delivery, based on the Fibtem test, reduces the total number of allogeneic blood products (red blood cells, FFP, cryoprecipitate and platelets) transfused after study medication until discharge, compared to placebo. Methods/design This is a prospective, randomised, double-blind placebo controlled trial. Women will enter an observational phase and if their Fibtem levels fall they will be randomised in the interventional phase. A total of 60 women will be randomised and women are eligible for the trial if they meet all of the following inclusion criteria: age 18 years or over, gestation ≥24 + 0 weeks, haemorrhage of about 1500 ml and on-going bleeding without another complication or haemorrhage of about 1000 ml and caesarean section/uterine atony/placental abruption/placenta praevia/cardiovascular instability or microvascular oozing. Participants with a Fibtem A5 < 16 mm will be randomly allocated to receive either a bolus infusion of fibrinogen concentrate or placebo (isotonic saline). The dose of fibrinogen concentrate or placebo will be calculated based on the woman’s ideal body weight for height and the measured Fibtem A5 with the aim of increasing the Fibtem A5 to 23 mm. Discussion The trial aims to provide evidence on the efficacy and safety of fibrinogen concentrate during acute bleeding in an obstetric setting. Trial registration ISRCTN ref: ISRCTN46295339 (01.07.2013); EudraCT: 2012-005511-11 (28.11.2012), UKCRN ref: 13940.
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Affiliation(s)
- Nadine Aawar
- Innovation, Methodology and Engagement, South East Wales Trials Unit, Institute of Translation, Cardiff University School of Medicine, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK.
| | - Raza Alikhan
- Department of Haematology, Cardiff and Vale University Health Board, Cardiff, UK.
| | - Daniel Bruynseels
- Department of Anaesthetics and Pain Control, Cardiff and Vale University Health Board, Cardiff, UK.
| | - Rebecca Cannings-John
- Innovation, Methodology and Engagement, South East Wales Trials Unit, Institute of Translation, Cardiff University School of Medicine, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK.
| | - Rachel Collis
- Department of Anaesthetics and Pain Control, Cardiff and Vale University Health Board, Cardiff, UK.
| | - John Dick
- Department of Anaesthetics, University College Hospital, London, UK.
| | - Christopher Elton
- Department of Anaesthetics, Leicester Royal Infirmary, Leicester, UK.
| | - Roshan Fernando
- Department of Anaesthetics, University College Hospital, London, UK.
| | - Judith Hall
- Department of Anaesthetics and Pain Control, Cardiff and Vale University Health Board, Cardiff, UK. .,Institute of Infection and Immunity, Critical Illness Research Group, Cardiff University School of Medicine, Cardiff, UK.
| | - Kerry Hood
- Innovation, Methodology and Engagement, South East Wales Trials Unit, Institute of Translation, Cardiff University School of Medicine, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK.
| | - Nicki Lack
- Department of Obstetrics, University College Hospital, London, UK.
| | - Shuba Mallaiah
- Department of Anaesthetics, Liverpool's Women's Hospital, Liverpool, UK.
| | - Helena Maybury
- Department of Obstetrics, Leicester Royal Infirmary, Leicester, UK.
| | - Jacqueline Nuttall
- Innovation, Methodology and Engagement, South East Wales Trials Unit, Institute of Translation, Cardiff University School of Medicine, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK.
| | - Shantini Paranjothy
- Institute of Primary Care and Public Health, Cardiff University School of Medicine, Cardiff, UK.
| | - Rachel Rayment
- Department of Obstetrics, Cardiff and Vale University Health Board, Cardiff, UK.
| | - Alexandra Rees
- Department of Obstetrics, Cardiff and Vale University Health Board, Cardiff, UK.
| | - Julia Sanders
- Innovation, Methodology and Engagement, South East Wales Trials Unit, Institute of Translation, Cardiff University School of Medicine, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK. .,Department of Obstetrics, Cardiff and Vale University Health Board, Cardiff, UK.
| | - Julia Townson
- Innovation, Methodology and Engagement, South East Wales Trials Unit, Institute of Translation, Cardiff University School of Medicine, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK.
| | - Andrew Weeks
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK.
| | - Peter Collins
- Department of Haematology, Cardiff and Vale University Health Board, Cardiff, UK. .,Institute of Infection and Immunity, Critical Illness Research Group, Cardiff University School of Medicine, Cardiff, UK.
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Obaji S, Jones C, Yates A, Gordon A, Wood A, Alikhan R, Collins P. Selective angiographic embolization for recurrent elbow and knee haemarthroses in haemophilia: a retrospective case series. Haemophilia 2015; 21:e226-e228. [DOI: 10.1111/hae.12629] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2014] [Indexed: 11/30/2022]
Affiliation(s)
- S. Obaji
- Department of Haematology; School of Medicine; Cardiff University; Cardiff UK
| | - C. Jones
- Department of Haematology; School of Medicine; Cardiff University; Cardiff UK
| | - A. Yates
- Department of Radiology; University Hospital of Wales; Cardiff UK
| | - A. Gordon
- Department of Radiology; University Hospital of Wales; Cardiff UK
| | - A. Wood
- Department of Radiology; University Hospital of Wales; Cardiff UK
| | - R. Alikhan
- Arthur Bloom Haemophilia Centre; University Hospital of Wales; Cardiff UK
| | - P. Collins
- Arthur Bloom Haemophilia Centre; University Hospital of Wales; Cardiff UK
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Affiliation(s)
- Gemma Scott
- Haemophilia and Thrombosis Centre; University Hospital of Wales; Cardiff UK
| | - Ali Jassem Mahdi
- Haemophilia and Thrombosis Centre; University Hospital of Wales; Cardiff UK
| | - Raza Alikhan
- Haemophilia and Thrombosis Centre; University Hospital of Wales; Cardiff UK
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Mumford AD, Ackroyd S, Alikhan R, Bowles L, Chowdary P, Grainger J, Mainwaring J, Mathias M, O'Connell N. Guideline for the diagnosis and management of the rare coagulation disorders: a United Kingdom Haemophilia Centre Doctors' Organization guideline on behalf of the British Committee for Standards in Haematology. Br J Haematol 2014; 167:304-26. [PMID: 25100430 DOI: 10.1111/bjh.13058] [Citation(s) in RCA: 191] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Andrew D Mumford
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
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Green L, Alikhan R, Curry N, Maclean R, Saja K, Stanworth S, Tait C, Tan J, Morris J, MacCallum P. Oral anticoagulant agent-associated bleeding events reporting system (ORANGE) study. Br J Haematol 2014; 167:274-6. [PMID: 24913255 DOI: 10.1111/bjh.12968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Laura Green
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK; Barts Health NHS Trust, London, UK; NHS Blood and Transplant, London, UK
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Alikhan R, Forster R, Cohen AT. Heparin for the prevention of venous thromboembolism in acutely ill medical patients (excluding stroke and myocardial infarction). Cochrane Database Syst Rev 2014; 2014:CD003747. [PMID: 24804622 PMCID: PMC6491079 DOI: 10.1002/14651858.cd003747.pub4] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Venous thromboembolic disease has been extensively studied in surgical patients. The benefit of thromboprophylaxis is now generally accepted, but it is medical patients who make up the greater proportion of the hospital population. Medical patients differ from surgical patients with regard to their health and the pathogenesis of thromboembolism and the impact that preventative measures can have. The extensive experience from thromboprophylaxis studies in surgical patients is therefore not necessarily applicable to non-surgical patients. This is an update of a review first published in 2009. OBJECTIVES To determine the effectiveness and safety of heparin (unfractionated heparin or low molecular weight heparin) thromboprophylaxis in acutely ill medical patients admitted to hospital, excluding those admitted to hospital with an acute myocardial infarction or stroke (ischaemic or haemorrhagic) or those requiring admission to an intensive care unit. SEARCH METHODS For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched November 2013) and CENTRAL (2013, Issue 10). SELECTION CRITERIA Randomised controlled trials comparing unfractionated heparin (UFH) or low molecular weight heparin (LMWH) with placebo or no treatment, or comparing UFH with LMWH. DATA COLLECTION AND ANALYSIS One review author identified possible trials and a second review author confirmed their eligibility for inclusion in the review. Two review authors extracted the data. Disagreements were resolved by discussion. We performed the meta-analysis using a fixed-effect model with the results expressed as odds ratios (ORs) with 95% confidence intervals (CIs). MAIN RESULTS Sixteen studies with a combined total of 34,369 participants with an acute medical illness were included in this review. We identified 10 studies comparing heparin with placebo or no treatment and six studies comparing LMWH to UFH. Just under half of the studies had an open-label design, putting them at a risk of performance bias. Descriptions of random sequence generation and allocation concealment were missing in most of the studies. Heparin reduced the odds of deep vein thrombosis (DVT) (OR 0.38; 95% CI 0.29 to 0.51; P < 0.00001). The estimated reductions in symptomatic non-fatal pulmonary embolism (PE) (OR 0.46; 95% CI 0.19 to 1.10; P = 0.08), fatal PE (OR 0.71; 95% CI 0.43 to 1.15; P = 0.16) and in combined non-fatal PE and fatal PE (OR 0.65; 95% CI 0.42 to 1.00; P = 0.05) associated with heparin were imprecise. Heparin resulted in an increase in major haemorrhage (OR 1.81; 95% CI 1.10 to 2.98; P = 0.02). There was no clear evidence that heparin had an effect on all-cause mortality and thrombocytopaenia. Compared with UFH, LMWH reduced the risk of DVT (OR 0.77; 95% CI 0.62 to 0.96; P = 0.02) and major bleeding (OR 0.43; 95% CI 0.22 to 0.83; P = 0.01). There was no clear evidence that the effects of LMWH and UFH differed for the PE outcomes, all-cause mortality and thrombocytopaenia. AUTHORS' CONCLUSIONS The data from this review describe a reduction in the risk of DVT in patients presenting with an acute medical illness who receive heparin thromboprophylaxis. This needs to be balanced against an increase in the risk of bleeding associated with thromboprophylaxis. The analysis favoured LMWH compared with UFH, with a reduced risk of both DVT and bleeding.
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Affiliation(s)
- Raza Alikhan
- University Hospital of WalesHaemophilia and Thrombosis CentreHeath ParkCardiffUKCF14 4XW
| | - Rachel Forster
- University of EdinburghUsher Institute of Population Health Sciences and InformaticsEdinburghUKEH8 9AG
| | - Alexander T Cohen
- Kings College HospitalDepartment of Vascular SurgeryDenmark HillLondonUKSE5 9RS
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Alikhan R, Rayment R, Keeling D, Baglin T, Benson G, Green L, Marshall S, Patel R, Pavord S, Rose P, Tait C. The acute management of haemorrhage, surgery and overdose in patients receiving dabigatran. Emerg Med J 2014; 31:163-8. [PMID: 23435652 PMCID: PMC3913117 DOI: 10.1136/emermed-2012-201976] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 01/06/2013] [Accepted: 01/07/2013] [Indexed: 12/20/2022]
Abstract
Dabigatran is an oral direct thrombin inhibitor (DTI) licensed for stroke prevention in atrial fibrillation and likely to be soon approved in Europe for treatment of venous thrombosis. Predictable pharmacokinetics and a reduced risk of intracranial haemorrhage do not negate the potential risk of haemorrhage. Unlike warfarin, there is no reversal agent and measurement of the anticoagulant effect is not 'routine'. The prothrombin time/international normalised ratio response to dabigatran is inconsistent and should not be measured when assessing a patient who is bleeding or needs emergency surgery. The activated partial thromboplastin time (APTT) provides a qualitative measurement of the anticoagulant effect of dabigatran. Knowledge of the time of last dose is important for interpretation of the APTT. Commercially available DTI assays provide a quantitative measurement of active dabigatran concentration in the plasma. If a patient receiving dabigatran presents with bleeding: omit/delay next dose of dabigatran; measure APTT and thrombin time (consider DTI assay if available); administer activated charcoal, with sorbitol, if within 2 h of dabigatran ingestion; give tranexamic acid (1 g intravenously if significant bleeding); maintain renal perfusion and urine output to aid dabigatran excretion. Dabigatran exhibits low protein binding and may be removed by dialysis. Supportive care should form the mainstay of treatment. If bleeding is life/limb threatening, consider an additional haemostatic agent. There is currently no evidence to support the choice of one haemostatic agent (FEIBA, recombinant factor VIIa, prothrombin complex concentrates) over another. Choice will depend on access to and experience with available haemostatic agent(s).
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Affiliation(s)
- Raza Alikhan
- Haemophilia and Thrombosis Centre, University Hospital of Wales, Cardiff, UK
| | - Rachel Rayment
- Haemophilia and Thrombosis Centre, University Hospital of Wales, Cardiff, UK
| | | | - Trevor Baglin
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Gary Benson
- Northern Ireland Haemophilia Centre and Thrombosis Unit, Belfast City Hospital, Belfast, UK
| | - Laura Green
- Department of Haematology, Barts and The London NHS Trust, London, UK
| | - Scott Marshall
- Department of Haematology, City Hospitals Sunderland NHS Foundation Trust, Sunderland, UK
| | - Raj Patel
- King's Thrombosis Centre, King's College Hospital, London, UK
| | - Sue Pavord
- Haemostasis & Thrombosis Unit, Leicester Haemophilia Centre, The Leicester Royal Infirmary, Leicester, UK
| | - Peter Rose
- Department of Haematology, Warwick Hospital, Warwick, UK
| | - Campbell Tait
- Department of Haematology, Glasgow Royal Infirmary, Glasgow, UK
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Abstract
Central venous catheters are commonly used in haematology departments for the administration of chemotherapy, blood products and parenteral nutrition in patients with haematological malignancy. Thrombosis is a recognized complication of such devices especially in oncology patients. Catheter-related thrombi (CRT) may lead to pulmonary embolism and infection, as well as catheter failure and potential delays in treatment. The vast majority of CRT are asymptomatic, thus a high index of suspicion is required in making the diagnosis. Doppler ultrasound or venography may be employed to identify CRT. Once confirmed, the initiation of treatment is a balance between the risks of anticoagulation against potential complications of CRT. A number of risk factors for CRT are discussed along with an overview of catheter types, their appropriate choice and intravascular positioning.
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Affiliation(s)
- Jim Murray
- Haemophilia and Thrombosis Centre, University Hospital of Wales, Cardiff, UK
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Keeling D, Alikhan R. Management of venous thromboembolism--controversies and the future. Br J Haematol 2013; 161:755-63. [PMID: 23531017 DOI: 10.1111/bjh.12306] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 02/18/2013] [Indexed: 11/30/2022]
Abstract
Despite the availability of comprehensive evidence-based guidelines there are difficult and controversial areas in the management of venous thromboembolism. Institutions and even countries disagree on the importance of calf vein thrombosis, with some rigorously detecting and treating it and others deliberately not looking for it. The need to treat proximal deep vein thrombosis and pulmonary embolism is accepted but which patients with an unprovoked first event should have long-term anticoagulation has become a difficult clinical decision. We are uncertain how to reduce the incidence of post-thrombotic syndrome seen in a substantial number of patients. How hard to look for an undiagnosed underlying cancer has become a contentious issue particularly in the United Kingdom following the recent publication of a guideline from the National Institute for Health and Clinical Excellence. Whilst we are wrestling with these dilemmas we are entering an era of new anticoagulants and have to solve the logistical problems of introducing them into clinical practice despite cost pressures. These issues will be explored in this review.
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Alikhan R, Rayment R, Keeling D, Baglin T, Benson G, Green L, Marshall S, Patel R, Pavord S, Rose P, Tait C. The acute management of haemorrhage, surgery and overdose in patients receiving dabigatran. Emerg Med J 2013. [PMID: 23435652 DOI: 10.1136/emermed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Dabigatran is an oral direct thrombin inhibitor (DTI) licensed for stroke prevention in atrial fibrillation and likely to be soon approved in Europe for treatment of venous thrombosis. Predictable pharmacokinetics and a reduced risk of intracranial haemorrhage do not negate the potential risk of haemorrhage. Unlike warfarin, there is no reversal agent and measurement of the anticoagulant effect is not 'routine'. The prothrombin time/international normalised ratio response to dabigatran is inconsistent and should not be measured when assessing a patient who is bleeding or needs emergency surgery. The activated partial thromboplastin time (APTT) provides a qualitative measurement of the anticoagulant effect of dabigatran. Knowledge of the time of last dose is important for interpretation of the APTT. Commercially available DTI assays provide a quantitative measurement of active dabigatran concentration in the plasma. If a patient receiving dabigatran presents with bleeding: omit/delay next dose of dabigatran; measure APTT and thrombin time (consider DTI assay if available); administer activated charcoal, with sorbitol, if within 2 h of dabigatran ingestion; give tranexamic acid (1 g intravenously if significant bleeding); maintain renal perfusion and urine output to aid dabigatran excretion. Dabigatran exhibits low protein binding and may be removed by dialysis. Supportive care should form the mainstay of treatment. If bleeding is life/limb threatening, consider an additional haemostatic agent. There is currently no evidence to support the choice of one haemostatic agent (FEIBA, recombinant factor VIIa, prothrombin complex concentrates) over another. Choice will depend on access to and experience with available haemostatic agent(s).
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Affiliation(s)
- Raza Alikhan
- Haemophilia and Thrombosis Centre, University Hospital of Wales, , Cardiff, UK
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Alikhan R, Rayment R, Baglin T, Benson G, Green L, Keeling D, Marshall S, Patel R, Pavord S, Rose P, Tait C. C0353 United Kingdom consensus based practical guide for the management of haemorrhage in patients receiving dabigatran. Thromb Res 2012. [DOI: 10.1016/j.thromres.2012.08.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Von Willebrand disease (vWD) is the most common hereditary bleeding disorder. The aim of therapy is to correct the dual hemostatic defect, due to defective platelet adhesion-aggregation and abnormal coagulation due to Factor VIII (FVIII) deficiency. The choice of treatment depends on a number of factors, including the severity of the bleed, the procedure planned, the subtype and severity of the disease and the age and morbidity of the patient. Desmopressin (DDAVP) is the treatment of choice for type 1 vWD as it increases endogenous release of FVIII and von Willebrand factor (vWF) and is also used in some subtypes of type 2 vWD. In those patients in whom DDAVP is ineffective or contraindicated, levels can be restored by infusing vWF:FVIII concentrates. The role of antifibrinolytic treatment is an important adjunct to replacement therapy during minor or major surgery involving mucosal surfaces. The dosing and timing of vWF:FVIII concentrates is important depending on the nature of the surgical procedure. The role of secondary prophylaxis needs to be further defined.
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Affiliation(s)
- Emma Tuohy
- Department of Haematology, University Hospital of Wales, Cardiff, UK
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