Blood circulation activating effect of Sanqi (Radix Notoginseng) on venous thromboembolism rat

OBJECTIVE

To explore the blood circulation activating effect and mechanism of Sanqi (Radix Notoginseng) in vivo, using a venous thromboembolism (VTE) rat model.

METHODS

We established the VTE rat model, and then intervened with low molecular weight heparin (LMWH), as well as low, medium and high doses of Sanqi (Radix Notoginseng), to observe the blood circulation activating effect of Sanqi (Radix Notoginseng) on VTE rats.

RESULTS

After the treatment with high concentrations of Sanqi (Radix Notoginseng), the pulmonary thromboembolism was alleviated, and the lower limb thrombosis was markedly improved. Moreover, the expression quantities of plasma activated partial thromboplastin time, prothrombin time and D-dimer, as well as endothelin, von Willebrand factor, and plasminogen activator inhibitor-1 in thrombosis segment tissues were markedly down-regulated; while those of nitric oxide and tissue-type plasminogen activator were up-regulated. After low and medium concentration Sanqi (Radix Notoginseng) treatment, no obvious improvement was observed in each index. Moreover, the high concentration Sanqi (Radix Notoginseng) showed comparable efficacy to the positive drug LMWH.

CONCLUSION

This data suggests that high concentration of Sanqi (Radix Notoginseng) is effective in preventing and treating VTE.

Systemic thrombosis in a large cohort of COVID-19 patients despite thromboprophylaxis: A retrospective study

Background

Incidence of thrombotic events associated to Coronavirus disease-2019 (COVID-19) is difficult to assess and reported rates differ significantly. Optimal thromboprophylaxis is unclear.

Objectives

We aimed to analyze the characteristics of patients with a confirmed thrombotic complication including inflammatory and hemostatic parameters, compare patients affected by arterial vs venous events and examine differences between survivors and non-survivors. We reviewed compliance with thromboprophylaxis and explored how the implementation of a severity-adjusted protocol could have influenced outcome.

Methods

Single-cohort retrospective study of COVID-19 patients admitted, from March 3 to May 3 2020, to the Infanta Leonor University Hospital in Madrid, epicenter of the Spanish outbreak.

Results

Among 1127 patients, 80 thrombotic events were diagnosed in 69 patients (6.1% of the entire cohort). Forty-three patients (62%) suffered venous thromboembolism, 18 (26%) arterial episodes and 6 (9%) concurrent venous and arterial thrombosis. Most patients (90%) with a confirmed thrombotic complication where under low-molecular-weight heparin treatment. Overt disseminated intravascular coagulation (DIC) was rare. Initial ISTH DIC score and pre-event CRP were significantly higher among non-survivors. In multivariate analysis, arterial localization was an independent predictor of mortality (OR = 18, 95% CI: 2.4–142, p < .05).

Conclusions

Despite quasi-universal thromboprophylaxis, COVID-19 lead to a myriad of arterial and venous thrombotic events. Considering the subgroup of patients with thrombotic episodes, arterial events appeared earlier in the course of disease and conferred very poor prognosis, and an ISTH DIC score ≥ 3 at presentation was identified as a potential predictor of mortality. Severity-adjusted thromboprophylaxis seemed to decrease the number of events and could have influenced mortality. Randomized controlled trials are eagerly awaited.

[Comparison on efficacy and safety of different bridging anticoagulation therapies in patients undergoing mechanical heart valve replacement surgery]

Objective: To evaluate the efficacy and safety of different bridging anticoagulant therapies in patients undergoing mechanical heart valve replacement (MHVR) surgery. Methods: Consecutive patients undergoing MHVR surgery from January 2018 to December 2018 in First Hospital of Lanzhou University were prospectively enrolled in this study. Patients were divided into unfractionated heparin (UFH) group and low molecular weight heparin (LMWH) group according to the postoperative bridging anticoagulation methods. Preoperative clinical data and postoperative related time and cost parameters, including drainage time, duration of stay in intensive care unit (ICU), postoperative time (interval from end of operation to discharge) and INR stabilization time (interval from start of bridge anticoagulation to INR value reaching the standard for 2 consecutive days) of all enrolled patients were collected, and all patients were followed up for 4 weeks and thromboembolic or bleeding events were analyzed. Multivariate logistic regression was used to determine the independent prognostic factors of thromboembolic or bleeding events after MHVR receiving various bridging anticoagulant therapies. Results: A total of 217 patients were included in the study, including 120 patients in the UFH group and 97 patients in the LMWH group. Stroke occurred in two patients in the UFH group, while no stroke event occurred in the LMWH group. The incidence of bleeding events was significantly higher (9.28%(9/97) vs. 1.67%(2/120), P=0.02), while the drainage time, duration of stay in ICU, postoperative time, INR stabilization time were all significantly shorter in LMWH group than in UFH group (all P<0.05). Multivariate logistic regression analysis showed that bridging anticoagulation therapies (OR=0.18, 95%CI 0.04-0.86, P=0.03), fibrinogen level (OR=1.99, 95%CI 1.16-3.41, P=0.01) and creatinine level (OR=1.05, 95%CI 1.01-1.08, P=0.04) were independent prognostic factors for bleeding events. Conclusion: LMWH use is associated with increased risk of bleeding events, but can significantly reduce the drainage time, duration of stay in ICU, postoperative time, INR stabilization time in patients post MHVR surgery.

Bullous hemorrhagic dermatosis due to enoxaparin use in a bullous pemphigoid patient

Adverse reactions of subcutaneous low molecular weight heparin or unfractionated heparin could be complications by bleeding, heparin-induced thrombocytopenia, drug-induced liver injury, osteoporosis, and cutaneous reactions. Heparin-induced skin lesions vary from allergic reactions like erythema, urticaria, eczema to intradermal microvascular thrombosis associated with heparin-induced thrombocytopenia. There is a rare cutaneous complication, called bullous hemorrhagic dermatosis. We experienced this rare case of the cutaneous complication caused by enoxaparin. Several tense bullous hemorrhagic lesions occurred after 3 days of enoxaparin in a known bullous pemphigoid patient who had aortic valve replacement surgery with a mechanical prosthesis. The bullous hemorrhagic lesions were regressed after the discontinuation of enoxaparin but recurred after re-administration. The lesions were controlled by the administration of systemic corticosteroid and alternative anticoagulant. To date, less than 20 cases have been reported worldwide. This is the first case of bullous hemorrhagic dermatosis induced by enoxaparin, a low-molecular-weight heparin in Korea. This is also the first case of bullous hemorrhagic dermatosis in a known bullous pemphigoid patient.

[Acute pulmonary embolism and contraindication of anticoagulation : Bedside implantation of a new temporary vena cava inferior filter]

Pulmonary embolism (PE), mostly caused by deep vein thrombosis, is a life-threatening complication in critically ill patients in the intensive care unit. A potential strategy to prevent PE in patients with contraindication for anticoagulant therapy is the implantation of a vena cava filter (VCF), to provide fast and safe PE protection against ascending thrombi. We report the case of a 56-year-old woman with an intracranial hemorrhage, who developed a PE. Because of acute contraindications for anticoagulant therapy, bedside implantation of a new VCF was performed to overcome the period of absolute contraindications for anticoagulation. After explanation, several thrombi were found on the filter.

Real life thromboprophylaxis in orthopedic surgery in Italy. Results of the GIOTTO study

INTRODUCTION

Data from a prospective, multicentre observational study (Studio GIOTTO) were analyzed to determine, in clinical practice, the pattern of VTE prophylaxis and adherence to international guidelines recommendations in major orthopedic surgery (MOS) - including total hip arthroplasty (THA), total knee arthroplasty (TKA) and hip fracture surgery (HFS) - and knee arthroscopic surgery (KAS).

METHODS

In 2010, the first consecutive 30 patients hospitalized in Italian centers for MOS and the first 15 for KAS were enrolled and treated according to the usual practice.

RESULTS

2010 patients were admitted for MOS (577 TKA, 787 THA and 646 HFS) and 993 for KAS; mean ± SD age was 71.7 ± 8 and 43.0 ± 15 years, and female prevalence was 65.6% and 31.1% in MOS and KAS, respectively. Most (66.7%; 95% CI: 65-69%) patients admitted for MOS received a combined VTE prophylaxis, consisting of both pharmacological and physical tools, and 33.2% (95% CI: 31-35%) only pharmacological. For KAS figures were 23.7 (95% CI: 21-26%) and 75.3% (95% CI: 72-77%). Most MOS (91%; 95% CI: 89-92%) and KAS (95% CI: 98-100%) patients receiving pharmacological thromboprophylaxis were treated with low molecular weight heparin (LMWH), for (median) 40 days in TKR, 39 days in THR, 44 in HFS, and 16 in KAS. Patients receiving <35 days of LMWH prophylaxis among those undergoing THR and HFS were 8.9% and 5.9%, respectively.

CONCLUSION

Although most patients undergoing orthopedic surgery received VTE prophylaxis, a gap between clinical practice and international guideline recommendations was observed. The reduced adherence to guideline recommendations is relevant for certain choices like type and duration of VTE, and physicians' behavior may reflect the changing approach of guidelines in their different editions.

Perioperative antithrombotic management in joint replacement surgeries

OBJECTIVES

To determine optimal perioperative antithrombotic management for patients with cardiac diseases undergoing joint replacement surgeries.

DATA SOURCES

MEDLINE and PubMed database search up to January 2013.

STUDY SELECTION

Those dealing with perioperative antithrombotic management of patients undergoing orthopaedic operations, especially joint replacement, and also those undergoing general surgery. Various combinations of the following key words were used in our search: "antiplatelet", "antithrombotic", "anticoagulant", "coronary stent", "perioperative", "venous thromboembolism", "cardiovascular", "surgery", "orthopaedic", "knee replacement", "hip replacement", "joint replacement", and "arthroplasty".

DATA EXTRACTION

Literature review, original articles, and best practice guidelines.

DATA SYNTHESIS

Patients should be stratified according to their risk of developing arterial thromboembolism in order to decide the most appropriate perioperative antiplatelet or anticoagulant regimen for them. After recent coronary stenting, including bare-metal stents implanted within 6 weeks and drug-eluting stents implanted within 6 months, surgery should be deferred. For venous thromboembolism prophylaxis in patients already on aspirin, the dosage should be adjusted as necessary or additional low-molecular-weight heparin administered.

CONCLUSION

The perioperative management of patients with cardiac diseases in receipt of antithrombotic agents is based upon a delicate balance between the perceived risk of arterial thromboembolism and the perceived risk of perioperative bleeding. One must exercise good judgement in deciding the most appropriate perioperative antithrombotic regimen. Venous thromboembolism is also a common problem after joint replacement surgeries. For patients already on aspirin, optimal venous thromboembolism prophylaxis is still being debated.