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1.
Regional citrate anticoagulation for continuous renal replacement therapy.
Kindgen-Milles, D, Brandenburger, T, Dimski, T
Current opinion in critical care. 2018;(6):450-454
Abstract
PURPOSE OF REVIEW The delivery of an effective dialysis dose in continuous renal replacement therapy (CRRT) depends on adequate anticoagulation of the extracorporeal circuit. In most patients, either systemic heparin anticoagulation (SHA) or regional citrate anticoagulation (RCA) is used. This review will outline the basics and rationale of RCA and summarize data on safety and efficacy of both techniques. RECENT FINDINGS The basic principle of RCA is to reduce the level of ionized calcium in the extracorporeal circuit via infusion of citrate. This way, effective anticoagulation restricted to the extracorporeal circuit is achieved. SHA and RCA were compared in a variety of studies. RCA significantly prolonged filter lifetime, reduced bleeding complications and provided excellent control of uremia and acid-base status. RCA was also safe in the majority of patients with impaired liver function, whereas caution must be exerted in those with severe multiorgan failure and persistent hyperlactatemia. SUMMARY RCA per se is safe and effective for anticoagulation of CRRT. Compared to SHA, efficacy of anticoagulation is improved and adverse effects are reduced. RCA can be recommended as the anticoagulation mode of choice for CRRT in most ICU patients.
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2.
Nonvitamin K Oral Anticoagulants in Patients With Atrial Fibrillation and Severe Renal Dysfunction.
Mahmood, M, Lip, GYH
Revista espanola de cardiologia (English ed.). 2018;(10):847-855
Abstract
Both atrial fibrillation (AF) and chronic kidney disease (CKD) are highly prevalent, especially with increasing age and associated comorbidities, such as hypertension, diabetes, heart failure, and vascular disease. The relationship between both AF and CKD seems to be bidirectional: CKD predisposes to AF while onset of AF seems to lead to progression of CKD. Stroke prevention is the cornerstone of AF management, and AF patients with CKD are at higher risk of stroke, mortality, cardiac events, and bleeding. Stroke prevention requires use of oral anticoagulants, which are either vitamin K antagonists (eg, warfarin), or the nonvitamin K antagonist oral anticoagulants (NOACs). While NOACs have been shown to be effective in mild-to-moderate renal dysfunction, there are a paucity of data regarding NOACs in severe and end-stage renal dysfunction. This review first discusses the evidence for NOACs in CKD. Second, we summarize the current knowledge regarding the efficacy and safety of NOACs to prevent AF-related stroke and systemic embolism in severe and end-stage renal disease.
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3.
[Oral anticoagulation using coumarins - an update].
Sucker, C, Litmathe, J
Wiener medizinische Wochenschrift (1946). 2018;(5-6):121-132
Abstract
Vitamin K antagonists (VKA) are used for the prophylaxis and treatment of thrombotic and thromboembolic events. Most important indications are venous thrombosis and pulmonary embolism, atrial fibrillation, and mechanical heart-valve replacement. Hence they are from high relevance for the neurologist and his daily praxis in cardio-neurological routine. Here, we give an overview about VKA with focus on mode of action, indications and efficacy, practical aspects of treatment, side effects, and monitoring.
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4.
Diagnostics and treatment of thrombotic antiphospholipid syndrome (APS): A personal perspective.
Pengo, V, Denas, G
Thrombosis research. 2018;:35-40
Abstract
Antiphospholipid Syndrome (APS) is a condition characterized by the occurrence of thromboembolic events and/or pregnancy loss combined with one laboratory criterion among Lupus Anticoagulant- LAC, anticardiolipin -aCL, and anti β2-Glycoprotein I -aβ2GPI antibodies. Several hypotheses were put forward to explain the causal role of antibodies in the clinical events but none is fully convincing. Current laboratory diagnosis is based on three tests (LAC, IgG/IgM aβ2GPI and IgG/IgM aCL antibodies). The triple-positive profile (all the three tests positive, same isotype) is associated with a higher risk for thrombosis. The mainstay of therapy in thrombotic APS is anticoagulation, with VKAs being the cornerstone. Low dose aspirin in combination or alone may have a role in arterial thrombosis, and in primary thromboprophylaxis. The Non-Vitamin K Antagonists Oral Anticoagulants (NOACs) role in the therapy of APS is under investigation but not verified. Alternative treatment options including rituximab and eculizumab have been successfully reported in few cases of catastrophic APS.
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5.
Anticoagulation Management in Patients with Valve Replacement.
Saksena, D, Muralidharan, S, Mishra, YK, Kanhere, V, Mohanty, BB, Srivastava, CP, Mange, J, Puranik, M, Nair, MP, Goel, P, et al
The Journal of the Association of Physicians of India. 2018;(1):59-74
Abstract
BACKGROUND Prosthetic valve implantation requires postoperative prophylactic anticoagulation to preclude thrombotic events. The aim of this review is to assess the role of anticoagulation therapy in the management of valve replacement patients. METHODOLOGY Literature from PubMed, Embase, Medline and Google Scholar were searched using the terms "valvular heart disease", "anticoagulant", "mechanical heart valve", "bioprosthesis", "bridging", "Vitamin K antagonist (VKA)", and "acenocoumarol". A committee comprising leading cardiothoracic surgeons from India was convened to review the literature and suggest key practice points. RESULTS Prosthetic valve implantation requires postoperative prophylactic anticoagulation to preclude thrombotic events. A paramount risk of thromboembolic events is observed during the first three months after surgery for both mechanical and bioprosthetic devices. The VKA therapy with individualized target international normalized ratio (INR) is recommended in patients after prosthetic valve replacement. Therapies for the management of prosthetic valve complications should be based on the type of complications. Special care is mandated in distinguished individuals and those with various co-morbidities. CONCLUSION In patients with prosthetic valve replacement, anticoagulant therapy with VKA seems to be an effective option. The role for non-VKA oral anticoagulants in the setting of prosthetic valve replacement has yet to be established. Furthermore, whether the novel oral anticoagulants are safe and efficacious in patients after placement of a bioprosthetic valve remains unanswered.
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6.
Management of thrombosis in children and neonates: practical use of anticoagulants in children.
Monagle, P, Newall, F
Hematology. American Society of Hematology. Education Program. 2018;(1):399-404
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Abstract
Venous thrombosis (VTE) in children and neonates presents numerous management challenges. Although increasing in frequency, VTE in children and neonates is still uncommon compared with adults. The epidemiology of VTE is vastly different in neonates vs children vs adolescents vs adults. In reality, pediatric thrombosis should be viewed as a multitude of rare diseases (eg, renal vein thrombosis, spontaneous thrombosis, catheter-related thrombosis, cerebral sinovenous thrombosis), all requiring different approaches to diagnosis and with different short- and long-term consequences, but linked by the use of common therapeutic agents. Further, children have fundamentally different physiology in terms of blood flow, developmental hemostasis, and, likely, endothelial function. The American Society of Hematology 2017 Guidelines for Management of Venous Thromboembolism: Treatment of Pediatric VTE provides up-to-date evidence-based guidelines related to treatment. Therefore, this article will focus on the practical use of therapeutic agents in the management of pediatric VTE, especially unfractionated heparin, low-molecular-weight heparin, and oral vitamin K antagonists, as the most common anticoagulants used in children. Direct oral anticoagulants (DOACs) remain in clinical trials in children and should not be used outside of formal trials for the foreseeable future.
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The impact of direct oral anticoagulants in traumatic brain injury patients greater than 60-years-old.
Prexl, O, Bruckbauer, M, Voelckel, W, Grottke, O, Ponschab, M, Maegele, M, Schöchl, H
Scandinavian journal of trauma, resuscitation and emergency medicine. 2018;(1):20
Abstract
BACKGROUND Traumatic brain injury (TBI) is the leading cause of death among trauma patients. Patients under antithrombotic therapy (ATT) carry an increased risk for intracranial haematoma (ICH) formation. There is a paucity of data about the role of direct oral anticoagulants (DOACs) among TBI patients. METHODS In this retrospective study, we investigated all TBI patients ≥60-years-old who were admitted to the intensive care unit (ICU) from January 2014 until May 2017. Patients were grouped into those receiving vitamin K antagonists (VKA), platelet inhibitors (PI), DOACs and no antithrombotic therapy (no-ATT). RESULTS One-hundred-eighty-six, predominantly male (52.7%) TBI patients with a median age of 79 years (range: 70-85 years) were enrolled in the study. Glasgow Coma Scale and S-100β were not different among the groups. Patients on VKA and DOACs had a higher Charlson Comorbidity Index compared to the PI group and no-ATT group (p = 0.0021). The VKA group received reversal agents significantly more often than the other groups (p < 0.0001). Haematoma progression in the follow-up cranial computed tomography (CCT) was lowest in the DOAC group. The number of CCT and surgical interventions were low with no differences between the groups. No relevant differences in ICU and hospital length of stay were observed. Mortality in the VKA group was significantly higher compared to DOAC, PI and no-ATT group (p = 0.047). DISCUSSION Data from huge registry studies displayed higher efficacy and lower fatal bleeding rates for DOACs compared to VKAs. The current study revealed comparable results. Despite the fact that TBI patients on VKAs received reversal agents more often than patients on DOACs (84.4% vs. 24.2%, p < 0.001), mortality rate was significantly higher in the VKA group (p = 0.047). CONCLUSION In patients ≥60 years suffering from TBI, anticoagulation with DOACs appears to be safer than with VKA. Anti-thrombotic therapy with VKA resulted in a worse outcome compared to DOACs and PI. Further studies are warranted to confirm this finding.
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Variations in clinical management of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation according to different equations for estimating renal function : Post hoc analysis of a prospective cohort.
Malavasi, VL, Pettorelli, D, Fantecchi, E, Zoccali, C, Laronga, G, Trenti, T, Lip, GYH, Boriani, G
Internal and emergency medicine. 2018;(7):1059-1067
Abstract
Prescription of non-vitamin K antagonist oral anticoagulants (NOACs) requires an assessment of renal function (RF) and the Cockcroft-Gault (CG) equation is traditionally recommended. The objective of the study was to evaluate the potential changes in NOACs management using different equations for estimating RF. In a post hoc analysis of a prospective cohort of patients with atrial fibrillation, we considered different equations: (1) CG for creatinine clearance (CrCl), (2) modification of diet in renal disease (MDRD), (3) CKD-EPI, (4) Berlin Initiative Study 1 (BIS-1) and (5) full age spectrum (FAS), for glomerular filtration rate (GFR). RF was classified according to CrCl in three categories: severely depressed (SD-RF) < 30 ml/min; moderately depressed (MD-RF) 30-49 ml/min; preserved/mildly depressed (P-RF) ≥ 50 ml/min. Concordances in the assignments were analyzed. A population of 402 patients (61.2% males, age 72 ± 11) was categorized according to CrCl: 12 patients (2.9%) as SD-RF, 81 (20.1%) as MD-RF, 309 (76.8%) as P-RF. A potential change in NOACs management could occur using GFR equations rather than CrCl in 16.9% of patients using MDRD formula, in 11.7% using BIS-1, in 14.7% using CKD-EPI and in 12.9% using the FAS equation. Important changes in RF estimates were more frequent in patients aged ≥ 75, but also BMI had a meaningful impact. Use of equations estimating GFR instead of the Cockcroft-Gault equation may result in changes in NOACs management in 12-17% of patients. In the elderly ≥ 75, more pronounced changes in RF classification are detectable according to different equations and NOACs dosing should be further investigated.
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Management and outcome of major bleeding in patients receiving vitamin K antagonists for venous thromboembolism.
Moustafa, F, Stehouwer, A, Kamphuisen, P, Sahuquillo, JC, Sampériz, Á, Alfonso, M, Pace, F, Suriñach, JM, Blanco-Molina, Á, Mismetti, P, et al
Thrombosis research. 2018;:74-80
Abstract
BACKGROUND The optimal management of major bleeding in patients receiving vitamin K antagonists (VKA) for venous thromboembolism (VTE) is unclear. METHODS We used the RIETE (Registro Informatizado Enfermedad TromboEmbólica) registry to assess the management and 30-day outcomes after major bleeding in patients receiving VKA for VTE. RESULTS From January 2013 to December 2017, 267 of 18,416 patients (1.4%) receiving long-term VKA for VTE had a major bleeding (in the gastrointestinal tract 78, intracranial 72, hematoma 50, genitourinary 20, other 47). Overall, 151 patients (57%) received blood transfusion; 110 (41%) vitamin K; 37 (14%) fresh frozen plasma; 29 (11%) pro-haemostatic agents and 20 (7.5%) a vena cava filter. During the first 30 days, 59 patients (22%) died (41 died of bleeding) and 13 (4.9%) had a thrombosis. On multivariable analysis, patients with intracranial bleeding (hazard ratio [HR]: 4.58; 95%CI: 2.40-8.72) and those with renal insufficiency at baseline (HR: 2.73; 95%CI: 1.45-5.15) had an increased mortality risk, whereas those receiving vitamin K had a lower risk (HR: 0.47; 0.24-0.92). On the other hand, patients receiving fresh frozen plasma were at increased risk for thrombotic events (HR: 4.22; 95%CI: 1.25-14.3). CONCLUSIONS Major bleeding in VTE patients receiving VKA carries a high mortality rate. Intracranial bleeding and renal insufficiency increased the risk. Fresh frozen plasma seems to increase this risk for recurrent VTE.
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10.
Dual (Anticoagulant Plus Single Antiplatelet) vs Triple (Anticoagulant Plus Dual Antiplatelet) Antithrombotic Therapy - "Real World" Experience.
Effron, MB, Gibson, CM
Progress in cardiovascular diseases. 2018;(4-5):531-536
Abstract
Atrial fibrillation (AF) is a common arrhythmia that increases in prevalence with advancing age and in patients with coronary artery disease, revascularization, particularly with percutaneous coronary intervention (PCI), is also common. Both disease states have thrombosis as a core pathophysiologic process which requires treatment - low sheer stress thrombi in AF and intracoronary high sheer stress thrombi in PCI. For the 10-20% of patients who have both AF and undergo PCI, preventing thrombotic complications will require inhibition of both processes requiring simultaneous use of anticoagulation and antiplatelet therapy. There is a broad experience of combining oral anticoagulation therapy, used to prevent stroke and systemic embolization, in AF with dual antiplatelet therapy, used to prevent stent thrombosis and thrombotic coronary events. This "triple antithrombotic therapy" (TT) has been evaluated through many observation studies, both small and large. TT has more frequently been associated with a significant increase in bleeding events with non-significant reduction in thrombotic events. Current guidelines recommend shorter duration of TT, especially in patients with high risk of bleeding.