Clinical practice guideline of the spanish society of oral surgery for oral surgery in patients with coagulation disorders / Guía de práctica clínica de la sociedad española de cirugía bucal para cirugía oral en pacientes con trastornos de la coagulación

Background: The number of patients treated with coagulation disorders, and more specifically with anticoagulanttherapy, has increased worldwide in recent years due to increased life expectancy in developed countries. Theprotocols for managing this type of patient in oral surgery has varied over recent years, especially after the appear-ance of new direct-acting oral anticoagulants (DOACs). The assessment of risk of bleeding in this type of patientwhen undergoing a surgical procedure continues to be a controversial issue for patients, dentists and general prac-titioners. The objective of this document is to offer recommendations, based on evidence, for decision making forpatients with coagulopathies who require dental surgical intervention. Material and Methods: Based on the indications of the “Preparation of Clinical Practice guidelines in the NationalHealth System. Methodological manual”, we gathered a group of experts who agreed on 15 PICO questions basedon managing patients with coagulation disorders in dental surgical procedures, such as fitting of implants or dentalextractions.Results: The 15 PICO questions were answered based on the available evidence, being limited in most cases due tothe lack of a control group. Two of the PICO questions were answered by the experts with a grade C recommendation,while the rest were answered with grade D.Conclusions: The results of this review highlight the need to undertake well designed clinical trials with controlgroups and with a representative sample size.(AU)

Assessment of knowledge and counseling practice of warfarin among pharmacists in UAE: A cross-sectional study

Background: Warfarin has long been regarded as the cornerstone anticoagulant for patients requiring long-term prevention or treatment of thromboembolic disorders. With adequate knowledge and counseling skills, hospital and community pharmacists can play a major role in enhancing warfarin therapy. Objective: to evaluate the knowledge and counseling practices toward warfarin among community and hospital pharmacists in UAE. Methods: A cross-sectional study involving community and hospital pharmacies was conducted with online questionnaire which was submitted to pharmacists focusing on their pharmacotherapeutic knowledge and patient education toward warfarin in UAE. Data were collected within 3 months (July, August and September 2021). SPSS Version 26 was used to analyze the data. The survey questions were sent to expert researchers in pharmacy practice for comments on their relevancy, clarity, and essentiality. Results: Among the target population sample size of 400 pharmacists were approached. Majority of the pharmacists in UAE (157/400, 39.3%) had 1-5 years of experience. Most of the participants (52%) have fair knowledge about warfarin and (62.1%) of them have fair counseling practices about warfarin. Hospital pharmacists have more knowledge than community pharmacists (Mean rank, Independent pharmacy: 166.30, Chain pharmacy: 138.01, Hospital pharmacy: 252.27, p<0.05) and they have better counseling practice than community pharmacists (Mean rank, Independent pharmacy: 188.83, Chain pharmacy: 170.18, Hospital pharmacy: 222.90, p<0.05). Conclusion: The study’s participants had moderate knowledge and counseling practices of warfarin. As a result, specialized training in warfarin therapy management for pharmacists is needed to improve therapeutic outcomes and avoid complications. Moreover, conferences or online courses should be held to train pharmacists on how to provide professional counseling to patients. (AU)

Tiempo en rango terapéutico e incidencia de complicaciones por warfarina en una cohorte retrospectiva de 20 años / Time in therapeutic range and incidence of warfarin complications in a 20-year retrospective cohort

Objetivo: Caracterizar el tiempo en rango terapéutico (TTR) y estimar la tasa de incidencia de complicaciones (PTIRc) en adultos con protocolo de warfarina. Diseño: Cohorte retrospectiva basada en registros médicos de pacientes mayores de 18años entre 1996 a 2016 y seguidos al menos tres meses. Emplazamiento: Unidad de Hematología de un centro especializado cardiovascular venezolano. Participantes: Registros médicos electrónicos. Mediciones principales: TTR y PTIRc. Las variables fueron: sexo, analfabetismo funcional, ocupación, international normalized ratio (INR) y tiempo de seguimiento, que fueron analizados con TTR and PTIRc mediante modelos de logística binomial y regresión de Poisson, respectivamente. Resultados: Un total de 2.770 pacientes fueron seguidos durante 1.201.380 días; el 42,3% tuvieron un TTR <65% y el 3,5% tuvieron indicación de INR 2,5-3,5. El 61,8% presentaron complicaciones. La PTIRc fue de 6,84/100 personas-mes (IC95%: 6,56-7,15). TTR <65% mostró OR ajustadas significativas con analfabetismo funcional e INR 2,5-3,5, mientras que para la mayor PTIRc se encontró un RR significativo en los dos factores mencionados, menor tiempo de seguimiento, TTR <65% y en mujeres. Conclusiones: A pesar de nuevos tratamientos anticoagulantes, la warfarina es útil. A medida que aumentó el tiempo de seguimiento el control fue mejor y la velocidad de aparición de complicaciones disminuyó; sin embargo, las condiciones que mostraron menor TTR y mayor velocidad de aparición de complicaciones requieren una profunda revisión del seguimiento, de manera especial en pacientes con analfabetismo funcional.(AU)

Objective: To characterize the time in therapeutic range (TTR) and estimate the incidence rate of complications (PTIRc) in adults with warfarin protocol. Design: Retrospective cohort based on medical records of patients older than 18years, between 1996 and 2016 and followed for at least three months. Site: Hematology unit of a Venezuelan specialized cardiovascular center. Participants: Electronic health record. Main measurements: TTR and PTIRc. The variables were sex, functional illiteracy, occupation, International Normalized Ratio (INR) and follow-up time, which were analyzed with TTR and PTIRc using binomial logistic and Poisson regression models, respectively. Results: 2,770 patients were followed up for a total of 1,201,380 days, 42.3% had a TTR<65% and 3.5% had INR 2.5-3.5. 61.8% had complications. PTIRc was 6.84/100 person-months (95%CI: 6.56-7.15). TTR<65% showed significant adjusted OR with functional illiteracy and INR 2.5-3.5, while for higher PTIRc a significant RR was found in the two factors mentioned, shorter follow-up time, TTR<65% and in women. Conclusions: Despite new anticoagulant treatments, warfarin is useful. As follow-up time increased, control was better and the rate of occurrence of complications decreased; however, the conditions that showed lower TTR and higher rate of occurrence of complications require a thorough review of follow-up especially in patients with functional illiteracy.(AU)

Validation and comparison between two warfarin dosing clinical algorithms and warfarin fixed dosing in specialized heart center: cross-sectional study

Background: Warfarin is well known as a narrow therapeutic index that has prodigious variability in response which challenges dosing adjustment for the maintenance of therapeutic international normalized ratio. However, an appreciated population not on new oral anticoagulants may still need to be stabilized with warfarin dosing. Objective: The current study’s main objective was to validate and compare two models of warfarin clinical algorithm models namely the Gage and the International Warfarin Pharmacogenetics Consortium (IWPC) with warfarin 5 mg fixed standard dosing strategy in a sample of Sudanese subjects. Method: We have conducted a cross-sectional study recruited from the out-patient clinic at a tertiary specialized heart center. We included subjects with unchanged warfarin dose (stabilized), and with therapeutic international normalized ratio. The predicted doses of warfarin in the two models were calculated by three different methods (accuracy, clinical practicality, and the clinical safety of the clinical algorithms). Main outcome measure: The primary outcomes were the measurements of the clinical (accuracy, practicality, and safety) in each of the two clinical algorithms models compared to warfarin 5 mg fixed standard dose strategy. (AU)

Anticoagulación oral en la enfermedad renal crónica con fibrilación auricular / Oral anticoagulation in chronic kidney disease with atrial fibrillation

La enfermedad renal crónica (ERC) y la fibrilación auricular (FA) frecuentemente coexisten, amplificando el riesgo de eventos cardiovasculares y de mortalidad. En pacientes con ERC estadio 3 y FA no valvular los anticoagulantes orales de acción directa (ACOD) han demostrado, comparados con antagonistas de la vitamina K (AVK), igual o superior eficacia en la prevención de ictus y embolismo sistémico, y mayor seguridad. No existen ensayos aleatorizados de la eficacia y la seguridad de ACOD y AVK en la ERC avanzada. Por otra parte, estudios observacionales sugieren que los ACOD, comparados con warfarina, se asocian a menor riesgo de daño renal agudo y de generación/progresión de la ERC. En este trabajo se revisan los aspectos epidemiológicos y fisiopatológicos de la asociación ERC y FA, las evidencias de la eficacia y seguridad de la warfarina y de los ACOD en las diversas fases de la ERC con FA, así como la comparación entre warfarina y ACOD en la eficacia y seguridad anticoagulante, y en sus efectos renales

Chronic kidney disease (CKD) and atrial fibrillation (AF) frequently coexist, amplifying the risk of cardiovascular events and mortality. In patients with CKD stage 3 and non-valvular AF, direct oral anticoagulants (DOACs) have shown, compared to vitamin K antagonists (VKA), equal or greater efficacy in the prevention of stroke and systemic embolism, and greater safety. There are no randomized trials of the efficacy and safety of DOACs and VKA in advanced CKD. On the other hand, observational studies suggest that DOACs, compared to warfarin, are associated with a lower risk of acute kidney damage and generation/progression of CKD. This paper reviews the epidemiological and pathophysiological aspects of the CKD and AF association, the evidence of the efficacy and safety of warfarin and ACODs in various stages of CKD with AF as well as the comparison between warfarin and ACODs in efficacy and anticoagulant safety, and in its renal effects

Cumplimiento terapéutico en pacientes en tratamiento con anticoagulantes orales en Atención Primaria / Therapeutic compliance in patients being treated with oral anticoagulants in Primary Care

Objetivo: evaluar y comparar el cumplimiento terapéutico entre los diferentes anticoagulantes orales. Diseño: estudio descriptivo transversal. Emplazamiento: Atención Primaria. Zona Básica de Salud de Bargas. Participantes: se incluyó a pacientes que llevasen más de 6 meses en tratamiento con anticoagulantes orales, pertenecientes a seis cupos de Medicina Familiar. Se excluyó a pacientes desplazados, incapaces de tomar la medicación de forma autónoma, ingresados o fallecidos durante el estudio. Mediciones principales: las variables estudiadas fueron: edad, sexo, nivel educativo, unidad familiar, tiempo de tratamiento, tipo de anticoagulante, efectos secundarios, polimedicación, tipo de receta, educación para la salud y cumplimiento terapéutico. Se realizó estadística descriptiva y analítica. Resultados: se evaluaron 110 pacientes con una edad media de 73,02 (desviación estándar [DE]: 12,06) años. Un 29,1% en tratamiento con anticoagulantes orales de acción directa (ACOD). La mediana de tiempo de tratamiento fue de 47 meses (rango intercuartílico: 16-77,25), el 84,5% eran polimedicados (7,36 ± 3,96 fármacos de media). Fueron cumplidores en total el 81,81% (intervalo de confianza [IC] 95% 73,32-88,52%). El 93,75% fue cumplidor con ACOD (IC 95% 79,19-99,23%) frente al 76,92% con acenocumarol (IC 95% 66,00-85,71%) (p = 0,055). El cumplimiento en polimedicados fue del 86%, frente al 58,8% en no polimedicados (p = 0,02). Conclusión: Nuestro estudio ha mostrado una aparente mayor adherencia terapéutica en los pacientes tratados con ACODs con respecto a los tratados con acenocumarol. La adherencia al tratamiento es mayor en los pacientes polimedicados.(AU)

Aim: To evaluate and compare treatment compliance among different oral anticoagulants. Design: Transversal descriptive study. Location: Primary Care. Bargas Basic Healthcare Area. Participants: Patients in treatment with oral anticoagulants more than 6 months who belonged to six Family Medicine quotas were included. Displaced patients, those unable to take medication autonomously, admitted to hospital or who died during the study were excluded. Primary endpoints: The variables studied were: age, sex, educational level, family unit, treatment time, type of anticoagulant, side effects, polymedication, type of prescription, education for health and treatment compliance. Descriptive statistics and analysis were performed. Results: 110 patients with a mean age of 73.02 (SD: 12.06) years old were studied. A total of 29.1% were in treatment with oral anticoagulants (OACs). Median treatment time was 47 months (interquartile range: 16-77.25). A total of 84.5% were polymedicated (7.36±3.96 drugs on average). In total 81.81% (95%CI 73.32-88.52%) were compliant. A total of 93.75% complied with OACs (95%CI 79.19-99.23%) compared to 76.92% with acenocumarol (95%CI 66.00-85.71%) (p=0.055). Compliance in polymedicated patients was 86% compared to 58.8% in non-polymedicated patients (p=0.02). Conclusion: Our study revealed an apparent greater treatment adherence in patients treated with OACs in regard to those treated with acenocumarol. Treatment adherence is greater in polymedicated patients.(AU)

Anticoagulación del paciente anciano pluripatológico con fibrilación auricular no valvular: papel del rivaroxabán / Anticoagulation in elderly patients with multiple comorbidities and nonvalvular atrial fibrillation: the role of rivaroxaban

La fibrilación auricular es muy frecuente en el paciente anciano. Aunque existe una amplia experiencia con los antagonistas de la vitamina K, el empleo de estos fármacos en el paciente anciano presenta numerosas limitaciones, con una mayor susceptibilidad a las hemorragias y un peor control de la anticoagulación que en la población general. Los anticoagulantes orales de acción directa han demostrado ser una mejor alternativa terapéutica para los pacientes ancianos, no solo por su mayor simplicidad de uso, sino por sus mayores eficacia y seguridad en comparación con los antagonistas de la vitamina K, con datos que en general concuerdan con los ensayos clínicos fundamentales. Sin embargo, en el paciente anciano hay una tendencia al uso de dosis inadecuadas, generalmente por infradosificación, sobre todo con algunos de ellos, lo que conlleva una menor protección contra los ictus, sin una clara ventaja antihemorrágica. El rivaroxabán se ha estudiado ampliamente en la población anciana y no solo en ensayos clínicos, sino también en multitud de estudios en la práctica clínica real, con datos muy consistentes. En estos estudios, en comparación con los antagonistas de la vitamina K, se ha demostrado que el rivaroxabán reduce el riesgo de ictus sin un incremento de las hemorragias mortales, con lo que tiene un beneficio clínico neto favorable en la población con fibrilación auricular no valvular con mayor riesgo tromboembólico

Atrial fibrillation is common in elderly patients. Although vitamin K antagonists have been widely used for many years, they have a number of limitations in elderly patients, who are particularly susceptible to bleeding and in whom anticoagulation control is poorer than in the general population. Direct oral anticoagulants have been shown to be a better therapeutic option for these patients, not only because they are simpler to use, but also because they are more effective and safer than vitamin K antagonists. Moreover, their performance in practice is generally consistent with that in pivotal clinical trials. Nevertheless, there is a tendency to administer inappropriate doses to elderly patients, generally underdosing, particularly in certain subgroups. This can result in less protection against stroke without any clear reduction in bleeding risk. Rivaroxaban has been widely studied in the elderly population, not only in clinical trials, but also in a range of studies in routine clinical practice - findings have been highly consistent. According to these studies, and compared to vitamin K antagonists, rivaroxaban reduces the risk of stroke without increasing the rate of fatal bleeding, with a net clinical benefit in patients with nonvalvular atrial fibrillation and a high thromboembolic risk

Perfil de seguridad de los anticoagulantes directos. Uso preferente en fibrilación auricular / Security profile of direct anticoagulants. Preferred use in atrial fibrillation

Se presenta un trabajo multidisciplinar realizado por especialistas de Cardiología, Hemostasia y Trombosis, Medicina Interna y Neurología en el que se exponen las evidencias científicas actuales que demuestran el mejor perfil de seguridad de los anticoagulantes orales de acción directa (ACOD) frente a los antivitamina K (AVK) y se discuten indicaciones y el papel de los antídotos específicos y hemostáticos para la reversión del efecto anticoagulante. El análisis sugiere que el mejor perfil de seguridad de los ACOD los hace especialmente útiles en pacientes con alto riesgo hemorrágico

A multidisciplinary panel of cardiologists, neurologists, internal medicine and specialists in hemostasis and thrombosis has elaborated this document showing recent scientific evidences supporting a better profile of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKA), as well as the indications of specific antidotes and hemostatic agents to reverse the anticoagulant effects of DOACs. The analysis reinforces the best profile of DOACs and its special benefit in patients with basal high hemorrhagic risk

Warfarina y Practicas Culturales / Warfarina and cultural practices / Warfarina e práticas culturais

La terapia anticoagulante es un tratamiento utilizado clínicamente desde la década de los años 50. Actualmente y a pesar de la aparición de nuevos fármacos la warfarina sigue siendo el medicamento más utilizado. La necesidad de monitoreo frecuente, además de la interacción con fármacos y alimentos, así como la necesidad de transformar la cotidianidad de las personas que la consumen, modifican las prácticas culturales de estos pacientes, pudiendo afectar aspectos tales como la adherencia. OBJETIVO GENERAL: Describir las prácticas culturales transformadas por las personas pertenecientes a un programa de anticoagulación en terapia con warfarina. METODOLOGÍA: Estudio cualitativo tipo micro etnografía, realizado en Bogotá, Colombia. RESULTADOS: Se contó con la participación de 10 informantes quienes asociado al uso de warfarina transformaron prácticas culturales entorno al conocimiento, la cotidianidad y las emociones

A terapia anticoagulante é um tratamento usado clinicamente desde a década de 50. Atualmente, apesar do surgimento de novos medicamentos, a varfarina continua sendo a medicação mais utilizada. A necessidade de monitoramento frequente, além da interações medicamentosas e com alimentos, como a necessidade de transformar a cotidianidade das pessoas que consomem a varfarina; modificam as práticas culturais desses pacientes, podendo afetar aspectos como a adesão ao tratamento. OBJETIVO: Descrever as práticas culturais transformadas por pessoas pertencentes a um programa de anticoagulação na terapia com varfarina. METODOLOGIA: estudo qualitativo tipo micro-etnografia, feito na Bogotá, Colômbia. RESULTADOS: Participaram 10 informantes que transformaram práticas culturais em torno ao conhecimento, a cotidianidade e as emoções associadas ao uso da varfarina

Anticoagulant therapy is a treatment used clinically since the 1950s. Currently, despite the appearance of new drugs, warfarin remains the most widely used one. The need for frequent monitoring, in addition to the interaction with drugs and foods, as well as the need to transform the everyday life of people who consume it, modify the cultural practices of these patients, and may affect aspects such as adherence. GENERAL OBJECTIVE: Describe the cultural practices transformed by people who are part of an anticoagulation program in warfarin therapy. METHODOLOGY: Qualitative study type micro ethnography, carried out in Bogotá, Colombia. RESULTS: We had the participation of 10 informants who, associated with the use of warfarin, transformed cultural practices around knowledge, everyday life and emotions

A descriptive study of antithrombotic medication patterns in adult patients with recent venous thromboembolism

Objectives: The objective of this study is to describe the most common self-reported antithrombotic therapy utilization patterns in a national cohort of patients with recent venous thromboembolism (VTE). Methods: Extant data from a national online survey administered to 907 patients 18 years of age or older with VTE in the last two years were analyzed. Patients' self-reported antithrombotic usage patterns used during three phases of treatment for the most recent VTE episode were summarized using descriptive statistics. Results: The following overall antithrombotic usage patterns were identified: warfarin (38.7%), direct oral anticoagulants (DOACs) (26.1%), switching between warfarin and DOACs (13.3%), aspirin only (8.7%), switching between different DOACs (4.5%), injectable anticoagulants only (3.9%), and no treatment (4.7%). Extended antithrombotic therapy beyond 90 days was reported by 65.7% of patients. Aspirin coadministration with anticoagulant therapy occurred for 33.7%. Conclusions: In this national sample of recent VTE sufferers warfarin therapy remains the most used anticoagulant followed closely by DOAC therapy. Switching between warfarin and DOACs and between different DOACs was common which could indicate adverse events or affordability issues. Aspirin coadministration with anticoagulant therapy was present in 1 of 3 patients and is a potential medication safety intervention for anticoagulation providers

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Anticoagulantes orales directos frente a antagonistas de la vitamina K en pacientes con fibrilación auricular de la práctica clínica: revisión sistemática y metanálisis / Direct oral anticoagulants versus vitamin K antagonists in real-life patients with atrial fibrillation. A systematic review and meta-analysis

Introducción y objetivos: Determinar la efectividad de los anticoagulantes orales directos frente a los antagonistas de la vitamina K en pacientes con fibrilación auricular de la práctica clínica. Métodos: Se realizó una revisión sistemática acorde con los estándares metodológicos de Cochrane. Los resultados de la revisión se publicaron según la declaración PRISMA. Se empleó la herramienta ROBINS-I para determinar el riesgo de sesgos. Resultados: Se incluyeron datos de 27 estudios diferentes provenientes de 30 publicaciones. En los estudios con seguimiento hasta 1 año, el apixabán (HR = 0,93; IC95%, 0,71-1,20) y dabigatrán (HR = 0,95; IC95%, 0,80-1,13) no se redujo significativamente el riesgo de ictus isquémico frente a la warfarina, pero sí el rivaroxabán (HR = 0,83; IC95%, 0,73-0,94). Con respecto al riesgo de hemorragias mayores, el apixabán (HR = 0,66; IC95%, 0,55-0,80) y el dabigatrán (HR = 0,83; IC95%, 0,70-0,97) lo redujeron significativamente frente a la warfarina, pero no el rivaroxabán (HR = 1,02, IC95%, 0,95-1,10), aunque con heterogeneidad entre los estudios. El apixabán (HR = 0,56; IC95%, 0,42-0,73), el dabigatrán (HR = 0,45; IC95%, 0,39-0,51) y el rivaroxabán (HR = 0,66; IC95%, 0,49-0,88) redujeron significativamente el riesgo de hemorragia intracraneal frente a la warfarina. El empleo de dosis bajas de anticoagulantes orales directos se asoció con una ligera mejoría del perfil de seguridad, pero con una marcada reducción de la efectividad en la prevención de ictus. Conclusiones: Los resultados de este metanálisis indican que, en comparación con la warfarina, la efectividad para prevenir el riesgo de ictus y de hemorragias de los anticoagulantes orales directos en los pacientes con fibrilación auricular de la práctica clínica real puede ser diferente

Introduction and objectives: To assess the effectiveness of direct oral anticoagulants vs vitamin K antagonists in real-life patients with atrial fibrillation. Methods: A systematic review was performed according to Cochrane methodological standards. The results were reported according to the PRISMA statement. The ROBINS-I tool was used to assess risk of bias. Results: A total of 27 different studies publishing data in 30 publications were included. In the studies with a follow-up up to 1 year, apixaban (HR, 0.93; 95%CI, 0.71-1.20) and dabigatran (HR, 0.95; 95%CI, 0.80-1.13) did not significantly reduce the risk of ischemic stroke vs warfarin, whereas rivaroxaban significantly reduced this risk (HR, 0.83; 95%CI, 0.73-0.94). Apixaban (HR, 0.66; 95%CI, 0.55-0.80) and dabigatran (HR, 0.83; 95%CI, 0.70-0.97) significantly reduced the major bleeding risk vs warfarin, but not rivaroxaban (HR, 1.02; 95%CI, 0.95-1.10), although with a high statistical heterogeneity among studies. Apixaban (HR, 0.56; 95%CI, 0.42-0.73), dabigatran (HR, 0.45; 95%CI, 0.39-0.51), and rivaroxaban (HR, 0.66; 95%CI, 0.49-0.88) significantly reduced the risk of intracranial bleeding vs warfarin. Reduced doses of direct oral anticoagulants were associated with a slightly better safety profile, but with a marked reduction in stroke prevention effectiveness. Conclusions: Data from this meta-analysis suggest that, vs warfarin, the stroke prevention effectiveness and bleeding risk of direct oral anticoagulants may differ in real-life patients with atrial fibrillation

Intervención coronaria percutánea y anticoagulantes orales / Percutaneous coronary intervention and oral anticoagulation

Los pacientes con anticoagulación oral crónica sometidos a intervención coronaria percutánea constituyen una población con alto riesgo y gran comorbilidad. Se trata de una población en crecimiento y con un pronóstico complejo por los eventos isquémicos y hemorrágicos que pueden padecer en el corto, medio y largo plazo. El tratamiento antitrombótico es sin duda uno de los aspectos fundamentales que considerar en esta población y el que más impacto pronóstico puede generar. El mantenimiento de la anticoagulación oral es el aspecto prioritario en esta población. En los últimos años se han estudiado diferentes regímenes antitrombóticos buscando fundamentalmente una reducción de eventos hemorrágicos, sin penalizar la eficacia. Para ello se ha estudiado sobre todo acortar la duración de la doble antiagregación añadida a la anticoagulación y el uso de antiagregantes plaquetarios en monoterapia, fundamentalmente el clopidogrel, además del anticoagulante oral. Actualmente la llegada de los anticoagulantes orales de acción directa ha generado una gran expectación e ilusión. Estos fármacos, con un mejor perfil de seguridad que los anticoagulantes dicumarínicos, pueden aportar en este contexto importantes mejoras pronósticas. Hay 3 ensayos clínicos con anticoagulantes orales de acción directa en este paciente tan complejo y, junto con otro que se encuentra en fase de seguimiento, es posible que contribuyan a modificar la práctica clínica habitual de forma relevante en los próximos años. Información sobre el suplemento: este artículo forma parte del suplemento titulado «Actualización en el tratamiento de los pacientes con fibrilación auricular sometidos a intervención coronaria», que ha sido patrocinado por Boehringer Ingelheim

Patients on long-term oral anticoagulation therapy who are scheduled to undergo a percutaneous coronary intervention are a high-risk population with a large number of comorbid conditions. This is a growing population that has a complicated prognosis because ischemic and bleeding events can occur over the short, medium and long term. Antithrombotic therapy, without doubt a key consideration in these patients, could have a substantial impact on prognosis. Maintenance therapy with oral anticoagulants is also a priority. Over the last few years, several antithrombotic regimens have been investigated with the principle aim of reducing hemorrhagic events while maintaining efficacy. To this end, studies have focused on: (i) shortening the duration of the dual antiplatelet therapy added to anticoagulation; and (ii) the use of antiplatelet monotherapy, particularly clopidogrel, along with an oral anticoagulant. Recently, the emergence of direct oral anticoagulants has generated great hope and excitement. These new drugs, which have a better safety profile than dicoumarinic anticoagulants, could produce substantial prognostic improvements in this context. The results of three clinical trials of direct oral anticoagulants in these highly complex patients are currently available. Their findings, together with another trial that is now in the follow-up phase, have the potential to substantially modify our usual clinical practice in coming years. Supplement information: this article is part of a supplement entitled "Treatment of patients with atrial fibrillation undergoing percutaneous coronary intervention: an update", which is sponsored by Boehringer Ingelheim

Tratamiento antitrombótico doble frente a triple / Dual versus triple antithrombotic therapy

El tratamiento antitrombótico para los pacientes con anticoagulación oral por fibrilación auricular que se someten a intervención coronaria percutánea es especialmente complejo, sobre todo por el elevado riesgo hemorrágico que para estos pacientes implica la combinación de fármacos antiagregantes y anticoagulantes. Pese a que hay poca evidencia científica en este contexto, en los últimos años han aparecido varios ensayos clínicos que han intentado evaluar la seguridad y la eficacia de estrategias de tratamiento antitrombótico triple (combinación de doble antiagregación y un anticoagulante) y doble (combinación de un único antiagregante y un anticoagulante), bien con antagonistas de la vitamina K, bien con anticoagulantes de acción directa. El objetivo de este artículo es aportar una visión general del estado actual del conocimiento sobre las distintas estrategias de tratamiento antitrombótico triple y doble para pacientes anticoagulados por fibrilación auricular no valvular a los que se practica una intervención coronaria percutánea, además de proponer una serie de recomendaciones prácticas para la atención clínica de estos pacientes. Información sobre el suplemento: este artículo forma parte del suplemento titulado «Actualización en el tratamiento de los pacientes con fibrilación auricular sometidos a intervención coronaria», que ha sido patrocinado por Boehringer Ingelheim

The management of antithrombotic treatment in patients who are receiving oral anticoagulants for atrial fibrillation and who are scheduled for a percutaneous coronary intervention is particularly complex, mainly because they have an elevated risk of bleeding due to their combined use of antiplatelet and anticoagulant agents. Despite the lack of evidence available in this setting, a number of clinical trials carried out in recent years have attempted to evaluate the safety and efficacy of triple antithrombotic therapy (i.e. dual antiplatelet therapy plus an anticoagulant drug) and dual antithrombotic therapy (i.e. a single antiplatelet agent plus an anticoagulant drug), both potentially based on vitamin K antagonists or direct oral anticoagulants. The aim of this article was to provide an overview of what is currently known about different approaches to triple and dual antithrombotic therapy in patients who are undergoing anticoagulation for nonvalvular atrial fibrillation and who are scheduled for percutaneous coronary intervention. In addition, some practical recommendations for the clinical management of these patients are made. Supplement information: this article is part of a supplement entitled "Treatment of patients with atrial fibrillation undergoing percutaneous coronary intervention: an update", which is sponsored by Boehringer Ingelheim

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Improving warfarin therapy through implementation of a hospital-based pharmacist managed clinic in Jamaica

Background: Pharmacist managed warfarin clinics can improve the anticoagulation status of non-valvular patients. The first of such services was implemented at the Cornwall Regional Hospital in Jamaica in 2013. Objectives: To assess the anticoagulation control of patients on warfarin therapy over six months in the pharmacist managed warfarin clinic at Cornwall Regional Hospital. Methods: Retrospective docket review for the period January 2014 to December 2016 was done to include data of patients attending routine clinic appointments for at least six months. Age, gender, date of visit, indication for warfarin therapy, warfarin dose and International Normalized Ratio readings were extracted. Percentage time spent in therapeutic range (TTR) was calculated by month for six months using the Rosendaal linear interpolation method. Patient anticoagulation status was categorized as poor (TTR<40%), moderate (TTR=40-64%) or good (TTR≥65%) and anticoagulation status at three months and six months was compared. Results: For the period of assessment, 52 patients were identified; the median age was 58 years and 36 patients were males. Deep vein thrombosis was the main indication for therapy (22 of 52) and median warfarin weekly dose ranged was 15.0-130 mg. At time of recruitment most of the patients were outside the target INR range (43 of 52). Within one month, the median TTR attained was 31% [IQR 62-10]. This significantly improved by second month to 60% [IQR 82-23] (p=0.001). By month three, the proportion of patients in good, moderate and poor anticoagulant status was 19/51, 15/51 and 17/51 respectively, which at six months changed to 23/51, 12/51. 16/51 respectively; thus, although coagulation status improved from month one to three, there was no significant improvement from month three to month six (p=0.31). Conclusions: The pharmacist managed warfarin clinic monitoring services were successful in attaining TTRs >40% and sustaining these values over six months. The services should therefore be encouraged

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