Recommendations for the future management of thrombocytopenia in patients with liver cirrhosis: A modified RAND/UCLA appropriateness method.

OBJECTIVE: The lack of consensus and specific guidelines, and the introduction of new treatments in thrombocytopenia management in liver cirrhosis patients, required a series of recommendations by experts to improve knowledge on this disease. This study's aim was to improve the knowledge around thrombocytopenia in liver cirrhosis patients, in order to contribute to the generation of future evidence to improve the management of this disease. PATIENTS AND METHODS: A modified version of the RAND/UCLA appropriateness method was used. The scientific committee, a multidisciplinary team of 7 experts in managing thrombocytopenia in liver cirrhosis patients, identified the expert panel, and participated in elaborating the questionnaire. Thirty experts from different Spanish institutions were invited to answer a 48-item questionnaire covering 6 areas on a nine-point Likert scale. Two rounds were voted. The consensus was obtained if >77.7% of panelists reached agreement or disagreement. RESULTS: A total of 48 statements were developed by the scientific committee and then voted by the experts, resulting in 28 defined as appropriate and completely necessary, relating to evidence generation (10), care circuit, (8), hemorrhagic risk assessment, decision-making and diagnostic tests (14), professionals' role and multidisciplinary coordination (9) and patient education (7). CONCLUSIONS: This is the first consensus in Spain on the management of thrombocytopenia in liver cirrhosis patients. Experts indicated several recommendations to be carried out in different areas that could help physicians make better decisions in their clinical practice.

Diagnosis and treatment of deep vein thrombosis of the lower and upper limbs. 2024 recommendations of the venous thromboembolism group of the Spanish Society of Internal Medicine.

Deep vein thrombosis (DVT) of the limbs is a common disease and causes significant morbidity and mortality. It is frequently the prelude to pulmonary embolism (PE), it can recur in 30% of patients and in 25-40% of cases they can develop post-thrombotic syndrome (PTS), with a significant impact in functional status and quality of life. This document contains the recommendations on the diagnosis and treatment of acute DVT from the Thromboembolic Disease group of the Spanish Society of Internal Medicine (SEMI). PE and thrombosis of unusual venous territories (cerebral, renal, mesenteric, superficial, etc.) are outside its scope, as well as thrombosis associated with catheter and thrombosis associated with cancer, which due to their peculiarities will be the subject of other positioning documents of the Thromboembolic Disease group of the Spanish Society of Internal Medicine (SEMI).

Bleeding risk assessment for stroke patients on antithrombotic therapy. / Evaluación del riesgo hemorrágico de la terapia antitrombótica en pacientes con ictus.

INTRODUCTION: After an ischemic cerebrovascular event the risk of new ischemic events is high, therefore antithrombotic therapy are indicated to prevent stroke recurrence. DISCUSSION: Despite its clear benefit, these therapies increase the risk of bleeding. Therefore, it is essential to identify high hemorrhagic risk patients. There are different predictive models of hemorrhage, in particular of intracranial hemorrhage, associated with the use of antiaggregants in patients who have presented an ischemic stroke or TIA, such as the CCSC, intracranial scales -B2LEED3S score or S2TOP-BLEED. However, though main international guidelines recommend the use of scales, in particular, the HAS-BLED score, to assess the risk of bleeding in anticoagulated patients, there is no specific recommendation in the case of the use of antiplatelet drugs. CONCLUSIONS: In this review we present the main models currently available for the prediction of bleeding of antithrombotic therapy in patients who have had a stroke or TIA.

[Antithrombotic treatment consensus protocol (anticoagulation and antiplatelet therapy) during the perioperative and periprocedural period in neurosurgery]. / Protocolo de consenso en el tratamiento antitrombótico (anticoagulación y antiagregación) durante el periodo perioperatorio y periprocedimiento en neurocirugía.

The use of antithrombotic medication (antiplatelet and/or anticoagulant therapy) is widespread. Currently, the management of neurosurgical patients receiving this type of therapy continues to be a problem of special importance. Patients receiving antithrombotic treatment may need neurosurgical care because of bleeding secondary to such treatment, non-haemorrhagic neurosurgical lesions requiring urgent attention, or simply elective neurosurgical procedures. In addition, the consequences of reintroducing early (bleeding or rebleeding) or late (thrombotic or thromboembolic) anticoagulation can be devastating. In this paper we present the antithrombotic treatment consensus protocol during the perioperative and periprocedural period, both in emergent surgery and in elective neurosurgical procedures.

Efficacy of bleeding risk scores in elderly patients with acute coronary syndromes.

INTRODUCTION AND OBJECTIVES: The incidence of acute coronary syndromes is high in the elderly population. Bleeding is associated with a poorer prognosis in this clinical setting. The available bleeding risk scores have not been validated specifically in the elderly. Our aim was to assess predictive ability of the most important bleeding risk scores in patients with acute coronary syndrome aged ≥ 75 years. METHODS: We prospectively included consecutive acute coronary syndromes patients. Baseline characteristics, laboratory findings, and hemodynamic data were collected. In-hospital bleeding was defined according to CRUSADE, Mehran, ACTION, and BARC definitions. CRUSADE, Mehran, and ACTION bleeding risk scores were calculated for each patient. The ability of these scores to predict major bleeding was assessed by binary logistic regression, receiver operating characteristic curves, and area under the curves. RESULTS: We included 2036 patients, with mean age of 62.1 years; 369 patients (18.1%) were ≥ 75 years. Older patients had higher bleeding risk (CRUSADE, 42 vs 22; Mehran, 25 vs 15; ACTION, 36 vs 28; P<.001) and a slightly higher incidence of major bleeding events (CRUSADE bleeding, 5.1% vs 3.8%; P=.250). The predictive ability of these 3 scores was lower in the elderly (area under the curve, CRUSADE: 0.63 in older patients, 0.81 in young patients; P=.027; Mehran: 0.67 in older patients, 0.73 in younger patients; P=.340; ACTION: 0.58 in older patients, 0.75 in younger patients; P=.041). CONCLUSIONS: Current bleeding risk scores showed poorer predictive performance in elderly patients with acute coronary syndromes than in younger patients.

Fibrinolíticos en tromboembolismo de pulmón: Nuevas alternativas para una indicación controvertida / Fibrinolytics in lung thromboembolism. New alternatives for a controversial prescription

El uso de fibrinolíticos en el tromboembolismo de pulmón (TEP) es un tema de debate que ha sufrido idas y venidas desde su primera descripción en la década del 60. Esta terapia que puede liberar rápidamente la obstrucción mecánica en la arteria pulmonar, tiene la limitante del alto riesgo hemorrágico. Justamente por la incidencia prohibitiva de sangrado mayor y cerebral, y por la falta de beneficio en la supervivencia, es que solo está indicado el uso de fibrinolíticos sistémicos en el reducido número de pacientes con TEP grave y descompensación hemodinámica. En el TEP de moderado riesgo, aun con sufrimiento del ventículo derecho (VD), no están indicados. En los últimos años ha surgido la alternativa de combinar bajas dosis de fibrinolíticos liberados localmente en la arteria pulmonar mediante un catéter que puede adjuntarse o no a ultrasonidos en el sitio de la trombosis. Esta forma de administrar los trombolíticos permite corregir la hipertensión pulmonar aguda y liberar el trombo prácticamente sin sangrados mayores o del SNC. Los estudios publicados son muy alentadores, pero la evidencia aún es muy escasa, se requiere un laboratorio de hemodinamia disponible en todo momento y no está exento de riesgos, con un costo considerable. Por el momento solo un reducido número de pacientes con TEP moderado y parámetros de mal pronóstico parece tener indicación para esta alternativa.

The use of fibrinolytics in lung thromboembolism (PTE) is a subject under debate since its first description in the 1960s. This therapy, which can rapidly resolve the mechanical obstruction in the pulmonary artery, has the limiting of a high hemorrhagic risk. Precisely because of the prohibitive incidence of major and cerebral bleeding and the lack of benefit in survival, the use of systemic thrombolytics is only indicated in the small number of patients with severe PE and hemodynamic instability. In moderate-risk PE, even with right ventricular (RV) dysfunction, they are not indicated. In recent years, an alternative has arisen, by combining low doses of fibrinolytics released locally into the pulmonary artery through a catheter that may, or may not, be attached to ultrasound at the site of thrombosis. This way of administering thrombolytics can correct acute pulmonary hypertension and eliminate the thrombus without major or CNS bleeds. Although the published studies are very encouraging, the evidence is still poor, a laboratory of hemodynamics is required at all times and this procedure is not free of risks, with a considerable cost. At the moment, only a small number of patients with moderate PE and poor prognosis seem to have an indication for this new alternative.