The risk of post-polypectomy bleeding among patients receiving antithrombotic agents: A prospective observational study

ABSTRACT BACKGROUND: In July 2012, the Japan Gastroenterological Endoscopy Society updated their guidelines for gastroenterological endoscopy in patients receiving antithrombotic therapy. Colonoscopic polypectomy procedures are associated with a high risk of bleeding. OBJECTIVES: The present study evaluated the safety of colonoscopic polypectomy procedures in terms of bleeding, among patients receiving antithrombotic therapy. DESIGN AND SETTING: Prospective observational study conducted in a tertiary-level public cardiovascular hospital in Istanbul, Turkey. METHODS: Colonoscopic polypectomies carried out in a single endoscopy unit between July 2018 and July 2019 were evaluated prospectively. The patients' data, including age, gender, comorbidities, whether antithrombotic drug use was ceased or whether patients were switched to bridging therapy, polyp size, polyp type, polyp location, histopathology, resection methods (hot snare, cold snare or forceps) and complications relating to the procedures were recorded. RESULTS: The study was completed with 94 patients who underwent a total of 167 polypectomy procedures. As per the advice of the physicians who prescribed antithrombotic medications, 108 polypectomy procedures were performed on 60 patients without discontinuing medication and 59 polypectomy procedures were performed on 34 patients after discontinuing medication. The age, gender distribution and rate of bleeding did not differ significantly between the patients whose medication was discontinued and those whose medication was continued (P > 0.05). CONCLUSION: This study found that the colonoscopic polypectomy procedure without discontinuation of antithrombotic medication did not increase the risk of bleeding. This procedure can be safely performed by experienced endoscopists in patients with an international normalized ratio (INR) below 2.5.

Revisão sistemática da profilaxia para tromboembolismo venoso após artroplastia do joelho: enoxaparina versus rivaroxabana / Systematic review of prophylaxis for venous thromboembolism after knee arthroplasty: enoxaparin versus rivaroxaban

RESUMO A artroplastia total do joelho é um procedimento eletivo, realizado em indivíduos relativamente saudáveis. Porém, devido ao risco inerente de tromboembolismo venoso, são utilizados fármacos para sua profilaxia. O objetivo do presente trabalho foi conduzir uma revisão sistemática da literatura para comparar a eficácia da enoxaparina e da rivaroxabana na prevenção desta complicação e no risco de sangramento intraoperatório. Foi feita uma revisão no site SciELO, Pubmed e Cochrane através dos descritores, artroplastia de joelho, rivaroxabana e enoxaparina através da estratégia de busca PICO. Os critérios de inclusão foram os artigos no período estudado, que comparavam ambas as drogas em cirurgias de artroplastia do joelho. Os critérios de relevância para tornar o estudo elegível foram definidos como: somente artigos publicados a partir 2010 e com casuística com mais de 20 pacientes foram considerados; somente estudos obtidos em sua íntegra foram analisados; somente estudos com seguimento maior do que 12 meses foram considerados relevantes. As variáveis utilizadas para a comparação dos artigos foram as complicações mais comuns no pós-operatório de artroplastias do joelho: tromboembolismo venoso e sangramento. Foi utilizado o Review Man 5.3 para estruturação da revisão. Os autores observaram que nos estudos analisados, considerando tromboembolismo venoso sintomático, a rivaroxabana resultou em maiores benefícios quando comparada com a enoxaparina.

ABSTRACT Total knee arthroplasty is an elective procedure performed on relatively healthy individuals. However, due to the inherent risk of venous thromboembolism, drugs are used for its prophylaxis. The objective of the present study was to conduct a systematic review of the literature to compare the efficacy of enoxaparin and rivaroxaban in preventing this complication and the risk of intraoperative bleeding. We reviewed the SciELO, Pubmed and Cochrane databases with the descriptors knee arthroplasty, rivaroxaban and enoxaparin through the PICO search strategy. Inclusion criteria were the articles during the study period comparing both drugs in knee arthroplasty. Relevant criteria to study eligibility were articles published since 2010 and with a sample of more than 20 patients; studies obtained in their entirety; and studies with follow-up of more than 12 months. The variables used to compare the articles were the most common postoperative complications of knee arthroplasties: venous thromboembolism and bleeding. We used the Review Man software, version 5.3, for structuring the review. In the studies analyzed, considering symptomatic venous thromboembolism, rivaroxaban resulted in higher benefits when compared to enoxaparin.

Manejo perioperatorio de pacientes usuarios de antiagregantes plaquetarios / Perioperative management of patients using antiplatelet agents

Resumen El uso de fármacos antiagregantes plaquetarios para prevención primaria y secundaria de eventos cardiovasculares es una práctica común en clínica. La terapia antiagregante plaquetaria disminuye significativamente la incidencia de eventos cardiovasculares, incluyendo infarto agudo al miocardio y accidente cerebro-vascular. Cada vez es más frecuente enfrentarse a pacientes en terapia antiagregante plaquetaria que serán sometidos a algún procedimiento quirúrgico, por tanto es fundamental conocer el manejo perioperatorio de estos fármacos, para disminuir los riesgos y complicaciones asociados a la suspensión o mantención de estas drogas en el período perioperatorio. Los antiagregantes plaquetarios de mayor uso en Chile son la aspirina y las tienopiridinas, siendo el clopidogrel el fármaco más utilizado en este grupo. El enfrentamiento perioperatorio de estos fármacos está supeditado al riesgo trombótico individual de cada paciente y al riesgo hemorrágico de cada cirugía. En cirugías no cardiacas, se sugiere mantener la aspirina, excepto en pacientes con bajo-moderado riesgo trombótico que serán sometidos a cirugías con alto riesgo de sangrado, en los cuales se recomienda suspenderla 5-7 días previo a la intervención quirúrgica. El clopidogrel se sugiere suspenderlo 5 días antes de la cirugía, excepto en pacientes con alto riesgo trombótico que se someterán a procedimientos quirúrgicos con riesgo hemorrágico bajo-moderado. En cirugías de revascularización miocárdica, se recomienda mantener aspirina y suspender clopidogrel 5 días antes del procedimiento. En relación al reinicio postquirúrgico de estos fármacos, se sugiere reanudar aspirina 6 h posterior a la cirugía y clopidogrel durante las primeras 24 h postoperatorias, asegurando previamente una adecuada hemostasia quirúrgica.

The use of antiplatelet drugs for primary and secondary prevention of cardiovascular disease events is a common clinical practice. Antiplatelet therapy significantly decreases the incidence of cardiovascular disease events, including acute myocardial infarction and cerebrovascular accident. It is increasingly common to face patients on antiplatelet therapy who will undergo some surgical procedure, so it is essential to know the perioperative management of these drugs, to reduce the risks and complications associated with the suspension or maintenance of these therapies in the perioperative period. The most common antiplatelet agents used in Chile are acetylsalicylic acid and thienopyridines, of which clopidogrel is the most frequent one. The perioperative management of these drugs has to be based on the individual thrombotic risk of each patient and the risk of hemorrhage of each surgery. In noncardiac surgeries, it is suggested to maintain acetylsalicylic acid, except in patients with low to moderate thrombotic risk who will undergo surgeries with a high risk of bleeding, in which case it is recommended to suspend it 5 to 7 days before surgery. Clopidogrel is suggested to be discontinued 5 days before surgery, except in patients with high thrombotic risk who will undergo surgical procedures with low to moderate risk of hemorrhage. In myocardial revascularization surgeries, it is recommended to maintain acetylsalicylic acid and to suspend clopidogrel 5 days before the procedure. Once assuring adequate surgical hemostasis, it is suggested to reinitiate acetylsalicylic acid 6 hours after surgery and to reinitiate clopidogrel during the first 24 postoperative hours.

Effects of hyaluronic acid on bleeding following third molar extraction

Abstract Objective To explore the effects of hyaluronic acid (HA) on bleeding and associated outcomes after third molar extraction. Methods Forty patients who had undergone molar extraction were randomly divided into two groups; 0.8% (w/v) HA was applied to the HA group (n=20) whereas a control group (n=20) was not treated. Salivary and gingival tissue factor (TF) levels, bleeding time, maximum interincisal opening (MIO), pain scored on a visual analog scale (VAS), and the swelling extent were compared between the two groups. Results HA did not significantly affect gingival TF levels. Salivary TF levels increased significantly 1 week after HA application but not in the control group. Neither the VAS pain level nor MIO differed significantly between the two groups. The swelling extent on day 3 and the bleeding time were greater in the HA group than in the control group. Conclusions Local injection of HA at 0.8% prolonged the bleeding time, and increased hemorrhage and swelling in the early postoperative period after third molar extractions.

Safety of warfarin therapy during cataract surgery under topical anesthesia / Segurança da terapia com varfarina durante cirurgia de catarata com anestesia tópica

ABSTRACT Purpose: To analyze the safety of warfarin therapy during cataract surgery under topical anesthesia. Methods: This was a prospective nonrandomized comparative study of 60 eyes of 60 patients treated with or without concurrent oral warfarin anticoagulant therapy, referred for cataract surgery under topical anesthesia. The sample included a treatment (n=30) and a control (n=30) group. Results: There were no records of intraoperative or postoperative intracameral bleeding complications in both the groups. At 1-month postoperative follow-up, 90.0% of patients presented spectacle-corrected visual acuity of at least 20/40. Conclusion: Cataract surgery by phacoemulsification with topical anesthesia can be successfully conducted without discontinuing warfarin. .

RESUMO Objetivo: Avaliar a segurança da cirurgia de catarata com anestesia tópica em pacientes em uso de varfarina. Métodos: Estudo comparativo não aleatorizado, prospectivo de 30 olhos de 30 indivíduos sob terapia anticoagulante por via oral com Varfarina que se submeteram à cirurgia de catarata com anestesia tópica. O grupo controle foi composto por 30 olhos de 30 pacientes, com indicação de cirurgia de catarata, que não faziam uso de terapia anticoagulante. Resultados: Não houve registro de complicações hemorrágicas intracamerais transoperatórias ou pós-operatórias em ambos os grupos. Na visita pós-operatória de 30 dias, 90,0% dos pacientes apresentavam acuidade visual corrigida por óculos de pelo menos 20/40. Conclusão: A cirurgia de catarata por facoemulsificação com anestesia tópica pode ser realizada com sucesso sem interrupção da terapia com varfarina. .

Validação de um escore para predição de eventos hemorrágicos em síndromes coronarianas agudas / Validation of a score for predicting bleeding events during acute coronary syndromes / Validación de un escore para predicción de eventos hemorrágicos en síndromes coronarios agudos

FUNDAMENTO: Sangramento é uma complicação grave em pacientes tratados para síndromes coronarianas agudas (SCA) com antitrombóticos e terapias invasivas. Consequentemente, o benefício dessas terapias deve ser analisado contra os potenciais riscos de complicações hemorrágicas. Desta forma, a determinação de um escore para estimar o risco individual de sangramento pode representar uma importante ferramenta na tomada de decisões clínicas. OBJETIVO: Criar e validar um escore de risco de sangramento para pacientes com SCA. MÉTODOS: Foram utilizados preditores independentes de sangramento relatados pelo Registro GRACE. Variáveis com odds ratio (OR) > 2,5 nesse Registro somaram 3 pontos (histórico anterior de sangramento), OR=1,5-2,4 somaram 2 pontos (clearance de creatinina< 30 ml/min, sexo feminino) e aquelas com OR < 1,5 somaram 1 ponto (clearance entre 30 e 60 ml/min, a cada 10 anos de idade > 30, infra ou supra-desnivelamento do segmento ST, doença arterial periférica e fumo). O escore foi validado em uma coorte de 383 indivíduos com SCA. Sangramento hospitalar foi definido como queda de hematócrito > 10 por cento, transfusão de sangue > 2 unidades, sangramento intracerebral ou sangramento fatal. RESULTADOS: A incidência de eventos hemorrágicos foi de 3,1 por cento e a estatística-C do escore foi 0,66 (IC95 por cento = 0,52-0,80), indicando capacidade preditiva para esses eventos. Aqueles com escore > 7 apresentaram 6 por cento de incidência de sangramento, comparados com 1,9 por cento se o escore era < 7 (RR=3,2; IC95 por cento=1,04-9,9; p=0,03). Houve uma interação entre um escore > 7 e um maior risco imposto pelo tratamento com Clopidogrel (p=0,02), bloqueadores IIb/IIIa (p=0,06) e revascularização cirúrgica (p < 0,001). CONCLUSÃO: O escore discrimina o risco de sangramento e é potencialmente útil na tomada de decisão clínica em SCA.

BACKGROUND: Bleeding is a major complication in patients treated for acute coronary syndromes (ACS) with antithrombotic and invasive therapies. Consequently, the benefit of such therapies should be balanced against the potential risk of hemorrhagic complications. Therefore, a score to estimate individual risk of bleeding might represent an important tool in clinical decision-making. OBJECTIVE: This study aims to create and validate a bleeding risk score for patients with ACS. METHODS: Independent predictors of bleeding reported by the GRACE Registry were utilized. Variables with odds ratio (OR) > 2.5 in that Registry added 3 points (previous history of bleeding), OR = 1.5-2.4 added 2 points (creatinine clearance < 30 ml/min, female gender) and those with OR < 1.5 added 1 point (clearance between 30 and 60 ml/min, each 10 years of age>30, ST-deviation, peripheral artery disease and smoking). The score was validated in a cohort of 383 individuals with ACS. In-hospital bleeding was defined as hematocrit fall > 10 percent, blood transfusion > 2 units, intracerebral bleeding or fatal bleeding. RESULTS: The incidence of bleeding events was 3.1 percent and the score's C-statistics was 0.66 (95 percent CI = 0.52-0.80), indicating a predictive ability towards these events. Those with a score > 7 had 6 percent incidence of bleeding, compared with 1.9 percent if the score was < 7 (RR = 3.2; 95 percentCI = 1.04-9.9; p = 0.03). There was an interaction between a score > 7 and greater risk imposed by treatment with Clopidogrel (p = 0.02), IIb/IIIa blockers (p = 0.06) and surgical revascularization (p < 0.001). CONCLUSION: The score discriminates bleeding risk and is potentially useful in clinical decision-making during ACS.

FUNDAMENTO: Sangrado es una complicación grave en pacientes tratados por síndromes coronarios agudos (SCA) con antitrombóticos y terapias invasivas. Consecuentemente, el beneficio de esas terapias debe ser analizado contra los potenciales riesgos de complicaciones hemorrágicas. De esta forma, la determinación de un escore para estimar el riesgo individual de sangrado puede representar una importante herramienta en la toma de decisiones clínicas. OBJETIVO: Crear y validar un escore de riesgo de sangrado para pacientes con SCA. MÉTODOS: Fueron utilizados predictores independientes de sangrado relatados por el Registro GRACE. Variables con odds ratio (OR) > 2,5 en ese Registro sumaron 3 puntos (histórico anterior de sangrado), OR=1,5-2,4 sumaron 2 puntos (clearance de creatinina < 30 ml/min, sexo femenino) y aquellas con OR < 1,5 sumaron 1 punto (clearance = 30-60 ml/min, a cada 10 años de edad > 30, infra o supra-desnivel del segmento ST, enfermedad arterial periférica y tabaco). El escore fue validado en una cohorte de 383 individuos con SCA. Sangrado intrahospitalario fue definido como caída de hematocrito > 10 por ciento, transfusión de sangre > 2 unidades, sangrado intracerebral o sangrado fatal. RESULTADOS: La incidencia de eventos hemorrágicos fue de 3,1 por ciento y la estadística-C del escore fue 0,66 (IC95 por ciento = 0,52-0,80), indicando capacidad predictiva para esos eventos. Aquellos con escore > 7 presentaron 6 por ciento de incidencia de sangrado, comparados con 1,9 por ciento si el escore era < 7 (RR=3,2; IC95 por ciento=1,04-9,9; P=0,03). Hubo una interacción entre un escore > 7 y un mayor riesgo impuesto por el tratamiento con Clopidogrel (P=0,02), bloqueadores IIb/IIIa (P=0,06) y revascularización quirúrgica (P<0,001). CONCLUSIÓN: El escore discrimina el riesgo de sangrado y es potencialmente útil en la toma de decisión clínica en SCA.

Minor oral surgery procedures in patients taking warfarin: a 5-year retrospective study at Sultan Qaboos University Hospital, Sultanate of Oman

Minor oral surgery [MOS] procedures in warfarinised patients carry the risk of post-operative bleeding. The aim of this study was to conduct a retrospective analysis and to describe the profile of warfarinised patients who underwent MOS procedures at Sultan Qaboos University Hospital. A retrospective study of 124 warfarinised patients [41 men and 83 women], who had a pre-operative international normalised ratio [INR] of