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1.
J Laryngol Otol ; 134(4): 316-322, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32281535

RESUMO

BACKGROUND: Individuals on anticoagulation therapy are at increased risk of bleeding, including epistaxis. There is a lack of available reversal agents for novel oral anticoagulation therapy. OBJECTIVE: This paper reviews the current literature on epistaxis in the context of novel oral anticoagulation use, in order to recommend guidelines on management. METHOD: A comprehensive search of published literature was conducted to identify all relevant articles published up to April 2019. RESULTS: Patients on oral anticoagulation therapy are over-represented in individuals with epistaxis. Those on novel oral anticoagulation therapy were more likely to relapse compared to patients on classic oral anticoagulants or non-anticoagulated patients. Idarucizumab is an effective antidote for bleeding associated with dabigatran use. Recommendations for epistaxis management in patients on novel oral anticoagulation therapy are outlined. CONCLUSION: Clinicians need to be aware of the potential severity of epistaxis and the increased likelihood of recurrence. High-quality studies are required to determine the efficacy and safety of andexanet alfa and ciraparantag, as well as non-specific reversal agents.


Assuntos
Anticorpos Monoclonais Humanizados/uso terapêutico , Antídotos/uso terapêutico , Epistaxe/tratamento farmacológico , Administração Oral , Idoso , Anticorpos Monoclonais Humanizados/administração & dosagem , Anticoagulantes/efeitos adversos , Anticoagulantes/uso terapêutico , Antídotos/administração & dosagem , Antitrombinas/efeitos adversos , Antitrombinas/uso terapêutico , Arginina/administração & dosagem , Arginina/análogos & derivados , Arginina/uso terapêutico , Conscientização , Dabigatrana/efeitos adversos , Dabigatrana/uso terapêutico , Epistaxe/induzido quimicamente , Epistaxe/epidemiologia , Fator Xa/administração & dosagem , Fator Xa/uso terapêutico , Inibidores do Fator Xa/efeitos adversos , Inibidores do Fator Xa/uso terapêutico , Primeiros Socorros/normas , Humanos , Masculino , Piperazinas/administração & dosagem , Piperazinas/uso terapêutico , Prevalência , Proteínas Recombinantes/administração & dosagem , Proteínas Recombinantes/uso terapêutico , Rivaroxabana/efeitos adversos , Rivaroxabana/uso terapêutico , Índice de Gravidade de Doença
2.
Medicine (Baltimore) ; 99(17): e19890, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32332662

RESUMO

RATIONALE: Dabigatran is an anticoagulant medication that has been widely used to prevent strokes caused by atrial fibrillation, deep vein thrombosis, and pulmonary embolism. However, the potential adverse effect of dabigatran of gastrointestinal mucosal injury is often neglected, and even induces esophagitis. PATIENT CONCERNS: A 77-year-old woman was admitted to the hospital with symptoms of progressive retrosternal pain, upper abdominal discomfort, and dysphagia. DIAGNOSIS: Esophagogastroduodenoscopy showed longitudinal sloughing mucosal casts in the distal esophagus. Histological examination showed squamous epithelium with neutrophil infiltration, partial epithelial degeneration, and Helicobacter pylori. Based on a literature review, medical history, and imaging examination, the patient was diagnosed with dabigatran-induced esophagitis. INTERVENTIONS: The patient recovered with standard H. pylori eradication therapy and proton pump inhibitor without discontinuing dabigatran. OUTCOMES: After 2 weeks, the retrosternal pain and dysphagia were relieved and upper abdominal discomfort was attenuated. LESSONS: Our case highlights the importance of physicians' awareness of the clinical and endoscopic characteristics of dabigatran-induced esophagitis and the importance of H. pylori-associated tests and eradication if necessary for patients with long-term dabigatran treatment.


Assuntos
Dabigatrana/efeitos adversos , Esofagite/etiologia , Dor Abdominal/tratamento farmacológico , Dor Abdominal/fisiopatologia , Idoso , Antitrombinas/efeitos adversos , Antitrombinas/uso terapêutico , Dabigatrana/uso terapêutico , Transtornos de Deglutição/tratamento farmacológico , Transtornos de Deglutição/fisiopatologia , Endoscopia do Sistema Digestório/métodos , Esofagite/fisiopatologia , Feminino , Helicobacter pylori/efeitos dos fármacos , Helicobacter pylori/patogenicidade , Humanos
3.
Int Heart J ; 61(2): 249-253, 2020 Mar 28.
Artigo em Inglês | MEDLINE | ID: mdl-32173706

RESUMO

Cryoballoon ablation is an established catheter-based approach to treat atrial fibrillation (AF). However, thromboembolic events cannot be avoided during cryoablation. There is little data regarding the blood coagulation status during freezing.The thrombin antithrombin complex (TAT) and prothrombin fragment 1+2 (F 1+2) of patient blood were measured during cryoballoon application when the cryoballoon temperature reached the nadir in 63 AF patients. TAT was also measured from porcine blood during cryoballoon freezing in 5 pigs.The TAT and F 1+2 increased from 6.60 ± 5.65 to 9.16 ± 7.28 ng/mL (P = 0.004) and from 279.6 ± 146.4 to 323.6 ± 169.1 pmol/L (P = 0.003) between the control and during freezing, respectively. The TAT increased from 0.46 to 0.87 ng/mL during freezing compared to that of pre-freezing (P < 0.05), and it returned to 0.39 ng/mL in 30 minutes after an intravenous edoxaban administration (N.S.).Dabigatran failed to exert sufficient anticoagulant effects during cryofreezing. In contrast, intravenous edoxaban seemed to provoke anticoagulation effects under extreme low temperature circumstances.


Assuntos
Antitrombinas/uso terapêutico , Criocirurgia/efeitos adversos , Dabigatrana/uso terapêutico , Piridinas/uso terapêutico , Tiazóis/uso terapêutico , Tromboembolia/etiologia , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Tromboembolia/prevenção & controle
4.
Medicine (Baltimore) ; 99(6): e19064, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32028428

RESUMO

BACKGROUND: This meta-analysis is to evaluate the efficacy and safety of bivalirudin in patients with ST-elevation myocardial infarction (STEMI). METHODS: PubMed, Cochrane Library, Embase, CNKI, CBMdisc, and VIP database were searched. Randomized controlled trial (RCT) was selected and the meta-analysis was conducted by RevMan 5.1. The primary efficacy endpoint was the incidence of major adverse cardiovascular events (MACE) and the primary safety endpoint was the incidence of major bleeding. Secondary efficacy endpoints were myocardial infarction (MI), target vessel revascularization (TVR), stent thrombosis (ST), stock, mortality, and thrombocytopenia. The pooled risk ratios (RRs) with the corresponding 95% confidence intervals (CI) were used to assess the efficacy and safety of bivalirudin vs heparin. RESULTS: Seven RCTs met the inclusion criteria, and 16,640 patients were included. We found that bivalirudin associated with lower risk of mortality (RR = 1.05; 95% CI = 0.74-1.49; P = .03; I = 2%), major bleeding (RR = 0.64; 95% CI = 0.54-0.75; P < .00001; I = 70%) and thrombocytopenia (RR = 0.39; 95% CI = 0.25-0.61; P < .0001; I = 0) compared with heparin. However, the use of bivalirudin increase the risk of MI(RR = 1.37; 95% CI = 1.10-1.71; P = .004; I = 25%) and ST(RR = 1.61; 95% CI = 1.05-2.47; P = .03; I = 70%) and has similar risk of MACE (RR = 1.00; 95% CI = 0.90-1.11; P = .97; I = 16%), TVR (RR = 1.43; 95% CI = 0.92-2.22; P = .11; I = 46%) and stock (RR = 1.43; 95% CI = 0.92-2.22; P = .11; I = 46%) compared with heparin used in STEMI patients. CONCLUSION: Bivalirudin associated with lower risk of mortality, major bleeding and thrombocytopenia compared with heparin. However, the use of bivalirudin increase the risk of MI and ST and has similar risk of MACE, TVR and stock compared with heparin used in STEMI patients.


Assuntos
Antitrombinas/uso terapêutico , Doença das Coronárias/cirurgia , Heparina/uso terapêutico , Fragmentos de Peptídeos/uso terapêutico , Intervenção Coronária Percutânea , Heparina/efeitos adversos , Hirudinas/efeitos adversos , Humanos , Fragmentos de Peptídeos/efeitos adversos , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto , Proteínas Recombinantes/efeitos adversos , Proteínas Recombinantes/uso terapêutico , Trombose/etiologia , Trombose/prevenção & controle , Resultado do Tratamento
6.
Diab Vasc Dis Res ; 16(6): 582-584, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31476896

RESUMO

OBJECTIVE: To investigate the association between admission plasma glucose and cardiovascular events in patients with acute myocardial infarction treated with modern therapies including early percutaneous coronary intervention and modern stents. METHODS: Patients (n = 5309) with established diabetes and patients without previously known diabetes with a reported admission plasma glucose, included in the VALIDATE trial 2014-2016, were followed for cardiovascular events (first of mortality, myocardial infarction, stroke, heart failure) within 180 days. Event rates were analysed by four glucose categories according to the World Health Organization criteria for hyperglycaemia and definition of diabetes. Odds ratios were calculated in a multivariate logistic regression model. RESULTS: Mean age was 67 ± 11 years. Previously known diabetes was present in 21.2% (n = 1124). Cardiovascular events occurred in 3.7%, 3.8%, 6.6% and 15.7% in the four glucose level groups and 9.9% in those with known diabetes (p < 0.001), while bleeding complications did not differ significantly (9.1%, 8.5%, 8.4%, 12.2% and 8.5%, respectively). After adjustment, odds ratio (95% confidence interval) was 1.00 (0.65-1.53) for group II, 1.62 (1.14-2.29) for group III and 3.59 (1.99-6.50) for group IV compared to the lowest admission plasma glucose group (group I). The corresponding number for known diabetes was 2.42 (1.71-3.42). CONCLUSION: In a well-treated contemporary population of acute myocardial infarction patients, 42% of those without diabetes had elevated admission plasma glucose levels with a greater risk for clinical events already within 180 days. Event rate increased with increasing admission plasma glucose levels. These findings highlight the importance of searching for undetected diabetes in the setting of acute myocardial infarction and that new treatment options are needed to improve outcome.


Assuntos
Glicemia/metabolismo , Diabetes Mellitus/sangue , Hiperglicemia/sangue , Infarto do Miocárdio/terapia , Admissão do Paciente , Intervenção Coronária Percutânea/efeitos adversos , Idoso , Anticoagulantes/uso terapêutico , Antitrombinas/uso terapêutico , Biomarcadores/sangue , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/mortalidade , Feminino , Insuficiência Cardíaca/mortalidade , Humanos , Hiperglicemia/diagnóstico , Hiperglicemia/mortalidade , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/sangue , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Intervenção Coronária Percutânea/instrumentação , Intervenção Coronária Percutânea/mortalidade , Recidiva , Sistema de Registros , Medição de Risco , Fatores de Risco , Stents , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Resultado do Tratamento , Regulação para Cima
7.
Clin Appl Thromb Hemost ; 25: 1076029619870249, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31418293

RESUMO

We compared the risks of switching to another oral anticoagulant (OAC) and discontinuation of direct oral anticoagulants (DOACs) among elderly patients with nonvalvular atrial fibrillation (NVAF) who were prescribed rivaroxaban or dabigatran versus apixaban. Patients (≥65 years of age) with NVAF prescribed DOACs (January 1, 2013 to September 30, 2017) were identified from the Humana research database and grouped into DOAC cohorts. Cox regression analyses were used to evaluate whether the risk for switching to another OAC or discontinuing index DOACs differed among cohorts. Of the study population (N = 38 250), 55.9% were prescribed apixaban (mean age: 78.6 years; 49.8% female), 37.3% rivaroxaban (mean age: 77.4 years; 46.7% female), and 6.8% dabigatran (mean age: 77.0 years; 44.0% female). Compared to patients prescribed apixaban, patients prescribed rivaroxaban (hazard ratio [HR]: 2.08; 95% confidence interval [CI], 1.92-2.25; P < .001) or dabigatran (HR: 3.74; 95% CI, 3.35-4.18, P < .001) had a significantly higher risk of switching to another OAC during the follow-up; compared to patients prescribed apixaban, the risks of discontinuation were also higher for patients treated with rivaroxaban (HR: 1.10; 95% CI, 1.07-1.13, P < .001) or dabigatran (HR: 1.29; 95% CI, 1.23-1.35, P < .001).


Assuntos
Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Substituição de Medicamentos/estatística & dados numéricos , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/administração & dosagem , Antitrombinas/uso terapêutico , Dabigatrana/uso terapêutico , Inibidores do Fator Xa/uso terapêutico , Feminino , Humanos , Masculino , Pirazóis/uso terapêutico , Piridonas/uso terapêutico , Estudos Retrospectivos , Rivaroxabana/uso terapêutico
8.
Blood Coagul Fibrinolysis ; 30(6): 304-307, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31419212

RESUMO

: Pregnancy carries a high risk of thromboembolic complications, especially in the postpartum period. This risk is particularly high in women with inherited thrombophilias, among these antithrombin deficiency seems to carry the highest risk. In this case, the use of low molecular weight heparin (LMWH) is recommended, while the use of antithrombin concentrate is controversial. We report our experience of seven pregnancies occurred in five women: two, with a personal and familiar history negative for venous thromboembolism, were treated with LMWH during pregnancy and antithrombin concentrate immediately before and after the delivery. The other three women had a personal and familiar history positive for venous thromboembolism and were treated with LMWH and antithrombin concentrate during all the pregnancy and the postpartum period. No thromboembolic or hemorrhagic complications were observed in both groups, demonstrating that our strategy could be safe and effective.


Assuntos
Deficiência de Antitrombina III/tratamento farmacológico , Complicações Hematológicas na Gravidez/tratamento farmacológico , Tromboembolia Venosa/prevenção & controle , Adulto , Deficiência de Antitrombina III/complicações , Deficiência de Antitrombina III/congênito , Antitrombinas/uso terapêutico , Feminino , Hemorragia/induzido quimicamente , Heparina de Baixo Peso Molecular/uso terapêutico , Humanos , Gravidez , Tromboembolia Venosa/etiologia , Adulto Jovem
10.
Hosp Pract (1995) ; 47(3): 113-122, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31317796

RESUMO

Direct oral anticoagulants (DOACs) include dabigatran etexilate, a direct thrombin inhibitor, and specific inhibitors of activated coagulation factor X (FXa; e.g. apixaban, betrixaban, edoxaban, rivaroxaban). DOACs are associated with lower rates of major and fatal bleeding events compared with warfarin. Clinicians may need to achieve rapid reversal of anticoagulation effects of the DOACs in an emergency setting. Idarucizumab and andexanet alfa, which reverse the anticoagulant effects of dabigatran and FXa inhibitors, respectively, are DOAC reversal agents available in the US. Other reversal agents (e.g. ciraparantag for heparins, DOACs) are in development. Alternative nonspecific agents (e.g. fresh frozen plasma, prothrombin complex concentrate) are available. Nonspecific prohemostatic agents can counteract the anticoagulant action of DOACs in emergency situations, when specific reversal agents are unavailable. However, specific reversal agents are efficacious and safe and should be preferred when available. In this review, we discuss practical issues in the initiation of DOAC therapy, situations where reversal may be needed, coagulation assays, reversal agents, and post-reversal complications in the context of published evidence and guidelines.


Assuntos
Anticorpos Monoclonais Humanizados/farmacologia , Anticoagulantes/administração & dosagem , Antitrombinas/uso terapêutico , Dabigatrana/antagonistas & inibidores , Fator X/antagonistas & inibidores , Fator Xa/farmacologia , Pacientes Internados , Proteínas Recombinantes/farmacologia , Administração Oral , Coagulação Sanguínea/efeitos dos fármacos , Serviços Médicos de Emergência , Fator Xa/agonistas , Inibidores do Fator Xa/uso terapêutico , Hemorragia/tratamento farmacológico , Humanos , Corpo Clínico Hospitalar
11.
Emerg Med Clin North Am ; 37(3): 529-544, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31262419

RESUMO

Central nervous system hemorrhage has multiple pathophysiologic etiologies, including intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), and traumatic brain injury (TBI). Given the nuances intrinsic to each of these etiologies and pathophysiologic processes, optimal blood pressure varies significantly and depends on type of hemorrhage and individual characteristics. This article reviews the most current evidence regarding blood pressure targets and provides guidance on reversal of anticoagulation for TBI, ICH, and SAH. It also describes the assessment, optimal therapeutic targets, and interventions to treat intracranial hypertension that can result from TBI, ICH, or SAH.


Assuntos
Hemorragias Intracranianas/terapia , Hipertensão Intracraniana/terapia , Anti-Hipertensivos/uso terapêutico , Antitrombinas/uso terapêutico , Pressão Sanguínea , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/terapia , Medicina de Emergência , Hemostáticos/uso terapêutico , Humanos , Hemorragias Intracranianas/diagnóstico , Hipertensão Intracraniana/diagnóstico , Hipertensão Intracraniana/etiologia , Transfusão de Plaquetas , Vasodilatadores/uso terapêutico
12.
Indian Heart J ; 71(2): 166-169, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31280831

RESUMO

The primary aortic thrombosis (PAT) is an uncommon noncardiac cause of distal peripheral embolization to lower extremities. Also, this condition develops in the absence of extensive atherosclerosis of aorta or abnormal dilatation like aneurysm of the aorta. In most of the cases, there was either no or minimal atherosclerosis of the aorta. The disease can involve any part of the aorta, but in most of the cases, the thoracic aorta below the origin of the left subclavian artery followed by the infrarenal portion of the abdominal aorta was the most common site of involvement. In our case, there was extensive thrombosis starting from the lower part of the thoracic aorta extending across both the renal arteries up to the aortic bifurcation without any underlying aortic pathology or hypercoagulable disease. There are no guidelines for the management of the PAT, but our experience is based on few case series, case reports, and meta-analysis where there are variable success rate using conservative medical management, endovascular procedure, or surgical thrombectomy. Vitamin K antagonist was the drug of choice in all the cases as a part of conservative medical management or used to prevent recurrence after the endovascular or surgical procedure. We present a case of PAT where the use of dabigatran leads to complete resolution and prevented the recurrence of the disease during two-year follow-up, which is the first and unique case report of the literature.


Assuntos
Antitrombinas/uso terapêutico , Doenças da Aorta/tratamento farmacológico , Dabigatrana/uso terapêutico , Trombose/tratamento farmacológico , Amputação , Doenças da Aorta/complicações , Doenças da Aorta/diagnóstico por imagem , Arteriopatias Oclusivas/etiologia , Arteriopatias Oclusivas/cirurgia , Feminino , Pé/irrigação sanguínea , Pé/cirurgia , Gangrena/etiologia , Gangrena/cirurgia , Humanos , Pessoa de Meia-Idade , Doenças Vasculares Periféricas/etiologia , Doenças Vasculares Periféricas/cirurgia , Trombose/complicações , Trombose/diagnóstico por imagem
13.
Turk Kardiyol Dern Ars ; 47(5): 413-416, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31311911

RESUMO

This case report illustrates the follow-up of a 57-year-old female with a type B aortic dissection (AD) under dabigatran treatment. The patient had been operated on 8 years earlier due to type A AD. The aortic valve was repaired and a 26-mm polyester fiber graft was applied to the ascending aorta and the aortic arch. In computerized tomography scans taken after the procedure, a dissection flap extending from the descending aorta to the iliac arteries was seen, but the patient was asymptomatic and no further surgery was performed. The patient was subsequently diagnosed with atrial fibrillation. A CHA2DS2VASc score of 3 was recorded and dabigatran treatment was initiated. The aortic aneurysm and dissection were followed up via computed tomography and echocardiography at regular intervals, and at 6 months no progression was seen. No thromboembolic or hemorrhagic events were observed. To our knowledge, this is the first case report of dabigatran treatment for a patient with a type B AD. Based on this case, the use of dabigatran would appear to be safe in a patient with an uncomplicated type B AD, but the results of this case need to be confirmed with extended follow-up and additional patients.


Assuntos
Aneurisma Dissecante/tratamento farmacológico , Antitrombinas/uso terapêutico , Aneurisma da Aorta Torácica/tratamento farmacológico , Dabigatrana/uso terapêutico , Aneurisma Dissecante/diagnóstico por imagem , Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/diagnóstico por imagem , Feminino , Humanos , Pessoa de Meia-Idade
14.
Carbohydr Polym ; 222: 115031, 2019 Oct 15.
Artigo em Inglês | MEDLINE | ID: mdl-31320064

RESUMO

The detailed structure of a further Chondroitin Sulfate from Litopenaeus vannamei shrimp (sCS) is described. The backbone structure was established by 1H/13C NMR, which identified 3-O-sulfated GlcA, 4-O-sulfated GalNAc, 6-O-sulfated GalNAc, and 4,6-di-O-sulfated GalNAc residues. GlcA is linked to GalNAc 4,6 di S and GlcA 3S is linked to GalNAc 4S, GalNAc 4,6 di-S and GalNAc6S residues. The anticoagulant properties of this sCS were evaluated by activated partial thromboplastin time, anti-IIa, anti-Xa and anti-heparin cofactor II-mediated activities, and sCS failed to stabilise antithrombin in a fluoresence shift assay. The anti-inflammatory effect of sCS was explored using a model of acute peritonitis, followed by leukocyte count and measurement of the cytokines, IL-1ß, IL-6 and TNF-α. The compound showed low clotting effects, but high anti-IIa activity and HCII-mediated thrombin inhibition. Its anti-inflammatory effect was shown by leukocyte recruitment inhibition and a decrease in pro-inflammatory cytokine levels. Although the biological role of sCS remains unknown, its properties indicate that it is suitable for studies of multi-potent molecules obtained from natural sources.


Assuntos
Anti-Inflamatórios/uso terapêutico , Antitrombinas/uso terapêutico , Sulfatos de Condroitina/uso terapêutico , Inflamação/tratamento farmacológico , Penaeidae/química , Peritonite/tratamento farmacológico , Animais , Anti-Inflamatórios/química , Anti-Inflamatórios/isolamento & purificação , Antitrombinas/química , Antitrombinas/isolamento & purificação , Sulfatos de Condroitina/química , Sulfatos de Condroitina/isolamento & purificação , Citocinas/metabolismo , Lipopolissacarídeos , Masculino , Camundongos , Camundongos Endogâmicos C57BL , Peso Molecular , Óxido Nítrico/metabolismo , Peritonite/induzido quimicamente , Células RAW 264.7 , Ratos Wistar
15.
Emerg Med Pract ; 21(8): 1-28, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31339254

RESUMO

Direct oral anticoagulant (DOAC) agents have become commonly used over the last 9 years for treatment and prophylaxis for thromboembolic conditions, following approvals by the United States Food and Drug Administration. These anticoagulant agents, which include a direct thrombin inhibitor and factor Xa inhibitors, offer potential advantages for patients over warfarin; however, bleeding emergencies with DOACs can present diagnostic and therapeutic challenges because, unlike traditional anticoagulants, their therapeutic effect cannot be easily monitored directly with common clotting assays. This review examines the growing body of evidence on the uses and risks of DOACs in the emergency department, including initiation of therapy and reversal strategies.


Assuntos
Anticoagulantes/efeitos adversos , Administração Oral , Anticoagulantes/uso terapêutico , Antitrombinas/efeitos adversos , Antitrombinas/uso terapêutico , Gerenciamento Clínico , Serviços Médicos de Emergência/métodos , Serviço Hospitalar de Emergência/organização & administração , Inibidores do Fator Xa/efeitos adversos , Inibidores do Fator Xa/uso terapêutico , Humanos , Tempo de Protrombina/métodos , Tomografia Computadorizada por Raios X/métodos , Ultrassonografia/métodos
16.
Drug Des Devel Ther ; 13: 1527-1533, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31190734

RESUMO

Atrial fibrillation increases the risk of stroke and death. The vitamin-K antagonist warfarin is recommended for patients with atrial fibrillation, but vitamin-K antagonists are cumbersome to use. Therefore, an effective, safe and convenient new anticoagulant is needed. Dabigatran acts by inhibiting free and fibrin-bound thrombin directly. It is an oral anticoagulant that was approved by the US Food and Drug Administration. The oral anticoagulant dabigatran has been used increasingly due to its good tolerance, predictable pharmacokinetics, effective anticoagulant effects, and absence of requirement of coagulation monitoring. However, an increasing prevalence of adverse events has been reported, some of them quite serious. Therefore, we searched and reviewed the literature on dabigatran with regard to adverse events, and proposed solutions to prevent and reduce the chance of adverse events occurring.


Assuntos
Antitrombinas/efeitos adversos , Dabigatrana/efeitos adversos , Antitrombinas/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Dabigatrana/uso terapêutico , Humanos
17.
Clin Drug Investig ; 39(9): 891-898, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31183629

RESUMO

BACKGROUND AND OBJECTIVE: Atrial fibrillation, the most frequent form of arrhythmia, affects 5-15% individuals aged > 80 years. Stroke is a major risk for atrial fibrillation patients. The benefits of anticoagulant therapy clearly outweigh the risk of hemorrhage, even in the elderly. Despite the efficacy of warfarin, many eligible patients receive no prophylactic antithrombotic therapy. New generation oral anticoagulants compare favorably with vitamin K antagonists in the prevention of thromboembolic events and hemorrhage. These new agents are likely to influence the prescribing habits of anticoagulants in atrial fibrillation. The aim of this study to investigate both the frequency and the determining factors of anticoagulant prescriptions in AF patients aged ≥ 80 years and followed up by private-practice cardiologists in France. METHODS: The OCTOFA (Atrial Fibrillation in Octogenarians) Study assessed the anticoagulant prescribing habits of cardiologists in France. The volunteer cardiologists recruited all consecutive patients fulilling the inclusion criteria. RESULTS: Between June 2013 and September 2016, 89 cardiologists recruited 738 eligible patients: age ≥ 80 years, non-valvular atrial fibrillation, no other compelling indication for anticoagulation therapy, no recent acute coronary syndrome or stroke. Most (90.7%) patients were on oral anticoagulant therapy: vitamin K antagonist or non-vitamin K antagonist oral anticoagulants, low molecular weight heparin (1.4%), aspirin (5.7%), and no antithrombotic treatment (2.2%). Patients on vitamin K antagonists were older (p < 0.001), had lower renal function (p = 0.033), and had a more frequent history of myocardial infarction (p < 0.001), heart failure (p = 0.001), peripheral artery disease (p = 0.033), major hemorrhage (p = 0.025), and falls (p = 0.045). Four determining factors of anticoagulant prescriptions were statistically significant: high CHA2DS2-VASc score (p < 0.001), high HAS-BLED score (p < 0.001), age > 90 years (p = 0.001), and moderate/severe cognitive impairment (p = 0.002). CONCLUSIONS: Most private-practice cardiologists prescribe anticoagulant treatment according to current guidelines in elderly atrial fibrillation patients. Non-vitamin K antagonist oral anticoagulants represent a significant proportion of prescriptions.


Assuntos
Antitrombinas/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Antitrombinas/administração & dosagem , Fibrilação Atrial/complicações , Feminino , França , Humanos , Masculino , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Varfarina/uso terapêutico
18.
Anesthesiology ; 131(3): 543-554, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31180918

RESUMO

BACKGROUND: The risk of thromboembolic complications with prothrombin complex concentrates (PCCs) appears low when used for reversal of vitamin K antagonists but might be different in other indications (e.g., trauma). A difference in risk could arise from the plasma ratio of pro- versus anticoagulant proteins. This study used a porcine trauma model to investigate combined treatment with PCC and antithrombin. The hypothesis was that antithrombin can modulate prothrombotic effects and prevent adverse events of PCC. METHODS: Nine treatment groups (n = 7 per group) were included: control (placebo), PCC (50 IU/kg), PCC plus antithrombin (three groups, with antithrombin doses of 12.5, 25, or 50 IU/kg), fibrinogen concentrate (100 mg/kg) plus PCC, fibrinogen concentrate plus PCC plus antithrombin dose of 50 IU/kg, tranexamic acid (15 mg/kg) plus fibrinogen concentrate plus PCC, and tranexamic acid plus fibrinogen concentrate plus PCC plus antithrombin dose of 50 IU/kg. In each group, bilateral femur fractures and thorax contusion were followed 60 min later by blunt liver injury. Study treatment was then administered, and animals were subsequently observed for 210 min. RESULTS: Total blood loss (mean ± SD) was statistically significantly lower in all three PCC plus antithrombin groups (PCC plus antithrombin dose of 50 IU/kg, 672 ± 63 ml; PCC plus antithrombin dose of 25 IU/kg, 535 ± 72 ml; and PCC plus antithrombin dose of 12.5 IU/kg, 538 ± 50 ml) than in the PCC group (907 ± 132 ml), which in turn had statistically significantly reduced bleeding versus the control group (1,671 ± 409 ml). Signs of disseminated intravascular coagulation were apparent with PCC monotherapy, and early deaths occurred with fibrinogen concentrate plus PCC, attributable to pulmonary emboli. Antithrombin was protective against both of these effects: signs of disseminated intravascular coagulation were absent from the PCC plus antithrombin groups, and there were no early deaths in the group with fibrinogen concentrate plus PCC plus antithrombin dose of 50 IU/kg. CONCLUSIONS: According to this trauma model, 50 IU/kg PCC increases the risk of disseminated intravascular coagulation and other thromboembolic complications, most notably when coadministered with fibrinogen concentrate. The addition of antithrombin appears to reduce this risk.


Assuntos
Antitrombinas/uso terapêutico , Fatores de Coagulação Sanguínea/efeitos adversos , Coagulação Intravascular Disseminada/prevenção & controle , Animais , Modelos Animais de Doenças , Coagulação Intravascular Disseminada/complicações , Masculino , Suínos , Ferimentos não Penetrantes/complicações
19.
Crit Care ; 23(1): 206, 2019 Jun 06.
Artigo em Inglês | MEDLINE | ID: mdl-31171018

RESUMO

In light of an aging population with increased cardiovascular comorbidity, the use of oral anticoagulation (OAC) is steadily expanding. A variety of pharmacological alternatives to vitamin K antagonists (VKA) have emerged over recent years (direct oral anticoagulants, DOAC, i.e., dabigatran, rivaroxaban, apixaban, and edoxaban) which show a reduced risk for the occurrence of intracerebral hemorrhage (ICH). Yet, in the event of ICH under OAC (OAC-ICH), hematoma characteristics are similarly severe and clinical outcomes likewise substantially limited in both patients with VKA- and DOAC-ICH, which is why optimal acute hemostatic treatment in all OAC-ICH needs to be guaranteed. Currently, International Guidelines for the hemostatic management of patients with OAC-ICH are updated as several relevant large-sized observational studies and recent trials have established treatment approaches for both VKA- and DOAC-ICH. While the management of VKA-ICH is mainly based on the immediate reversal of elevated levels of international normalized ratio using prothrombin complex concentrates, hemostatic management of DOAC-associated ICH is challenging requiring specific antidotes, notably idarucizumab and andexanet alfa. This review will provide an overview of the latest studies and trials on hemostatic reversal agents and timing and summarizes the effects on hemorrhage progression and clinical outcomes in patients with OAC-ICH.


Assuntos
Anticoagulantes/efeitos adversos , Antídotos/farmacologia , Hemorragia Cerebral/tratamento farmacológico , Administração Oral , Anticoagulantes/uso terapêutico , Antídotos/efeitos adversos , Antídotos/uso terapêutico , Antitrombinas/efeitos adversos , Antitrombinas/uso terapêutico , Coagulação Sanguínea/efeitos dos fármacos , Hemorragia Cerebral/complicações , Fator Xa/uso terapêutico , Inibidores do Fator Xa/efeitos adversos , Inibidores do Fator Xa/uso terapêutico , Humanos , Proteínas Recombinantes/uso terapêutico , Ácido Tranexâmico/efeitos adversos , Ácido Tranexâmico/uso terapêutico
20.
J Vasc Surg ; 70(1): 274-284.e5, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31230646

RESUMO

OBJECTIVE: The direct thrombin inhibitor bivalirudin (BIV) was shown to be superior to unfractionated heparin (UFH) in percutaneous coronary interventions for reducing procedural blood loss. The aim of this study was to compare outcome profiles of BIV and UFH in peripheral endovascular procedures (PEPs) by synthesizing the currently available data. METHODS: Following the PRISMA statement, we conducted a comprehensive literature search using Medline, Cochrane CENTRAL, PubMed, EMBASE, CINAHL Google scholar, and clinicaltrials.gov. We recruited randomized, controlled trials and well-conducted observational studies that compared UFH and BIV in PEPs requiring anticoagulation, excluding endovascular cardiac procedures and coronary interventions. Random-effects meta-analyses were conducted to compare the outcome profiles of these two agents. RESULTS: Thirteen articles containing 17 studies involving a total of 21,057 patients were enrolled. Of these, 2 were randomized controlled trials, 2 were prospective cohort studies, and 10 were retrospective studies. There were no significant differences between BIV and UFH in terms of procedural success rates, major and minor perioperative bleeding, transfusion, perioperative transient ischemic attack, or hemorrhagic strokes. However, compared with UFH, BIV had significantly lower odds ratios (OR) of perioperative mortality (OR, 0.58; 95% confidence interval [CI], 0.40-0.86), major adverse cardiovascular events (OR, 0.65; 95% CI, 0.51-0.83), net adverse clinical events (OR, 0.75; 95% CI, 0.63-0.88), perioperative myocardial infarction (OR, 0.73; 95% CI, 0.55-0.98), major vascular complications (OR, 0.59; 95% CI, 0.39-0.91), and minor vascular complications (OR, 0.58; 95% CI, 0.40-0.84). CONCLUSIONS: Compared with UFH, PEPs using BIV had comparable procedural success rates and odds of perioperative transient ischemic attack and hemorrhagic stroke. However, procedures with BIV had a lower but nonsignificant odds of perioperative bleeding and transfusion. Depending on the procedures conducted, the patients who received BIV will have reduced or comparable odds of perioperative mortality, myocardial infarction, major adverse cardiovascular events, net adverse clinical events, and major and minor vascular complications. Therefore, BIV may be chosen solely as an alternative procedural anticoagulant to UFH for PEPs.


Assuntos
Anticoagulantes/uso terapêutico , Antitrombinas/uso terapêutico , Procedimentos Endovasculares , Heparina/uso terapêutico , Fragmentos de Peptídeos/uso terapêutico , Doenças Vasculares Periféricas/terapia , Anticoagulantes/efeitos adversos , Antitrombinas/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Hemorragia/induzido quimicamente , Heparina/efeitos adversos , Hirudinas/efeitos adversos , Humanos , Ataque Isquêmico Transitório/etiologia , Infarto do Miocárdio/etiologia , Estudos Observacionais como Assunto , Segurança do Paciente , Fragmentos de Peptídeos/efeitos adversos , Doenças Vasculares Periféricas/mortalidade , Ensaios Clínicos Controlados Aleatórios como Assunto , Proteínas Recombinantes/efeitos adversos , Proteínas Recombinantes/uso terapêutico , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Resultado do Tratamento
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