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1.
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
2.
Praxis (Bern 1994) ; 109(2): 65-70, 2020 Feb.
Artigo em Alemão | MEDLINE | ID: mdl-32019448

RESUMO

CME:Heparin-Induced Thrombocytopenia Abstract. Heparin-induced thrombocytopenia (HIT) is a dangerous, potentially fatal, immunologically mediated side effect of heparin. Typically, five to ten days after heparin exposure there is a decrease in platelet count with a mean of 60 x 109/l. Due to an activation of thrombocytes by HIT antibodies, venous or more rarely arterial thromboses may occur. The diagnosis of HIT includes the calculation of the probability of a HIT using the 4T Score and the laboratory detection of HIT antibodies. The HIT therapy represents the immediate discontinuation of the heparin therapy as well as the beginning of an alternative therapeutic anticoagulation.


Assuntos
Anticoagulantes , Heparina , Trombocitopenia , Trombose , Anticorpos , Anticoagulantes/efeitos adversos , Heparina/efeitos adversos , Humanos , Trombocitopenia/induzido quimicamente
4.
Rev Assoc Med Bras (1992) ; 65(11): 1349-1355, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31800895

RESUMO

OBJECTIVE: To assess the frequency and severity of prescriptions errors with potentially dangerous drugs (heparin and potassium chloride for injection concentrate) before and after the introduction of a computerized provider order entry (CPOE) system. METHODS: This is a retrospective study that compared errors in manual/pre-typed prescriptions in 2007 (Stage 1) with CPOE prescriptions in 2014 (Stage 2) (Total = 1,028 prescriptions), in two high-complexity hospitals of Belo Horizonte, Brasil. RESULTS: An increase of 25% in the frequency of errors in Hospital 1 was observed after the intervention (p<0.001). In contrast, a decreased error frequency of 85% was observed in Hospital 2 (p<0.001). Regarding potassium chloride, the error rate remained unchanged in Hospital 1 (p>0.05). In Hospital 2, a significant decrease was recorded in Stage 2 (p<0.001). A reduced error severity with heparin (p<0.001) was noted, while potassium chloride-related prescription severity remain unchanged (p> 0.05). CONCLUSIONS: The frequency and severity of medication errors after the introduction of CPOE was affected differently in the two hospitals, which shows a need for thorough observation when the prescription system is modified. Control of new potential errors introduced and their causes for the adoption of measures to prevent these events must be in place during and after the implementation of this technology.


Assuntos
Prescrição Eletrônica/estatística & dados numéricos , Heparina/administração & dosagem , Sistemas de Registro de Ordens Médicas , Erros de Medicação/estatística & dados numéricos , Cloreto de Potássio/administração & dosagem , Brasil , Prescrição Eletrônica/normas , Heparina/efeitos adversos , Humanos , Cloreto de Potássio/efeitos adversos , Estudos Retrospectivos
6.
J Coll Physicians Surg Pak ; 29(10): 986-992, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31564275

RESUMO

Heparin-induced thrombocytopenia (HIT) is an immune-mediated response to heparin administration. HIT following cardiopulmonary bypass (CPB) procedures has not been clearly delineated in pediatric populations. By comprehensive retrieval of the pertinent literature published since 2000, 19 reports were collected with 33 pediatric patients recruited into this study. A female predominance was noted in this patient setting. HIT occurred after a mean heparin exposure of 2.8 times. Pediatric HIT following CPB showed different features from that with no CPB, by a longer span on postoperative day 1-16, and a significant negative correlation between the platelet count and time of occurrence of thrombocytopenia on postoperative day 1-8. The thrombus formation developed on postoperative day 13. Heparin discontinuation and use of coganulant substitute are the important treatments of choice. In HIT patients, continued heparin use may cause patient death or recurrence of HIT. HIT-related thrombosis was present in 69.6% of the patients with similar incidence rates of arterial and venous thrombosis; and the thrombosis could be managed by medical, surgical or device explant methods. The direct thrombin inhibitors lepirudin, argatroban and bivalirudin as well as the factor Xa inhibitor danaparoid can be used safely in most of the pediatric patients. The event-free survival rate of this patient setting was 69.7%.


Assuntos
Anticoagulantes/efeitos adversos , Ponte Cardiopulmonar , Heparina/efeitos adversos , Trombocitopenia/induzido quimicamente , Criança , Humanos
7.
Mar Drugs ; 17(9)2019 Sep 17.
Artigo em Inglês | MEDLINE | ID: mdl-31533230

RESUMO

Protamine sulfate (PS) is a polycationic protein drug obtained from the sperm of fish, and is used to reverse the anticoagulant effect of unfractionated heparin (UFH). However, the interactions between PS, UFH, and platelets are still not clear. We measured the platelet numbers and collagen-induced aggregation, P-selectin, platelet factor 4, ß-thromboglobulin, prostacyclin metabolite, D-dimers, activated partial thromboplastin time, prothrombin time, anti-factor Xa, fibrinogen, thrombus weight and megakaryocytopoiesis in blood collected from mice and rats in different time points.. All of the groups were treated intravenously with vehicle, UFH, PS, or UFH with PS. We found a short-term antiplatelet activity of PS in mice and rats, and long-term platelet-independent antithrombotic activity in rats with electrically-induced thrombosis. The antiplatelet and antithrombotic potential of PS may contribute to bleeding risk in PS-overdosed patients. The inhibitory effect of PS on the platelets was attenuated by UFH without inducing thrombocytopenia. Treatment with UFH and PS did not affect the formation, number, or activation of platelets, or the thrombosis development in rodents.


Assuntos
Anticoagulantes/efeitos adversos , Antagonistas de Heparina/efeitos adversos , Heparina/efeitos adversos , Protaminas/efeitos adversos , Trombocitopenia/diagnóstico , Animais , Anticoagulantes/administração & dosagem , Plaquetas/efeitos dos fármacos , Modelos Animais de Doenças , Hemorragia/sangue , Hemorragia/induzido quimicamente , Hemorragia/prevenção & controle , Heparina/administração & dosagem , Antagonistas de Heparina/administração & dosagem , Humanos , Masculino , Camundongos , Tempo de Tromboplastina Parcial , Agregação Plaquetária/efeitos dos fármacos , Protaminas/administração & dosagem , Ratos , Trombocitopenia/sangue , Trombocitopenia/induzido quimicamente , Fatores de Tempo
8.
BMJ Case Rep ; 12(9)2019 Sep 16.
Artigo em Inglês | MEDLINE | ID: mdl-31527216

RESUMO

A middle-aged woman with history of antiphospholipid syndrome, admitted to our hospital for lethargy and persistent chest pain, developed during hospitalisation intracerebral transverse sinus and sigmoid vein thromboses, retinal thromboses, acute renal failure and cardiac involvement associated with thrombocytopaenia. Diagnosis of catastrophic antiphospholipid syndrome was made and treated with IV steroids, heparin infusion and double filtration plasmapheresis (DFPP) without fresh frozen plasma. Heparin-induced thrombocytopaenia was second diagnosed because of persistent severe thrombocytopaenia after 2 weeks of treatment associated with positive conversion of antibodies against platelet factor 4, and a positive functional assay. The clinical course was complicated by cerebellar haematomas that appeared a few days after the last session of DFPP. Heparin-induced thrombocytopaenia was managed by administration of argatroban, a direct thrombin inhibitor with an increase in platelet count. Neurologically, the patient recovered completely and was discharged on vitamin K antagonist treatment and regular dialysis.


Assuntos
Síndrome Antifosfolipídica/complicações , Síndrome Antifosfolipídica/terapia , Heparina/efeitos adversos , Trombocitopenia/induzido quimicamente , Trombocitopenia/terapia , Anticoagulantes/uso terapêutico , Doença Catastrófica , Dor no Peito , Terapia Combinada , Feminino , Glucocorticoides/uso terapêutico , Humanos , Pessoa de Meia-Idade , Plasmaferese
9.
Clin Cardiol ; 42(10): 995-1002, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31483512

RESUMO

BACKGROUND: Perioperative bridging in atrial fibrillation (AF) is associated with low thromboembolic rates but high bleeding rates. Recent guidance cautions the practice of bridging except in high risk patients. However, the practice of bridging varies widely and little data exist regarding appropriate anticoagulation intensity when using intravenous unfractionated heparin (UFH). HYPOTHESIS: To determine if high intensity UFH infusion regimens are associated with increased bleeding rates compared to low intensity regimens for bridging patients with AF. METHODS: We conducted a single center retrospective cohort study of admitted patients with non-valvular AF receiving UFH for ≥24 hours. UFH intensities were chosen at the providers' discretion. The primary endpoint was the rate of bleeding defined by the International Society on Thrombosis and Hemostasis during UFH infusion or within 24 hours of discontinuation. The secondary endpoint was a composite of cardiovascular events, arterial thromboembolism, venous thromboembolism, myocardial infarctions and death during UFH infusion. RESULTS: A total of 497 patients were included in this analysis. Warfarin was used in 82.1% and direct acting oral anticoagulants in 14.1% of patients. The rate of any bleed was higher among high intensity compared to low intensity UFH regimens (10.5% vs 4.9%, odds ratio = 2.29, 95% confidence interval = 1.07-4.90). Major bleeding was significantly higher among high intensity compared to low intensity UFH regimens. There was no difference in composite thrombotic events or death. CONCLUSIONS: Low intensity UFH infusions, targeting lower anticoagulation targets, were associated with decreased bleeding rates without a signal of increased thromboembolic events in hospitalized AF patients.


Assuntos
Fibrilação Atrial/tratamento farmacológico , Heparina/administração & dosagem , Tromboembolia Venosa/prevenção & controle , Idoso , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Fibrilação Atrial/sangue , Fibrilação Atrial/complicações , Coagulação Sanguínea , Relação Dose-Resposta a Droga , Feminino , Seguimentos , Hemorragia/epidemiologia , Hemorragia/prevenção & controle , Heparina/efeitos adversos , Humanos , Incidência , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos/epidemiologia , Tromboembolia Venosa/sangue , Tromboembolia Venosa/etiologia
10.
J Clin Pharm Ther ; 44(5): 809-812, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31486123

RESUMO

WHAT IS KNOWN AND OBJECTIVE: The off-label use of fondaparinux in patients with heparin-induced thrombocytopenia with thrombosis (HITT) has historically been controversial. We present a case of successful fondaparinux use to treat HITT confirmed by the serotonin-release assay in the setting of other significant clotting and bleeding risk factors. CASE SUMMARY: We report a 19-year-old male with a history of Factor V Leiden and recent neurosurgery treated with fondaparinux after developing HITT confirmed by the serotonin-release assay (SRA). The patient achieved full platelet recovery on fondaparinux and was successfully transitioned to warfarin therapy without further thrombotic nor bleeding complications. WHAT IS NEW AND CONCLUSION: This case demonstrates a clear example of success of fondaparinux use to treat SRA-confirmed HITT in the setting of complicating factors and adds to the existing literature supporting the use of fondaparinux for HIT.


Assuntos
Fator V/metabolismo , Inibidores do Fator Xa/uso terapêutico , Fondaparinux/uso terapêutico , Serotonina/metabolismo , Trombocitopenia/tratamento farmacológico , Trombose/tratamento farmacológico , Adulto , Anticoagulantes/uso terapêutico , Coagulação Sanguínea/efeitos dos fármacos , Hemorragia/tratamento farmacológico , Hemorragia/metabolismo , Heparina/efeitos adversos , Humanos , Masculino , Trombocitopenia/induzido quimicamente , Trombocitopenia/metabolismo , Trombose/metabolismo , Adulto Jovem
12.
Transfus Apher Sci ; 58(4): 505-507, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31387833

RESUMO

Lung transplantation surgery often relies on the use of intraoperative extracorporeal membrane oxygenation (ECMO) and necessitates the need for high dose anticoagulation. Heparin induced thrombocytopenia complicates intraoperative anticoagulation management during lung transplant surgery requiring ECMO. Though other anticoagulants such as argatroban and bivalrudin are utilized for the treatment of Heparin Induced Thrombocytopenia (HIT), the lack of reversal agents makes it difficult to use these agents intraoperatively in cases with high bleeding risk. This is especially true in patients with end stage fibrotic lung disease with calcified mediastinal lymphadenopathy and pulmonary hypertension undergoing lung transplantation. Here we describe a case of HIT in a patient with Sarcoidosis listed for lung transplant who was treated with Therapeutic Plasma Exchange and Intravenous Immune globulin preoperatively and successfully underwent lung transplantation with the use of intraoperative venoarterial ECMO and heparin anticoagulation.


Assuntos
Heparina/efeitos adversos , Imunoglobulinas Intravenosas/administração & dosagem , Transplante de Pulmão , Troca Plasmática , Cuidados Pré-Operatórios , Trombocitopenia , Heparina/administração & dosagem , Humanos , Masculino , Pessoa de Meia-Idade , Sarcoidose Pulmonar/sangue , Sarcoidose Pulmonar/terapia , Trombocitopenia/sangue , Trombocitopenia/induzido quimicamente , Trombocitopenia/terapia
13.
Am J Case Rep ; 20: 980-987, 2019 Jul 09.
Artigo em Inglês | MEDLINE | ID: mdl-31285416

RESUMO

BACKGROUND Heparin-induced thrombocytopenia (HIT) is the development of thrombocytopenia caused by exposure to heparin. Here, we report the case of a 58-year-old male with HIT who then underwent a successful simultaneous liver-kidney transplantation (SLKT). CASE REPORT The patient had end-stage hepatitis due to a hepatitis C virus (HCV) infection and was on hemodialysis due to nephropathy related to HCV. Furthermore, he was diagnosed with HIT caused by the administration of heparin for hemodialysis during these treatments. Fortunately, there was no evidence of thromboses and HIT antibody converted negative immediately. Four years after the occurrence of HIT, SLKT was performed for liver and kidney failure. Although the donor was heparinized, the donor grafts were flushed on a backtable by an organ preservation solution without heparin to reduce residual heparin. The subsequent transplantation was uneventful. After the operation, anticoagulation with argatroban, a direct thrombin inhibitor, was started instead of heparin. In the postoperative course, neither thrombosis nor graft dysfunction occurred. CONCLUSIONS SLKT in a patient who had a history of HIT could be performed safely.


Assuntos
Heparina/efeitos adversos , Transplante de Rim , Transplante de Fígado , Trombocitopenia/induzido quimicamente , Anticoagulantes/efeitos adversos , Hepatite C/complicações , Humanos , Masculino , Pessoa de Meia-Idade
14.
J Surg Res ; 243: 399-409, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31277018

RESUMO

BACKGROUND: Extracorporeal membrane oxygenation (ECMO), a rescue therapy for pulmonary failure, has traditionally been limited by anticoagulation requirements. Recent practice has challenged the absolute need for anticoagulation, expanding the role of ECMO to patients with higher bleeding risk. We hypothesize that mortality, bleeding, thrombotic events, and transfusions do not differ between heparin-sparing and full therapeutic anticoagulation strategies in veno-venous (VV) ECMO management. MATERIALS AND METHODS: Adult VV ECMO patients between October 2011 and May 2018 at a single center were reviewed. A heparin-sparing strategy was implemented in October 2014; we compared outcomes in an as-treated fashion. The primary end point was survival. Secondary end points included bleeding, thrombotic complications, and transfusion requirements. RESULTS: Forty VV ECMO patients were included: 17 (147 circuit-days) before and 23 (214 circuit-days) after implementation of a heparin-sparing protocol. Patients treated with heparin-sparing anticoagulation had a lower body mass index (28.5 ± 7.1 versus 38.1 ± 12.4, P = 0.01), more often required inotropic support before ECMO (82 versus 50%, P = 0.05), and had a lower mean activated clotting time (167 ± 15 versus 189 ± 15 s, P < 0.01). There were no significant differences in survival to decannulation (59 versus 83%, P = 0.16) or discharge (50 versus 72%, P = 0.20), bleeding (32 versus 33%, P = 1.0), thromboembolic events (18 versus 39%, P = 0.17), or transfusion requirements (median 1.1 versus 0.9 unit per circuit-day, P = 0.48). CONCLUSIONS: Survival, bleeding, thrombotic complications, and transfusion requirements did not differ between heparin-sparing and full therapeutic heparin strategies for management of VV ECMO. VV ECMO can be a safe option in patients with traditional contraindications to anticoagulation.


Assuntos
Anticoagulantes/efeitos adversos , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Hemorragia/induzido quimicamente , Heparina/efeitos adversos , Trombose/prevenção & controle , Adulto , Contraindicações de Medicamentos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Trombose/etiologia , Adulto Jovem
15.
J Stroke Cerebrovasc Dis ; 28(10): 104283, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31324409

RESUMO

INTRODUCTION: Administering intravenous IV tissue plasminogen activator (tPA) is the recommended standard of care in acute ischemic stroke (AIS), although it is not recommended to administer intravenous thrombolysis with tPA following heparin reversal with protamine sulfate in patients with AIS. METHODS: We describe a case series of three patients and the most comprehensive literature review published to date in this specific subset of AIS patients undergoing thrombolysis following heparin reversal with protamine sulfate. The literature review was based on a scoping review methodology performed on four databases; PubMed, CINAHL, Web of Science, and Cochrane Library. All sources were searched from the inauguration of the database until February 2019. A total of six articles involving eight patients were identified. RESULTS: The primary safety outcome of no symptomatic intracranial hemorrhage (sICH) was met in all eleven patients, although only seven cases had a good functional outcome at 3 months. CONCLUSIONS: In appropriately selected AIS patients, coagulopathy correction appears to be safe from an sICH standpoint and may be beneficial. However, given the potential for bias with observational databases, case reports and case series, extreme caution is warranted in applying these results to routine clinical practice.


Assuntos
Anticoagulantes/uso terapêutico , Coagulação Sanguínea/efeitos dos fármacos , Isquemia Encefálica/tratamento farmacológico , Fibrinolíticos/administração & dosagem , Antagonistas de Heparina/uso terapêutico , Heparina/uso terapêutico , Protaminas/uso terapêutico , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/administração & dosagem , Administração Intravenosa , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/efeitos adversos , Isquemia Encefálica/sangue , Isquemia Encefálica/diagnóstico , Feminino , Fibrinolíticos/efeitos adversos , Heparina/efeitos adversos , Antagonistas de Heparina/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Protaminas/efeitos adversos , Acidente Vascular Cerebral/sangue , Acidente Vascular Cerebral/diagnóstico , Terapia Trombolítica/efeitos adversos , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento
16.
Transfus Apher Sci ; 58(4): 525-528, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31327731

RESUMO

We present important laboratory testing and clinical management strategies used to safely discharge home a 69-year old woman with heparin-induced thrombocytopenia (HIT) from the hospital. She was admitted for a coronary artery bypass graft procedure for which she was anticoagulated with heparin. Shortly after the procedure she developed thrombocytopenia and was diagnosed with HIT using the 4Ts scoring system, a latex-enhanced immunoassay (LEI) screen and confirmatory serotonin release assay. Her anticoagulation was switched from heparin to argatroban, and response to treatment was monitored in the laboratory using LEI. Unfortunately, she also received platelet transfusions and subsequently developed multifocal deep vein thrombosis with worsening platelet counts with nadir less than 10 x 10^3/µL. After five therapeutic plasma exchange procedures we noted an improvement in platelet counts, which plateaued into the 50s x 10^3/µL. Furthermore, the LEI remained positive. At this juncture we decided to transition from argatroban to fondaparinux so that she could leave the hospital in stable condition. Upon follow-up with hematology she exhibited no worsening clinical signs or symptoms of disease, and platelet counts markedly improved to within normal limits of detection. In this report we examine the utility of LEI in monitoring patients with HIT, therapeutic plasma exchange in the management of severe HIT (with thrombosis), and the use of subcutaneous fondaparinux in managing HIT in the outpatient setting.


Assuntos
Heparina/efeitos adversos , Trombocitopenia , Idoso , Ponte de Artéria Coronária , Feminino , Fondaparinux/administração & dosagem , Heparina/administração & dosagem , Humanos , Ácidos Pipecólicos/administração & dosagem , Contagem de Plaquetas , Transfusão de Plaquetas , Trombocitopenia/sangue , Trombocitopenia/induzido quimicamente , Trombocitopenia/terapia , Trombose Venosa/sangue , Trombose Venosa/induzido quimicamente , Trombose Venosa/terapia
17.
Cutis ; 103(6): 365;366;370, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31348451

RESUMO

Unfractionated heparin (UFH) is frequently used in the treatment of venous thromboembolism and acute coronary syndrome. There are many common cutaneous adverse reactions to this medication. We present a unique case of hemorrhagic bullae limited to the oral mucosa that developed within 6 hours of a patient receiving UFH.


Assuntos
Hemorragia/induzido quimicamente , Heparina/efeitos adversos , Mucosa Bucal/patologia , Dermatopatias Vesiculobolhosas/induzido quimicamente , Idoso de 80 Anos ou mais , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Hemorragia/diagnóstico , Heparina/administração & dosagem , Humanos , Masculino , Dermatopatias Vesiculobolhosas/diagnóstico
18.
Thromb Res ; 180: 55-61, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31220752

RESUMO

BACKGROUND: Heparin-induced thrombocytopenia (HIT) is caused by platelet-activating antibodies that recognize platelet factor 4/heparin (PF4/hep)-complexes. The in vitro demonstration of PF4/hep antibodies using functional assays is essential for an optimal management of patients suspected to have HIT. However, conventional functional assays are technically challenging and limited to specialized laboratories. In contrast, flow cytometers are commonly used in routine laboratories. The aim of this study is to investigate the performance characteristics of a commercially available, flow cytometer based assay in the diagnosis of HIT. STUDY DESIGN: Sera of consecutive patients with suspected HIT were investigated using the Emo-test HIT Confirm® assay and compared to the standard method consisting of an IgG-specific enzyme immunoassay (EIA) for anti-PF4/hep antibodies and the heparin induced platelet aggregation (HIPA) test. RESULTS: 390 sera were included in the study, 164 sera tested IgG EIA-positive, of which 33 also tested HIPA-positive. No HIPA-positive samples were EIA-negative. In the Emo-test HIT Confirm® assay, 112 sera revealed positive results (%Hepla > 13); however, 51 (45.5%) were EIA-negative. Of the 33 HIPA-positive/EIA-positive HIT sera, 23 tested positive in the Emo-test HIT Confirm® assay, 2 gave ambiguous results, and 8 sera yielded false-negative results. Accordingly, the HIT Confirm® assay showed a sensitivity of 69.7% with a slightly better specificity of 75.4% compared to the EIA (sensitivity 100%, specificity 63.3%). An increase in diagnostic specificity for HIT to 85% was found when positive results were obtained in both the Emo-test HIT Confirm® assay and EIA. CONCLUSION: The Emo-Test HIT Confirm® assay may improve the specificity of laboratory investigations of HIT. However, the assay can only be recommended in combination with an immunoassay due to the high rate of false negativity. Our observation indicates a need to establish external quality assessment for functional assays to avoid such clinically relevant pitfalls.


Assuntos
Anticoagulantes/efeitos adversos , Heparina/efeitos adversos , Trombocitopenia/induzido quimicamente , Trombocitopenia/diagnóstico , Idoso , Reações Falso-Negativas , Feminino , Citometria de Fluxo/métodos , Humanos , Técnicas Imunoenzimáticas , Masculino , Pessoa de Meia-Idade , Agregação Plaquetária/efeitos dos fármacos , Plasma Rico em Plaquetas/efeitos dos fármacos
19.
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
20.
Eur J Haematol ; 103(3): 225-233, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31206215

RESUMO

OBJECTIVES: Reliable diagnosis of heparin-induced thrombocytopenia and thrombosis (HIT) is mandatory for patient management, yet prompt determination of pathogenic antibodies remains an unmet clinical challenge. Common immunoassays carry inherent limitations and functional assays which detect antibody-mediated platelet activation are not usually readily available to routine laboratories, especially the serotonin release assay (SRA), being technically demanding, time consuming, and requires high level expertise. To overcome some of these limitations, we have developed a practical functional flow cytometric assay (FCA) for routine clinical use. METHODS: A simple FCA is described which avoids platelet manipulation, is highly specific and sensitive compared with SRA, and provides rapid results. RESULTS: Of the 650 consecutive samples, from HIT-suspected patients, 99 (15.3%) were positive by the PaGIA Heparin/PF4 immunoassay and 31 (4.8%) by FCA. Average platelet activation was 11-fold higher in PaGIA+/FCA+ vs PaGIA-/FCA- samples. Of 21 SRA-positive samples, 19 were FCA-positive (relative sensitivity 90.5%), and of 42 SRA-negative samples, 40 were FCA-negative (relative specificity 95.2%). The FCA showed significantly higher correlation with the clinical presentation of HIT (4Ts score) performed on 182 patients, compared with PaGIA Heparin/PF4 (ROC-plot analysis, AUC 0.93 vs 0.63, P < 0.001). At a 92% sensitivity, the assay specificity was 96%. CONCLUSIONS: The present FCA is practical for routine testing, providing prompt reliable results for initial diagnosis and confirmation, to effectively assist in HIT patient management.


Assuntos
Plaquetas/metabolismo , Citometria de Fluxo , Heparina/efeitos adversos , Trombocitopenia/diagnóstico , Trombocitopenia/etiologia , Trombose/diagnóstico , Trombose/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Autoanticorpos/imunologia , Gerenciamento Clínico , Feminino , Citometria de Fluxo/métodos , Humanos , Imunoensaio/métodos , Masculino , Pessoa de Meia-Idade , Ativação Plaquetária , Contagem de Plaquetas , Curva ROC , Avaliação de Sintomas , Trombocitopenia/sangue , Trombose/sangue , Adulto Jovem
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