Knowledge and attitude of dental students in treating patients on antiplatelet and/ or anticoagulant medications

Background: Antiplatelet and anticoagulant medications are widely prescribed for the prevention of thromboembolic events. Dental management of patients taking such medications can be troublesome because of the possibility of excessive bleeding during surgical procedures. On the other hand, stopping these medications will increase the risk of thromboembolic complications. This study aimed to evaluate the level of knowledge and attitude of dental students and internship trainees at King Saud university in treating patients on antiplatelet and/or anticoagulant medications.Methods: A 17-question survey was distributed among dental students in third, fourth, and fifth (seniors) academic year levels, as well as internship trainees. The survey included questions aiming to evaluate participants’ knowledge in treating patients on antiplatelet and/or anticoagulant medications. A total of 281 surveys were returned complete.Results: In our study, most participants were aware of aspirin (86.1%) and warfarin (92.2%) but only a few were aware of newer medications like rivaroxaban (10.7%) or apixaban (8.2%). The majority of participants would consult with the patient’s physician (76.9%) before stopping any medications and/or would rely on local hemostatic techniques to control bleeding (70.8%).Conclusions: In this study, we concluded that only a small percentage of participants were aware of and following the latest guidelines. The findings of the present study suggest a need for educational programs and workshops regarding this topic.

Safety and interaction of direct oral anticoagulants with antiarrhythmic drugs

The use of direct oral anticoagulants minimized the risks associated with vitamin K antagonist (warfarin) therapy. Currently, direct oral anticoagulants have priority over warfarin for the prevention of thromboembolic events in patients with atrial fibrillation and a number of other conditions requiring anticoagulant therapy. Direct oral anticoagulants along with antiarrhythmic therapy are the accepted strategy for atrial fibrillation treatment. At the same time, the effect of drug-drug interactions (DDI) between direct oral anticoagulants and antiarrhythmic drugs, which have common points of metabolic application, has not been fully elucidated. In order to provide effective and safe anticoagulant and antiarrhythmic therapy in patients with AF, it is important to understand the mechanisms and severity of DDI of direct oral anticoagulants and antiarrhythmic agents. This review discusses the issues of DDI of direct oral anticoagulants and antiarrhythmic drugs used to treat atrial fibrillation.

Prevention of Thromboembolic Events in COVID-19

Background: COVID-19 has developed into a global pandemic with respiratory compromise and systemic coagulopathy causing significant morbidity and mortality. Methods: A retrospective analysis was performed on all COVID-19 patients hospitalized between March and June 2020. Findings: Of 1265 COVID-19 positive hospitalized patients identified, 138 (10.9%) had a thromboembolism. Mortality rate in COVID-19 patients with thrombosis was 31.9%, significantly higher than COVID-19 patients who did not have thrombosis 10% (p<0.0001). The incidence of thrombosis was significantly less in those who received steroids at 14% as compared to other COVID-19 therapies: tocilizumab 25% (p=0.0031), hydroxychloroquine 42% (p<0.0001), and remdesivir 72% (p<0.0001). There was no difference in mortality in patients who had prophylactic enoxaparin 40.5% than therapeutic enoxaparin 51.7% (p= 0.3491). Adjusting for demographics, a logistics model showed no mortality difference in patients who had either dosing of anticoagulation (p=0.5810). The bleeding rate was 12.3%, significantly higher than reported bleeding rates for hospitalized nonCOVID-19 patients on anticoagulants at 7.2% (p<0.05). Interpretation: Our study shows the incidence of thrombosis in hospitalized COVID-19 patients was higher than the general population. The lowest incidence of thrombosis occurred in COVID-19 patients who received steroids. There was no mortality difference in patients who received prophylactic versus therapeutic anticoagulation prior to thrombosis, but there was a high incidence of bleeding events. Funding: No outside funding was used

The way to a man’s heart is through his stomach: a case of myocardial infarction mimic and pseudo-tamponade in a polytrauma patient

Background There exists a therapeutic conflict between haemorrhage control and prevention of thromboembolic events following polytrauma and complications are not uncommon. Such opposing therapies can result in unexpected pathophysiology and there is a real risk of misdiagnosis resulting in harm. This case presents a previously unreported complication of prevention and management of thromboembolism- STEMI (ST elevation myocardial infarction) and tamponade mimic secondary to retroperitoneal haematoma. Case presentation We present a 50-year-old male polytrauma patient who following treatment for presumed pulmonary embolus demonstrated classical clinical findings of myocardial infarction and pericardial tamponade secondary to a retroperitoneal haematoma. This is an event not previously reported in the literature. The risk of adverse outcome by management along the standard lines of STEMI (ST elevation myocardial infarction) was averted through awareness for alternative aetiology via a multi-team approach which resulted in percutaneous drainage of the haematoma and complete resolution of symptoms. Conclusions This manuscript highlights the therapeutic conflict between haemorrhage control and prevention of thromboembolic events in critically injured, the importance of high index of suspicion in this patient cohort and the benefits of multidisciplinary decision making in the complex patient through a not previously published pathophysiologic phenomenon.

Direct oral anticoagulants versus vitamin K antagonists in patients with antiphospholipid syndrome: systematic review and meta-analysis

BackgroundDespite vitamin K antagonists (VKA) being the gold standard in the prevention of thromboembolic events in antiphospholipid syndrome (APS), non-vitamin K antagonists oral anticoagulants/direct oral anticoagulants (DOACs) have been used off-label.ObjectiveWe aimed to perform a systematic review comparing DOACs to VKA regarding prevention of thromboembolic events, occurrence of bleeding events and mortality in patients with APS.MethodsAn electronic database search was performed through MEDLINE, CENTRAL and Web of Science. After data extraction, we pooled the results using risk ratio (RR) and 95% CI. Heterogeneity was assessed using the I². The outcomes considered were all thromboembolic events as primary, and major bleeding, all bleeding events and mortality as secondary. Evidence confidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation methodology.ResultsWe included 7 studies and a total of 835 patients for analyses. Thromboembolic events were significantly increased in DOACs arm, compared with VKA—RR 1.69, 95% CI 1.09 to 2.62, I²—24%, n=719, 6 studies. In studies using exclusively rivaroxaban, which was the most representative drug in all included studies, the thromboembolic risk was increased threefold (RR 3.36, 95% CI 1.53 to 7.37). The risks of major bleeding, all bleeding events and mortality were not significantly different from control arm. The grade of certainty of our results is very low.ConclusionsCurrent evidence suggests DOACs use, particularly rivaroxaban, among patients with APS, is less effective than VKA since it is associated with 69% increased risk of thromboembolic events.Trial registration numberCRD42020216178.

The Clinical Pharmacist assessment in the prophylaxis of venous thromboembolism in a university hospital

Objetive: to evaluate the adherence of health professionals to interventions by the clinical pharmacist service in the prevention of venous thromboembolism in a teaching hospital. Methods: This is a retrospective study in which, through data collection and analysis statistics (considering p <0.05 as the level of significance), pharmaceutical therapies related to drug prescription related to prophylaxis of venous thromboembolism (following the protocol in force at the institution) for patients admitted to a teaching hospital in Minas Gerais from December 2019 to August 2020.. The level of acceptance of clinical pharmacy interventions regarding the need to prescribe prophylactic anticoagulants, change in anticoagulation dosage, prescription of two or more anticoagulants and the lack of risk classification was evaluated for the development of venous thromboembolism for inpatients. Results: in the nine-month period, 62 pharmaceutical interventions were performed before the clinical staff, with 82.25% adherence: need for prescription of anticoagulants (82.75%); change in anticoagulation dosage (80%) and prescription of two or more anticoagulants (100%). In the same period, 2070 interventions (100%) with the nursing team were identified regarding the lack of risk classification for the development of venous thromboembolism for patients admitted via the RM Saude system. Conclusion: the evaluation allowed to identify the importance of the clinical pharmacist in the prevention of thromboembolic events for patients admitted to a hospital.

Thrombolome and Its Emerging Role in Chronic Kidney Diseases

Patients with chronic kidney disease (CKD) are at an increased risk of thromboembolic complications, including myocardial infarction, stroke, deep vein thrombosis, and pulmonary embolism. These complications lead to increased mortality. Evidence points to the key role of CKD-associated dysbiosis and its effect via the generation of gut microbial metabolites in inducing the prothrombotic phenotype. This phenomenon is known as thrombolome, a panel of intestinal bacteria-derived uremic toxins that enhance thrombosis via increased tissue factor expression, platelet hyperactivity, microparticles release, and endothelial dysfunction. This review discusses the role of uremic toxins derived from gut-microbiota metabolism of dietary tryptophan (indoxyl sulfate (IS), indole-3-acetic acid (IAA), kynurenine (KYN)), phenylalanine/tyrosine (p-cresol sulfate (PCS), p-cresol glucuronide (PCG), phenylacetylglutamine (PAGln)) and choline/phosphatidylcholine (trimethylamine N-oxide (TMAO)) in spontaneously induced thrombosis. The increase in the generation of gut microbial uremic toxins, the activation of aryl hydrocarbon (AhRs) and platelet adrenergic (ARs) receptors, and the nuclear factor kappa B (NF-κB) signaling pathway can serve as potential targets during the prevention of thromboembolic events. They can also help create a new therapeutic approach in the CKD population.

Features of the management of patients with atrial fibrillation during the covid-19 pandemic: current questions and possible answers

This publication is devoted to the tactics of management of patients with atrial fibrillation during the pandemic of new coronavirus infection (COVID-19). Among the key issues of relevance during this period, we thought it possible to consider the epidemiology, prevalence, and pathophysiological mechanisms of atrial fibrillation in patients with COVID-19, as well as treatment strategies with regard to obvious hospitalization, rhythm control/restoration and prevention of thromboembolic events. A separate issue is the tactics regarding the prescription or continuation of therapy aimed at the prevention of thromboembolic events and possible drug interactions in patients treated for COVID-19 and receiving anticoagulant therapy with direct oral anticoagulants for atrial fibrillation. Keywords: atrial fibrillation, COVID-19, thromboembolic events, anticoagulant therapy For citation: Napalkov DA, Sokolova AA, Skripka AI. Features of the management of patients with atrial fibrillation during the COVID-19 pandemic: current questions and possible answers, Consilium Medicum. 2021; 23 (1): 32–34. DOI: 10.26442/20751753.2021.1.200669