Bleeding risk of submuscular ICD implantation with continued oral anticoagulation versus heparin bridging therapy

2017 ◽  
Vol 33 (4) ◽  
pp. 441-446 ◽  
Author(s):  
Simon Pecha ◽  
Ayhan Ayikli ◽  
Iris Wilke ◽  
Samer Hakmi ◽  
Yalin Yildirim ◽  
...  
Keyword(s):  
Oral Anticoagulation ◽  
Bleeding Risk ◽  
Bridging Therapy ◽  
Icd Implantation

A Clinician’s Guide to Perioperative Bridging for Patients on Oral Anticoagulation

2010 ◽  
Vol 23 (4) ◽  
pp. 303-312 ◽  
Author(s):  
Michelle T. Martin ◽  
Ann M. Kuchta ◽  
Edith A. Nutescu
Keyword(s):  
Risk Stratification ◽  
Oral Anticoagulation ◽  
Oral Anticoagulant Therapy ◽  
Bleeding Risk ◽  
Careful Consideration ◽  
Invasive Procedures ◽  
Bridging Therapy ◽  
Thrombosis Risk ◽  
Perioperative Anticoagulation ◽  
Risk Of Hemorrhage

Updates in recent clinical guidelines have led to a change in the management of perioperative anticoagulation for patients on oral anticoagulant therapy. No standardized bridging consensus exists in the literature. The necessity for bridging therapy is determined based on careful consideration of the thrombosis risk versus the bleeding risk of the procedure. Risk stratification will aid the decision to bridge or not to bridge. Patients are bridged with agents with appropriate kinetics to allow for their elimination prior to the time of the procedure in order to decrease the risk of hemorrhage during invasive procedures. This intent of this article is to discuss perioperative bridging therapy and provide a practical guide for the clinician.

The current treatment and predictors of outcome in elderly patients with non-ST-elevation myocardial infarction in an all comers population: the POPular Age registry

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
M.E Gimbel ◽  
D.R.P.P Chan Pin Yin ◽  
R.S Hermanides ◽  
F Kauer ◽  
A.H Tavenier ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Elderly Patients ◽  
Major Bleeding ◽  
Oral Anticoagulation ◽  
Dual Antiplatelet Therapy ◽  
Bleeding Risk ◽  
Cardiovascular Death ◽  
St Elevation ◽  
One Year

Abstract Background Elderly patients form a large and growing part of the patients presenting with non-ST-elevation myocardial infarction (NSTEMI). Choosing the optimal antithrombotic treatment in these elderly patients is more complicated because they frequently have characteristics indicating both a high ischaemic and high bleeding risk. Purpose We describe the treatment of elderly patients (>75 years) admitted with NSTEMI, present the outcomes (major adverse cardiovascular events (MACE) and bleeding) and aim to find predictors for adverse events. Methods The POPular AGE registry is an investigator initiated, prospective, observational, multicentre study of patients aged 75 years or older presenting with NSTEMI. Patients were recruited between August 1st, 2016 and May 7th, 2018 at 21 sites in the Netherlands. The primary composite endpoint of MACE included cardiovascular death, non-fatal myocardial infarction and non-fatal stroke at one-year follow-up. Results A total of 757 patients were enrolled. During hospital stay 76% underwent coronary angiography, 34% percutaneous coronary intervention and 12% coronary artery bypass grafting (CABG). At discharge 78.6% received aspirin (non-users mostly because of the combination of oral anticoagulant and clopidogrel), 49.7% were treated with clopidogrel, 34.2% with ticagrelor and 29.6% were prescribed oral anticoagulation. Eighty-three percent of patients received dual antiplatelet therapy (DAPT) or dual therapy consisting of oral anticoagulation and at least one antiplatelet agent for a duration of 12 months. At one year, the primary outcome of cardiovascular death, myocardial infarction or stroke occurred in 12.3% of patients and major bleeding (BARC 3 or 5) occurred in 4.8% of the patients. The risk of MACE and major bleeding was highest during the first month and stayed high over time for MACE while the risk for major bleeding levelled off. Independent predictors for MACE were age, renal function, medical history of CABG, stroke and diabetes. The only independent predictor for major bleeding was haemoglobin level on admission. Conclusion In this all-comers registry, most elderly patients (≥75 years) with NSTEMI are treated with DAPT and undergoing coronary angiography the same way as younger NSTEMI patients from the SWEDEHEART registry. Aspirin use was lower as was the use of the more potent P2Y12 inhibitors compared to the SWEDEHEART which is very likely due to the concomitant use of oral anticoagulation in 30% of patients. The fact that ischemic risk stays constant over 1 year of follow-up, while the bleeding risk levels off after one month may suggest the need of dual antiplatelet therapy until at least one year after NSTEMI. Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): AstraZeneca

Thromboprophylaxis in atrial fibrillation: device therapy and surgical techniques

ESC CardioMed ◽  
2018 ◽  
pp. 2198-2204
Author(s):  
Thorsten Lewalter ◽  
Clemens Jilek ◽  
Klaus Tiemann
Keyword(s):  
Antiplatelet Therapy ◽  
Oral Anticoagulation ◽  
Left Atrial ◽  
Surgical Techniques ◽  
Bleeding Risk ◽  
Surgical Approaches ◽  
Antiplatelet Medication ◽  
High Bleeding Risk ◽  
Bleeding History

The concept of left atrial appendage (LAA) occlusion is to mainly prevent stroke by excluding the most relevant source of embolism from the blood circulation. The LAA can be occluded by a number of interventional or surgical approaches. Following a successful LAA occlusion implant procedure or surgical LAA exclusion, oral anticoagulation is typically terminated, followed by antiplatelet therapy, which is routinely used in the post-implant phase for 3–6 months. The need for chronic antiplatelet therapy is still unclear. Most patients are maintained on a single antiplatelet medication, but patients with a particularly high bleeding risk receive no chronic drug therapy. Currently, the main indication for LAA occluder implantation or LAA exclusion is stroke prevention in patients at high stroke risk, with contraindications for long-term oral anticoagulation due to a bleeding history or an otherwise elevated risk for major bleeding.

4037Nurse counseling of patients with atrial fibrillation to improve compliance to oral anticoagulation

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
R Chilian-Hof ◽  
S Schnupp ◽  
C Mahnkopf ◽  
J Brachmann ◽  
C Kleinecke
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K ◽  
Oral Anticoagulation ◽  
Vitamin K Antagonists ◽  
Randomised Trial ◽  
Female Gender ◽  
Bleeding Risk ◽  
Telephone Counseling ◽  
Bleeding Events

Abstract Background Atrial fibrillation (AF) is the most frequent arrhythmia with a prevalence of 1%–2% in the general population. Oral anticoagulation (OAC) is state-of-the art for preventions of thromboembolic events, in particular ischemic stroke, in patients with atrial fibrillation. Despite its proven benefit, numerous studies have documented under use of OAC for a variety of reasons. Purpose To establish a program of nurse counseling in patient with atrial fibrillation and treatment with oral anticoagulation. The program is designed to improve patients satisfaction, compliance to OAC, prevention of medication errors, ischemic and bleeding events. Methods Patients with atrial fibrillation and treatment with oral anticoagulation were prospectively identified at the department of cardiology of our clinic. They received a 30 minutes nurse counseling about oral anticoagulation during the hospital stay and another 30 minutes telephone counseling 3 months after inclusion. Furthermore, they received a brochure to inform about atrial fibrillation, oral anticoagulation and methods to improve medication compliance. Demographic characteristics with stroke and bleeding risk (CHA2DS2-VASc and HAS-BLED scores), as well as procedural data were systematically assessed in a predefined standardized way and captured in a dedicated database. Results Between June 2017 and January 2018, a total of 617 patients (female gender: 43.1%) with atrial fibrillation and oral anticoagulation received nurse counseling. Demographic and follow-up data of 204 patients (female gender: 85/204 (41.7%); mean age 69.7±17.3, CHA2DS2-VASc score 4.2±1.7, HAS-BLED score 2.8±0.37) were assessed in a dedicated database. Indication for OAC was paroxysmal and persistent/permanent AF in 110/204 (53.9%), 93/204 (45.6%) and others 17 (8.3%), respectively. 33/2014 (16.2%) were treated with vitamin K antagonists, and 172/204 (84.3%) with non-vitamin K antagonists. After a follow-up of 0.46±2.9 years and 187 patients-years the rates of cardiovascular death, major bleeding events and all-cause stroke and TIA were 1.07%, 2.14% and 1.61% per 100 patient-years. Conclusion Nurse counseling in patients with atrial fibrillation and treatment with oral anticoagulation has been established at the REGIOMED clinics, Germany. Its effectiveness in terms of quality of live, medication complications and cardiovascular events has to be proven in a randomised trial. Acknowledgement/Funding Daichi-Sankyo

Thromboprophylaxis in atrial fibrillation: device therapy and surgical techniques

2018 ◽  
Author(s):  
Thorsten Lewalter ◽  
Clemens Jilek ◽  
Peter Sick
Keyword(s):  
Antiplatelet Therapy ◽  
Oral Anticoagulation ◽  
Blood Circulation ◽  
Surgical Techniques ◽  
Bleeding Risk ◽  
Surgical Approaches ◽  
Antiplatelet Medication ◽  
High Bleeding Risk ◽  
Bleeding History

The concept of left atrial appendage (LAA) occlusion is to mainly prevent stroke by excluding the most relevant source of embolism from the blood circulation. The LAA can be occluded by a number of interventional or surgical approaches. Following a successful LAA occlusion implant procedure or surgical LAA exclusion, oral anticoagulation is typically terminated, followed by antiplatelet therapy, which is routinely used in the post-implant phase for 3–6 months. The need for chronic antiplatelet therapy is still unclear. Most patients are maintained on a single antiplatelet medication, but patients with a particularly high bleeding risk receive no chronic drug therapy. Currently, the main indication for LAA occluder implantation or LAA exclusion is stroke prevention in patients at high stroke risk, with contraindications for long-term oral anticoagulation due to a bleeding history or an otherwise elevated risk for major bleeding.

Pharmacogenetics of Oral Anticoagulation - VKORC1-Haplotypes Determine the Inter-Individual and Inter-Ethnical Variability.

Blood ◽  
2006 ◽  
Vol 108 (11) ◽  
pp. 719-719
Author(s):  
Christof Geisen ◽  
Matthias Watzka ◽  
Katja Sittinger ◽  
Beate Luxembourg ◽  
Michael Steffens ◽  
...  
Keyword(s):  
Genetic Variability ◽  
Oral Anticoagulation ◽  
Gene Locus ◽  
Direct Sequencing ◽  
Warfarin Dose ◽  
Haplotype Frequency ◽  
Bleeding Risk ◽  
Dose Requirement ◽  
Gene Encoding ◽  
Vkorc1 Gene

Abstract Purpuse: Coumarins are known for their high inter-individual and inter-ethnical variability of the dose-response association (i.e. significant higher maintenance dose in Africans and lower dose in Chinese). Recently, common SNPs of the VKORC1 gene (encoding the molecular target of coumarins, vitamin K epoxide reductase) were shown to be associated with lower warfarin dose requirement (c.-1639G>A [rs17878363], c.173+1000C>T [rs9934438]). In order to clarify whether these SNPs are part of more extended haplotypes, we established a comprehensive haplotype map of the entire VKORC1 gene locus. The association of VKORC1-haplotypes with coumarin dose requirement was analysed in different ethnical populations and patient cohorts. Methods: In 200 German blood donors the VKORC1 gene locus was analysed by direct sequencing. VKORC1 genotype data in 7 additional populations from Africa, Asia and Europe were retrieved from internet databases. Haplotype frequencies were inferred using EHplus and FAMHAP. Unselected patients receiving phenprocoumon (n=61) and patient cohorts of European origin with either increased coumarin sensitivity (n=14, weekly phenprocoumon dose <6mg) or partial coumarin resistance (n=36, weekly phenprocoumon dose >42 mg or warfarin dose>70mg) were typed for VKORC1 haplotypes. Results: In 200 controls we identified 28 SNPs within the VKORC1 gene. 6 SNPs formed 3 main haplotypes covering more than 99% of the genetic variability of VKORC1 (VKORC1*2: 42%, VKORC1*3: 38%, and VKORC1*4: 20%). SNPs associated with low warfarin dose (rs17878363, rs9934438) were in complete linkage disequilibrium with the VKORC1*2 haplotype. Haplotype frequency in Africans and Chinese differed significantly from the European sample (for VKORC1*2: Europeans 42%, Chinese 95%, Africans 14%). In 61 unselected patients receiving phenprocoumon c.-1639AA genotype patients (homozygous VKORC1*2) required less phenprocoumon (1.40 mg/d) than AG (2.12 mg/d) and GG patients (3.02 mg/d).13 of 14 patients (93%) with increased coumarin sensitivity but none of the patients with partial coumarin resistance were c.-1639AA. Vice versa, the c.-1639G allele (present in the non VKORC1*2 haplotypes) was found homozygous in 31 patients (86%) with partial coumarin resistance but in none of the patients with increased coumarin sensitivity. Conclusions: Three main haplotypes represent more than 99% of VKORC1’s genetic variability in Europeans. VKORC1 haplotypes are strongly associated with the inter-individual and inter-ethnical variability of oral anticoagulation. In future studies, VKORC1-haplotype testing may provide a clinically relevant predictor of coumarin dosing and bleeding risk in oral anticoagulation.

A Concept for Long-Term Anticoagulation Based On the Individual Risk of Lethal Pulmonary Embolism (PE) and Lethal Bleeding Using Oral Anticoagulants.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 4174-4174
Author(s):  
Rainer B. Zotz ◽  
Christoph Sucker ◽  
Andrea Gerhardt
Keyword(s):  
Risk Factors ◽  
Oral Anticoagulation ◽  
Factor V Leiden ◽  
Bleeding Risk ◽  
Individual Risk ◽  
Factor V ◽  
Benefit Analysis ◽  
Initial Event ◽  
Risk Benefit Analysis

Abstract Abstract 4174 Objectives Indications for an indefinite oral anticoagulation are a matter of debate in patients with a first unprovoked proximal DVT. Methods An individual risk-benefit analysis is made using published prospective studies by determining the patient-specific lethal risk of bleeding under oral anticoagulation compared with the estimation of lethal PE-risk by type of initial thrombosis (spontaneous vs. secondarily caused, with or without PE). Results According to this risk-benefit analysis, long-term oral anticoagulation is indicated to prevent lethal PE in all patients with low risk of bleeding (1% per year, 0.1 % lethal bleeding per year) in the risk group with lethal PE > 0.2 % per year. This risk group includes patients with idiopathic proximal thrombosis and PE in the initial event (also without thrombophilic risk factors) and patients with an idiopathic initial event without PE, who have relevant thrombophilic risk factors with a relative risk ≥ 2, such as antithrombin deficiency, homozygous factor V Leiden or a combined heterozygous factor V Leiden and prothrombin G20210A mutation. In case of a higher bleeding tendency (0.3% lethal bleeding per year in a patient group with 1-2 bleeding risk factors like age >65 or diabetes) other risk-benefit estimations are present. Conclusions Our individual risk stratification is in contrast to current therapy recommendations, which generally consider long-term oral anticoagulation for patients with an idiopathic initial proximal DVT with a low bleeding risk, but do not specify these in individual cases. Disclosures: No relevant conflicts of interest to declare.

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