Modulating the Intensity of Oral Anticoagulation Therapy with Direct Oral Anticoagulants: Feasible or Not?

Objective: To evaluate current clinical evidence for management of oral anticoagulation therapy after gastrointestinal bleeding (GIB) with an emphasis on whether to, when to, and how to resume an anticoagulation therapy. Data Sources: Relevant articles from MEDLINE, Cochrane Library, and EMBASE databases were identified from 1946 through May 20, 2017, using the keywords: gastrointestinal hemorrhage or gastrointestinal bleeding and antithrombotic therapy or anticoagulation therapy or warfarin or dabigatran or rivaroxaban or apixaban or edoxaban.Study Selection and Data Extraction: All English-language studies assessing management of oral anticoagulation therapy after GIB were evaluated. Data Synthesis: A total of 9 studies were identified. Four retrospective cohort studies showed that resuming anticoagulation therapy was associated with significantly lower rate of thromboembolism (TE) in the general population. Meta-analyses and prospective cohort studies also supported this finding. Two retrospective cohort studies indicated an increase in GIB when anticoagulation reinitiation occurred in less than 7 days without a decrease in TE. Resuming therapy between 7 and 15 days did not demonstrate a significant increase in GIB or TE. A large retrospective study showed that apixaban was associated with the significantly lowest risk of GIB compared with both rivaroxaban and dabigatran. Conclusion: Anticoagulation therapy resumption is recommended, with resumption being considered between 7 and 14 days following GIB regardless of the therapy chosen. Data for warfarin management after GIB should be applied with caution to direct oral anticoagulants (DOACs) because of the quicker onset and experimental nature of reversal agents. Apixaban may be a preferred option when restarting a DOAC therapy.

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Activated clotting time on the day of atrial fibrillation ablation for minimally interrupted and uninterrupted direct oral anticoagulation therapy: Sequential changes, differences among direct oral anticoagulants, and ablation safety outcomes

Journal of Cardiovascular Electrophysiology ◽

10.1111/jce.14260 ◽

2019 ◽

Vol 30 (12) ◽

pp. 2823-2833

Author(s):

Hirosuke Yamaji ◽

Takashi Murakami ◽

Kazuyoshi Hina ◽

Shunich Higashiya ◽

Hiroshi Kawamura ◽

...

Keyword(s):

Atrial Fibrillation ◽

Oral Anticoagulation ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Anticoagulation Therapy ◽

Atrial Fibrillation Ablation ◽

Clotting Time ◽

Oral Anticoagulation Therapy ◽

Activated Clotting Time ◽

Safety Outcomes

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COST EFFECTIVENESS OF ORAL ANTICOAGULATION THERAPY FOR NON-VALVULAR ATRIAL FIBRILLATION PATIENTS: WARFARIN VERSUS THE NEW ORAL ANTICOAGULANTS RIVAROXABAN, DABIGATRAN AND APIXABAN

Journal of the American College of Cardiology ◽

10.1016/s0735-1097(18)31031-3 ◽

2018 ◽

Vol 71 (11) ◽

pp. A490 ◽

Cited By ~ 2

Author(s):

Ismael Ortiz-Cartagena ◽

Antonio Orraca Gotay ◽

Jose Acevedo

Keyword(s):

Atrial Fibrillation ◽

Cost Effectiveness ◽

Oral Anticoagulation ◽

Oral Anticoagulants ◽

Anticoagulation Therapy ◽

New Oral Anticoagulants ◽

Oral Anticoagulation Therapy

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The prevalence of long-term oral anticoagulation therapy in a cardiology center in Bucharest, Romania

Medicine and Pharmacy Reports ◽

10.15386/cjmed-837 ◽

2018 ◽

Vol 91 (1) ◽

pp. 37-41

Author(s):

Adelina-Mihaela Sorescu ◽

Tudor Enache ◽

Suzana Guberna

Keyword(s):

Oral Anticoagulation ◽

Economic Status ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Anticoagulation Therapy ◽

Cross Sectional Study ◽

Similar Data ◽

Cross Sectional ◽

Oral Anticoagulation Therapy ◽

Vein Thrombosis

Background and aims. Few studies discuss the prevalence of oral anticoagulation therapy (OAT) in clinical practice, despite their increasing use worldwide. In America, studies established that 20% to 80% of the patients with indication benefit from OAT. In Romania, there is no data regarding the utilization of oral anticoagulants. Thus, this study aims to determine the trends of OAT.Methods. We designed a cross-sectional study of the patients admitted to the Cardiology Department of the “Bagdasar-Arseni” Clinical Emergency Hospital, Bucharest, from the 1st of November 2016 until the 31st of January 2017. We considered OAT indications to be: atrial fibrillation/flutter (AF), pulmonary embolisms (PE), deep vein thrombosis (DVT), intramural or intracavitary thrombi and left ventricle aneurysms. Statistical analysis was performed with EpiInfo.Results. There were 783 patients admitted, 253 of these having an OAT indication (mean age 73.25 years, 53.75% female). Only 162 patients (64.03%) received it, either Vitamin K Antagonists (VKA) (78 patients, 48.14%), or Novel Oral Anticoagulants (NOAC) (84 patients, 51.85%). Reasons for not indicating such therapy included the hemorrhage risk (43.27%), the lack of adherence to the treatment (18.56%), the impossibility of INR monitoring (21.84%), the economic status (10.21%) and others (6.12%). 221 patients had AF (87.35%), 141 (63.8%) receiving OAT, VKA (67 patients, 47.51%), or NOAC (74 patients, 52.48%). 17 patients (6.71%) had a PE and/or DVT. 15 (88.23%) received OAT, AVK (11 patients, 73.33%), or NOAC (4 patients, 26.67%). 15 patients (5.92%) had other OAT indications (excepting AF or PE/DVT), 11 receiving OAT (73.33%), AVK (8 patients, 72.72%), or NOAC (3 patients, 27.27%).Conclusions. Our study determined that 64.03% of those with indication received OAT. Similar data is reported in the USA, suggesting an underuse of anticoagulants. The risk of hemorrhage, lack of adherence, the impossibility of INR monitoring or the economic status were some of the reasons for not recommending OAT.

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Management of epistaxis in patients on novel oral anticoagulation therapy

The Journal of Laryngology & Otology ◽

10.1017/s0022215120000754 ◽

2020 ◽

Vol 134 (4) ◽

pp. 316-322

Author(s):

J P K Ho ◽

N Bari ◽

F Riffat

Keyword(s):

Oral Anticoagulation ◽

Oral Anticoagulants ◽

Anticoagulation Therapy ◽

Efficacy And Safety ◽

Oral Anticoagulation Therapy ◽

Reversal Agents ◽

Risk Of Bleeding ◽

Increased Risk ◽

Comprehensive Search ◽

Anticoagulated Patients

AbstractBackgroundIndividuals on anticoagulation therapy are at increased risk of bleeding, including epistaxis. There is a lack of available reversal agents for novel oral anticoagulation therapy.ObjectiveThis paper reviews the current literature on epistaxis in the context of novel oral anticoagulation use, in order to recommend guidelines on management.MethodA comprehensive search of published literature was conducted to identify all relevant articles published up to April 2019.ResultsPatients 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.ConclusionClinicians 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.

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Direct oral anticoagulation and mortality in moderate to high-risk atrial fibrillation

Heart ◽

10.1136/heartjnl-2018-314476 ◽

2019 ◽

Vol 105 (19) ◽

pp. 1487-1492 ◽

Cited By ~ 1

Author(s):

Ronen Arbel ◽

Ruslan Sergienko ◽

Ariel Hammerman ◽

Sari Dotan-Greenberg ◽

Erez Batat ◽

...

Keyword(s):

Atrial Fibrillation ◽

Oral Anticoagulation ◽

Lower Risk ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Anticoagulation Therapy ◽

Treated Group ◽

Newly Diagnosed ◽

Risk Of Death ◽

All Cause Mortality

ObjectiveAlthough direct oral anticoagulants (DOAC) are the recommended antithrombotic therapy for patients with non-valvular atrial fibrillation (NVAF), anticoagulation in patients with NVAF is still inadequate. The effect of withholding DOAC therapy on patient survival is unknown. Therefore, our objective was to compare all-cause mortality rates between DOAC-treated patients with NVAF and similar patients receiving no anticoagulation.MethodsWe performed a retrospective cohort study analysing Clalit Health Services’ extensive electronic database, regarding all newly diagnosed, anticoagulant-naïve patients with NVAF who were eligible for DOAC therapy from 1 January 2011 to 31 December 2016. Patients who received DOAC therapy were matched by propensity scoring to patients receiving no anticoagulation. The primary outcome was all-cause mortality. Final patient follow-up date was 15 May 2017.Results18 901 eligible patients were identified. 8298 received treatment with a DOAC and 10 603 received no anticoagulation therapy. Of those, 5657 patients who received DOAC therapy were matched with 5657 patients who did not receive any anticoagulant. Death occurred in 715 patients in the DOAC-treated group (7.6% per year) and in 2075 patients in the non-anticoagulated patient group (11.1% per year). DOAC therapy was associated with significantly lower risk for all-cause mortality (HR=0.69, 95% CI 0.63 to 0.75, p<0.001). The benefit of DOAC therapy was demonstrated across all subgroups analysed.ConclusionsIn this cohort of newly diagnosed patients with NVAF, DOAC therapy was associated with a significantly lower risk of death compared with no oral anticoagulation. Our findings provide further evidence for the importance of providing DOAC anticoagulation in patients with NVAF.

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Impact of oral anticoagulation therapy on postoperative atrial fibrillation outcomes: a systematic review and meta-analysis

Thrombosis Journal ◽

10.1186/s12959-021-00342-2 ◽

2021 ◽

Vol 19 (1) ◽

Author(s):

Mariana Fragão-Marques ◽

Francisco Teixeira ◽

Jennifer Mancio ◽

Nair Seixas ◽

João Rocha-Neves ◽

...

Keyword(s):

Atrial Fibrillation ◽

Cardiac Surgery ◽

Oral Anticoagulation ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Random Effect ◽

Anticoagulation Therapy ◽

Thromboembolic Events ◽

Oral Anticoagulation Therapy ◽

All Cause Mortality

Abstract Background Post-operative atrial fibrillation (POAF) is the most common complication after cardiac surgery. Recent studies had shown this phenomenon is no longer considered transitory and is associated with higher risk of thromboembolic events or death. The aim of this study was to systematically review and analyze previous studies comparing oral anticoagulation therapy with no anticoagulation, regarding these long-term outcomes. Methods PubMed/MEDLINE, EMBASE, Web of Science and Cochrane Database were systematically searched to identify the studies comparing the risk of stroke, or thromboembolic events or mortality of POAF patients who received anticoagulation compared with those who were not anticoagulated. Incidence of stroke, thromboembolic events and all-cause mortality were evaluated up to 10 years after surgery. Time-to-event outcomes were collected through hazard ratio (HR) along with their variance and the early endpoints using frequencies or odds ratio (OR). Random effect models were used to compute statistical combined measures and 95% confidence intervals (CI). Heterogeneity was evaluated through Q statistic-related measures of variance (Tau2, I2, Chi-squared test). Results Eight observational cohort studies were selected, including 15,335 patients (3492 on Oral Anticoagulants (OAC) vs 11,429 without OAC) that met the inclusion criteria for qualitative synthesis. Patients had a wide gender distribution (38.6–82.3%), each study with a mean age above 65 years (67.5–85). Vitamin K antagonists were commonly prescribed anticoagulants (74.3–100%). OAC was associated with a protective impact on all-cause mortality at a mean of 5.0 years of follow-up (HR is 0.85 [0.72–1.01]; p = 0.07; I2 = 48%). Thromboembolic events did not differ between the two treatment arms (HR 0.68 [0.40–1.15], p = 0.15). Conclusion Current literature suggests a possibly protective impact of OAC therapy for all-cause mortality in patients with new-onset atrial fibrillation after cardiac surgery. However, it does not appear to impact thromboembolism rate.

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Reversing Direct Oral Anticoagulants in Acute Intracranial Hemorrhage

Critical Care Nurse ◽

10.4037/ccn2019160 ◽

2019 ◽

Vol 39 (3) ◽

pp. e1-e8

Author(s):

Melissa A. Nestor ◽

Bryan Boling

Keyword(s):

Intracerebral Hemorrhage ◽

Intracranial Hemorrhage ◽

Oral Anticoagulation ◽

Oral Anticoagulant ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Anticoagulation Therapy ◽

Direct Oral Anticoagulant ◽

Acute Hemorrhage ◽

Anticoagulation Reversal

Intracerebral hemorrhage is a major source of morbidity and mortality, accounting for 10% of all strokes. Oral anticoagulation therapy, while necessary to prevent thromboembolic complications, increases the risk of intracerebral hemorrhage and can potentially worsen bleeding in cases of acute hemorrhage. Before the introduction of direct oral anticoagulant agents in 2010, warfarin was the only option for oral anticoagulation. These new agents have an improved safety profile compared with warfarin but require different reversal strategies. Anticoagulation reversal in the setting of acute intracerebral hemorrhage is an evolving field. This article covers the most common direct oral anticoagulant medications, various available anticoagulant reversal strategies, and the latest guidelines for anticoagulation reversal in patients with acute intracranial hemorrhage.

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Chronic Oral Anticoagulation and Clinical Outcome in Hospitalized COVID-19 Patients

Cardiovascular Drugs and Therapy ◽

10.1007/s10557-021-07194-y ◽

2021 ◽

Author(s):

Vincenzo Russo ◽

Roberta Bottino ◽

Antonello D’Andrea ◽

Angelo Silverio ◽

Marco Di Maio ◽

...

Keyword(s):

Clinical Outcome ◽

Vitamin K ◽

Oral Anticoagulation ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Anticoagulation Therapy ◽

Study Groups ◽

Oral Anticoagulation Therapy ◽

Risk Of Mortality ◽

Artery Disease

Abstract Purpose The clinical course of COVID-19 may be complicated by acute respiratory distress syndrome (ARDS) and thromboembolic events, which are associated with high risk of mortality. Although previous studies reported a lower rate of death in patients treated with heparin, the potential benefit of chronic oral anticoagulation therapy (OAT) remains unknown. We aimed to investigate the association between OAT with the risk of ARDS and mortality in hospitalized patients with COVID-19. Methods This is a multicenter retrospective Italian study including consecutive patients hospitalized for COVID-19 from March 1 to April 22, 2020, at six Italian hospitals. Patients were divided into two groups according to the chronic assumption of oral anticoagulants. Results Overall, 427 patients were included; 87 patients (19%) were in the OAT group. Of them, 54 patients (13%) were on treatment with non-vitamin k oral anticoagulants (NOACs) and 33 (8%) with vitamin-K antagonists (VKAs). OAT patients were older and had a higher rate of hypertension, diabetes, and coronary artery disease compared to No-OAT group. The rate of ARDS at admission (26% vs 28%, P=0.834), or developed during the hospitalization (9% vs 10%, P=0.915), was similar between study groups; in-hospital mortality (22% vs 26%, P=0.395) was also comparable. After balancing for potential confounders by using the propensity score matching technique, no differences were found in term of clinical outcome between OAT and No-OAT patients Conclusion Oral anticoagulation therapy, either NOACs or VKAs, did not influence the risk of ARDS or death in patients hospitalized with COVID-19.

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