Clinical outcome in patients with venous thromboembolism receiving concomitant anticoagulant and antiplatelet therapy

Patients undergoing total hip arthroplasty or total knee arthroplasty have a high risk for post-operative venous thromboembolism. The current study addressed the use of fondaparinux post-operatively in 556 patients with antiplatelet therapy in order to prevent deep vein thrombosis as well as demonstrate efficacy in preventing arterial thrombotic events. Results provided evidence for a safe and effective prophylaxis strategy, involving the change from low molecular weight heparin pre-operatively to fondaparinux postoperatively. Also, fondaparinux proved effective as a unique post-operative therapy in the prevention of venous thromboembolism with no adverse effects, such as major bleeding or arterial thrombosis in patients with pre-operative antiplatelet therapy.

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Optimal Medical Therapy on Top of Dual-Antiplatelet Therapy: 1-Year Clinical Outcome in Patients With Acute Coronary Syndrome: The START Antiplatelet Registry

Angiology ◽

10.1177/0003319719895171 ◽

2019 ◽

Vol 71 (3) ◽

pp. 235-241 ◽

Cited By ~ 1

Author(s):

Plinio Cirillo ◽

Luigi Di Serafino ◽

Vittorio Taglialatela ◽

Paolo Calabrò ◽

Emilia Antonucci ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Clinical Outcome ◽

Antiplatelet Therapy ◽

Medical Therapy ◽

Real World ◽

Dual Antiplatelet Therapy ◽

Optimal Medical Therapy ◽

Cerebrovascular Event ◽

Coronary Syndrome ◽

The Impact

Optimal medical therapy (OMT) at discharge is recommended after acute coronary syndrome (ACS). Few studies report the impact of OMT on long-term clinical outcome in a real-world scenario. We evaluated the impact of discharge OMT on top of dual-antiplatelet therapy (DAPT) on clinical outcome in the real-world ACS population of the Survey on anTicoagulated pAtients RegisTer ANTIPLATELET registry. The primary end point was major adverse cardiac and cerebrovascular event (MACCE), a composite of death, myocardial infarction, stroke, or target vessel revascularization. The co-primary end point was net adverse cardiac and cerebrovascular event (NACE), based on MACCE plus major bleeding. Consecutive patients with ACS with 1-year follow-up were enrolled. They were evaluated at discharge for the use of a β-blocker, angiotensin-converting enzyme inhibitor/angiotensin II receptor blockers and statins. Optimal medical therapy was defined as the use of ≥2 of 3 medications. At multivariate analysis, both MACCE and NACE were significantly higher in non-OMT patients than in OMT patients (MACCE 18 [19] vs 59 [9], hazard ratio [HR] = 0.44 [0.26-0.75], P = .002, NACE 19 [20] vs 67 [10], HR = 0.47 [0.28-0.79], P = .004). In this real-world scenario, OMT at discharge on top of DAPT seems associated with a better clinical outcome compared with patients discharged on non-OMT.

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The Combination of Oral Anticoagulant and Antiplatelet Therapies: Stay One Step Ahead

Journal of Cardiovascular Pharmacology and Therapeutics ◽

10.1177/1074248420923528 ◽

2020 ◽

Vol 25 (5) ◽

pp. 391-398

Author(s):

Fabiana Lucà ◽

Simona Giubilato ◽

Stefania Angela Di Fusco ◽

Angelo Leone ◽

Stefano Poli ◽

...

Keyword(s):

Atrial Fibrillation ◽

Venous Thromboembolism ◽

Antiplatelet Therapy ◽

Oral Anticoagulant ◽

Acute Coronary Syndromes ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Clinical Scenarios ◽

Coronary Syndromes

Antithrombotic drugs, which include antiplatelets and anticoagulants, are effective in prevention and treatment of many cardiovascular disorders such as acute coronary syndromes, stroke, and venous thromboembolism and are among the drugs most commonly prescribed worldwide. The advent of direct oral anticoagulants, which are safer alternatives to vitamin K antagonists and do not require laboratory monitoring, has revolutionized the treatment of nonvalvular atrial fibrillation and venous thromboembolism. The combination of oral anticoagulant and antiplatelet therapy is required in many conditions of great clinical impact such as the coexistence of atrial fibrillation and coronary artery disease, with indication to percutaneous coronary intervention. However, strategies that combine anticoagulant and antiplatelet therapies lead to a significant increase in bleeding rates and it is crucial to find the right combination in the single patient in order to optimize the ischemic and bleeding risk. The aim of this review is to explore the evidence and controversies regarding the optimal combination of anticoagulant and antiplatelet therapy through the consideration of past dogmas and new perspectives from recent clinical trials and to propose a tailored therapeutic approach, according to specific clinical scenarios and individual patient characteristics. In particular, we separately explored the clinical settings of stable and acute coronary syndromes and percutaneous revascularization in patients with atrial fibrillation.

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Long-term quality of VKA treatment and clinical outcome after extreme overanticoagulation in 14,777 AF and VTE patients

Thrombosis and Haemostasis ◽

10.1160/th14-06-0537 ◽

2015 ◽

Vol 113 (04) ◽

pp. 881-890 ◽

Cited By ~ 9

Author(s):

Nic J. G. M. Veeger ◽

Nakisa Khorsand ◽

Hanneke C. Kluin-Nelemans ◽

Hilde A. M. Kooistra ◽

Karina Meijer ◽

...

Keyword(s):

Atrial Fibrillation ◽

Venous Thromboembolism ◽

Clinical Outcome ◽

Vitamin K ◽

Vitamin K Antagonists ◽

P Value ◽

Risk Of Bleeding ◽

Increased Risk

SummaryVitamin K antagonists (VKA) are widely used in atrial fibrillation and venous thromboembolism (VTE). Their efficacy and safety depend on individual time in the therapeutic range (iTTR). Due to the variable dose-response relationship within patients, also patients with initially stable VKA treatment may develop extreme overanticoagulation (EO). EO is associated with an immediate bleeding risk, but it is unknown whether VKA treatment will subsequently restabilise. We evaluated long-term quality of VKA treatment and clinical outcome after EO. EO was defined as international normalized ratio (INR) ≥ 8.0 and/or unscheduled vitamin K supplementation. We included a consecutive cohort of initially stable atrial fibrillation and venous thromboembolism patients. In EO patients, the 90 days pre- and post-period were compared. In addition, patients with EO were compared with patients without EO using a matched 1:2 cohort. Of 14,777 initially stable patients, 800 patients developed EO. The pre-period was characterised by frequent overanticoagulation, and half of EO patients had an inadequate iTTR (< 65 %). After EO, underanticoagulation became more prevalent. Although the mean time between INR-measurements decreased from 18.6 to 13.2 days, after EO inadequate iTTR became more frequent (62 %), p-value < 0.001. A 2.3 times (95 % confidence interval [CI] 2.0–2.5) higher risk for iTTR< 65 % after EO, was accompanied by increased risk of bleeding (hazard ratio [HR] 2.1;CI 1.4–3.2), VKA-related death 17.0 (HR 17.0;CI 2.1–138) and thrombosis (HR 5.7;CI 1.5–22.2), compared to the 1600 controls. In conclusion, patients continuing VKA after EO have long-lasting inferior quality of VKA treatment despite intensified INR-monitoring, and an increased risk of bleeding, thrombosis and VKA-related death.Note: There have been no previous presentations, reports or publications of the complete data that appear in the article. Parts of the data in this article have been presented as a poster at the American Society of Hematology (ASH) congress 2013, New Orleans, United States.

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A Mendelian Randomization Analysis Of Lipoprotein(A) Lowering And Cardiovascular Risk Stratified By Ldl Cholesterol, Gender, And Antiplatelet Therapy: Implications For Clinical Outcome Trials

Atherosclerosis ◽

10.1016/j.atherosclerosis.2019.06.021 ◽

2019 ◽

Vol 287 ◽

pp. e8

Author(s):

J. Katzmann ◽

U. Laufs ◽

B.A. Ference

Keyword(s):

Cardiovascular Risk ◽

Clinical Outcome ◽

Antiplatelet Therapy ◽

Ldl Cholesterol ◽

Mendelian Randomization ◽

Lipoprotein A ◽

Mendelian Randomization Analysis ◽

Randomization Analysis

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Clinical outcome of patients with venous thromboembolism and recent major bleeding: findings from a prospective registry (RIETE)

Journal of Thrombosis and Haemostasis ◽

10.1111/j.1538-7836.2005.01167.x ◽

2005 ◽

Vol 3 (4) ◽

pp. 703-709 ◽

Cited By ~ 35

Author(s):

J. A. NIETO ◽

A. D. DE TUESTA ◽

P. J. MARCHENA ◽

G. TIBERIO ◽

J. A. TODOLI ◽

...

Keyword(s):

Venous Thromboembolism ◽

Clinical Outcome ◽

Major Bleeding

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Clinical Outcome of Patients with Venous Thromboembolism and Recent Major Bleeding: Findings from a Prospective Registry (RIETE).

Blood ◽

10.1182/blood.v104.11.708.708 ◽

2004 ◽

Vol 104 (11) ◽

pp. 708-708

Author(s):

Manuel Monreal ◽

José Nieto ◽

Ana de Tuesta ◽

Pablo Marchena ◽

Gregorio Tiberio ◽

...

Keyword(s):

Clinical Trials ◽

Venous Thromboembolism ◽

Clinical Outcome ◽

Clinical Outcomes ◽

Major Bleeding ◽

Bleeding Complications ◽

P Value ◽

Minor Bleeding ◽

Fatal Bleeding ◽

Overall Mortality

Abstract Introduction Patients who have experienced a recent major bleeding episode are usually excluded from clinical trials of venous thromboembolism (VTE) treatment. Therefore, recommendations based on evidence from clinical trials of VTE treatment may not be optimal for these patients. The Registro Informatizado de la Enfermedad TromboEmbólica (RIETE), initiated in March 2001, is a multicenter, observational registry gathering data on VTE treatment practices and clinical outcomes in patients with objectively confirmed, symptomatic, acute VTE. The aim of this analysis was to study outcomes in patients with VTE who had experienced major bleeding <30 days prior to VTE diagnosis. Methods Patients with objectively confirmed symptomatic acute VTE are consecutively enrolled into the RIETE registry. Patients are excluded if they are participating in a therapeutic clinical trial or not available for 3-months follow-up. Patient characteristics, details of antithrombotic therapy, and clinical outcomes at 3-months are recorded. Results Of 6361 patients enrolled up to January 2004, 170 (2.7%) had experienced recent major bleeding prior to VTE diagnosis: 69 (40.6%) gastrointestinal tract; 60 (35.3%) intracranial; 41 (24.1%) other. More patients with recent major bleeding had cancer compared with those without recent major bleeding (26.4% vs 20.4%, respectively; p=0.05). More patients who experienced recent major bleeding had undergone surgery <2 months prior to enrollment or had immobility ≥4 days. The incidences of recurrent PE and minor, major, and fatal bleeding complications were also higher in patients who had experienced recent major bleeding (table 1). Patients with recent major bleeding and cancer had an increased incidence of major bleeding compared to those without cancer (20.0% vs. 2.4%, respectively; OR 10.0; 95% CI 2.3–50.0; p<0.001); 11.0% of patients who had recent major bleeding prior to VTE diagnosis and cancer experienced fatal PE compared with none in patients who had recent major bleeding but without cancer (OR 4.1; 95% CI 4.98–17; p<0.05). Conclusion Patients with VTE and recent major bleeding prior to VTE diagnosis (2.7% of total enrolled patients) had poorer clinical outcomes, in terms of bleeding complications, fatal PE and overall mortality compared with those who had not experienced recent major bleeding. In patients who had recent major bleeding prior to VTE diagnosis, those with cancer had a poorer clinical outcome than those without cancer. Table 1. Clinical outcome of enrolled patients 3-month outcome Recent major bleeding No recent major bleeding OR (95% CI) p value n (%) n=170 n=6191 Fatal bleeding 7 (4.1) 41 (0.6) 6.4 (2.6-15) <0.001 Major bleeding 12 (7.1) 146 (2.3) 3.1 (1.6-5.9) 0.001 Minor bleeding 12 (7.1) 172 (2.8) 2.6 (1.4-5.0) <0.005 Fatal (initial) PE 1 (0.6) 14 (0.2) 2.6 (0.2-19) NS Fatal (recurrent) PE 4 (2.4) 33 (0.5) 4.5 (1.3-14) <0.05 Recurrent VTE 8 (4.7) 184 (2.9) 1.6 (0.7-3.4) NS Overall mortality 25 (15.0) 479 (7.7) 2.1 (1.3-3.2) <0.005

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