Unusual case of soft palate and uvula haematoma in a patient on anticoagulant drugs

A 91-year-old Caucasian man on warfarin for atrial fibrillation presented in view of sudden-onset haemoptysis with fresh bleeding with clots immediately after having eaten a piping-hot traditional cheesecake (pastizz) and burning the soft-palate of his mouth. The haemoptysis had resolved by the time that the patient had arrived to hospital. On examination, a 2 cm by 2 cm dark red, solitary mass could be seen just anterior to the uvula. This was not causing any pain or discomfort to the patient. Blood results were mostly unremarkable except for a raised international normalised ratio (INR) of 3.53. The patient was administered 5 mg vitamin K orally in attempt to lower the INR level and warfarin was subsequently omitted for 7 days. He was also prescribed oral steroids on discharge. The lesion resolved in 7 days and warfarin was restarted then with no further consequences.

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Gaps in translation from trials to practice: Non-vitamin K antagonist oral anticoagulants (NOACs) for stroke prevention in atrial fibrillation

Thrombosis and Haemostasis ◽

10.1160/th13-12-1032 ◽

2014 ◽

Vol 111 (05) ◽

pp. 783-788 ◽

Cited By ~ 36

Author(s):

Darae Ko ◽

Christina L. Cove ◽

Elaine M. Hylek

Keyword(s):

Atrial Fibrillation ◽

Clinical Practice ◽

Vitamin K ◽

Stroke Prevention ◽

Current Knowledge ◽

Oral Anticoagulants ◽

Vitamin K Antagonist ◽

Major Advance ◽

Single Target ◽

Anticoagulant Drugs

SummaryWorldwide there is a tremendous need for affordable anticoagulants that do not require monitoring. The advent of the non-warfarin oral anticoagulant drugs represents a major advance for stroke prevention in atrial fibrillation (AF). The objectives of this review are to 1) identify gaps in our current knowledge regarding use of these single target anticoagulant drugs; 2) outline the potential implications of these gaps for clinical practice, and thereby, 3) highlight areas of research to further optimise their use for stroke prevention in AF.

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Non-Vitamin K Oral Anticoagulant Drugs for Stroke Prevention in Patients with Atrial Fibrillation and Chronic Kidney Disease

Current Medicinal Chemistry ◽

10.2174/0929867323666160210130109 ◽

2016 ◽

Vol 23 (19) ◽

pp. 2055-2069 ◽

Cited By ~ 2

Author(s):

Tatjana S. Potpara ◽

Vera Jokic ◽

Nikolaos Dagres ◽

Torben B. Larsen ◽

Deirdre A. Lane ◽

...

Keyword(s):

Atrial Fibrillation ◽

Chronic Kidney Disease ◽

Kidney Disease ◽

Vitamin K ◽

Stroke Prevention ◽

Oral Anticoagulant ◽

Anticoagulant Drugs

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Direct anticoagulant drugs to overcome limitations of vitamin K antagonists. A critical appraisal of data in atrial fibrillation patients

Expert Opinion on Emerging Drugs ◽

10.1517/14728214.2013.777427 ◽

2013 ◽

Vol 18 (1) ◽

pp. 9-23 ◽

Cited By ~ 11

Author(s):

Matteo Nicola Dario Di Minno ◽

Anna Russolillo ◽

Alessandro Di Minno ◽

Marina Camera ◽

Alessandro Parolari ◽

...

Keyword(s):

Atrial Fibrillation ◽

Vitamin K ◽

Critical Appraisal ◽

Vitamin K Antagonists ◽

Anticoagulant Drugs

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Az edoxabán véralvadásgátló hatásossága és biztonságossága nonvalvuláris pitvarfibrillációban

Orvosi Hetilap ◽

10.1556/650.2018.31014 ◽

2018 ◽

Vol 159 (12) ◽

pp. 466-469

Author(s):

Andrea Szegedi ◽

Zoltán Csanádi

Keyword(s):

Atrial Fibrillation ◽

Anticoagulant Therapy ◽

Vitamin K ◽

Oral Anticoagulant ◽

Randomized Trials ◽

Vitamin K Antagonists ◽

Thromboembolic Events ◽

Direct Oral Anticoagulant ◽

Anticoagulant Drugs

Abstract: The significantly increased incidence of stroke and systemic embolisation caused by atrial fibrillation can be prevented by adequately adjusted anticoagulant therapy. Vitamin K antagonists effectively decrease the risk of thromboembolic events but this effect is influenced by many factors. The development of the new direct oral anticoagulant drugs (DOAC) in the last few years provided new opportunities for us to choose the suitable anticoagulant therapy. According to the results of the ENGAGE AF–TIMI 48 and ENSURE-AF multicenter, randomized trials, edoxaban, the recently introduced DOAC is equally effective as the traditional coumarin therapy, nevertheless, it ensures more tolerable anticoagulation for patients suffering from non-valvular atrial fibrillation. Orv Hetil. 2018; 159(12): 466–469.

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Prevalence of drug-drug interactions for oral anticoagulant drugs in patients with atrial fibrillation and relationship with outcomes: a population-based cohort study

European Heart Journal ◽

10.1093/ehjci/ehaa946.3376 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

M Proietti ◽

L Cortesi ◽

F Spagnoli ◽

A Nobili ◽

A Marengoni

Keyword(s):

Atrial Fibrillation ◽

Drug Interactions ◽

Vitamin K ◽

Oral Anticoagulants ◽

Population Based ◽

Vitamin K Antagonist ◽

Administrative Databases ◽

Italian Region ◽

Increased Risk ◽

Anticoagulant Drugs

Abstract Introduction The introduction of non-vitamin K antagonist oral anticoagulants (NOACs) changed the treatment of atrial fibrillation (AF) patients, promising a better safety profile and a lower chance of interaction with drugs than vitamin K antagoniste (VKA). Aim To evaluate the prevalence of possible drug-drug interactions (DDIs) in a cohort of newly anticoagulated AF patients, their impact on outcomes and possible differences between VKA and NOACs users. Methods We performed an analysis derived from administrative databases in Lombardy Italian region. All patients ≥40 years admitted from 01/06/2013 to 30/06/2018 with an AF diagnosis that were VKA or NOACs new users were included in this analysis. Possible DDIs were evaluated according to the prescription of OAC therapy, on the basis of current available evidence. Stroke, intracerebral hemorrhage (ICH), any bleeding and all-cause death were the study outcomes. Results Among the 122816 patients included in the analysis, mean (SD) age 76.3 (9.6) with 47.3% females, a mean (SD) CHA2DS2-VASc of 3.5 (1.4) was found. A total of 70180 (57.1%) patients were prescribed with VKA and 52636 (42.9%) with NOACs. A possible DDI was recorded in 63273 (51.5%). Patients exposed to DDIs were older and less likely female (both p<0.0001) and with a higher mean (SD) CHA2DS2-VASc (p<0.0001). Rate of stroke, ICH, any bleeding and all-cause death were higher in those patients exposed to DDIs (all p<0.001). After full adjustment, exposure to possible DDIs was associated with an increased risk for any bleeding (HR: 1.08, 95% CI: 1.05–1.12) and all-cause death (HR: 1.10, 95% CI: 1.07–1.13), with no differences for stroke and ICH. Comparing VKA and NOACs patients exposed to possible DDIs, we found that VKA users exposed to possible DDIs, after adjustments, were at higher risk for all the outcomes (Table). Conclusions In a large cohort of AF patients newly prescribed with OAC, possible DDIs were largely prevalent, in particular in VKA users. Presence of a possible DDI is associated with an increased risk of any bleeding and all-cause death. VKA users exposed to a possible DDI were at higher risk for any outcome than NOACs users exposed to a possible DDI. Funding Acknowledgement Type of funding source: None

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A REVIEW ON A COMPARATIVE STUDY ON EFFECTIVENESS AND SAFETY OF NOVEL ORAL ANTICOAGULANTS IN PATIENTS WITH ATRIAL FIBRILLATION

International Journal of Pharmaceutical and Biological Science Archive ◽

10.32553/ijpba.v7i2.122 ◽

2019 ◽

Vol 7 (2) ◽

Author(s):

Priyanka P K ◽

Mathew George ◽

Lincy Joseph

Keyword(s):

Atrial Fibrillation ◽

Vitamin K ◽

Therapeutic Option ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Novel Oral Anticoagulants ◽

Thrombin Inhibitors ◽

Direct Thrombin Inhibitors ◽

Systemic Embolism ◽

Anticoagulant Drugs

Atrial fibrillation (AF) is characterized as an extremely rapid and disorganized atrial activation. These irregular heartbeats will cause blood to collect within the heart and potentially form a clot, which can travel to a person’s brain and cause a stroke. AF increases stroke risk by 3 to 5 fold. Vitamin K antagonists (VKAs) are highly effective for the prevention of stroke, mainly of ischemic origin, in patients with AF. For this reason, VKAs are currently recommended in all AF patients at moderate to high risk for stroke or systemic embolism (SSE). VKAs have significant limitations, particularly their unpredictable anticoagulant response and numerous food and drug interactions, mandating regular laboratory monitoring. These limitations make treatment with VKAs problematic for many patients; as a result, only about half of all potentially eligible AF patients are treated with VKAs. Over the last several years, novel oral anticoagulant drugs (NOACs), including direct thrombin inhibitors (dabigatran) and factor Xa inhibitors (apixaban & rivaroxaban), have been developed. New orally administered anticoagulant drugs have emerged as potential alternatives to VKAs for the prevention of ischaemic stroke or systemic embolism in patients with chronic atrial fibrillation. Novel oral anticoagulants (NOACs), due to their a lot of predictable therapeutic result and more favorable haemorrhagic risk profile, represent a particularly attractive therapeutic option in AF patients. Keywords: Novel oral anticoagulants (NOACs), Vitamin K antagonist (VKAs), Atrial fibrillation, Apixaban, Dabigatran, Rivaroxaban.

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New Drugs for Thromboembolic Prevention in Atrial Fibrillation

European Cardiology Review ◽

10.15420/ecr.2010.6.4.64 ◽

2010 ◽

Vol 6 (4) ◽

pp. 64

Author(s):

Jose L Merino ◽

Jose López-Sendón ◽

◽

Keyword(s):

Atrial Fibrillation ◽

Vitamin K ◽

Negative Impact ◽

Vitamin K Antagonists ◽

Coagulation Factor ◽

Developed Countries ◽

New Drugs ◽

Risk Scores ◽

Bleeding Events ◽

Risk Patients

Atrial fibrillation (AF) is the most frequent sustained arrhythmia and its prevalence is increasing in developed countries. This progressive increase and the negative impact of this arrhythmia on the patient’s prognosis make AF one of the main healthcare problems faced today. This has led to intense research into the main aspects of AF, one of them being thromboembolism prevention. AF patients have a four to five times higher risk of stroke than the general population. Several factors increase thromboembolic risk in patients with AF and the use of risk scores, such as the Congestive Heart Failure, Hypertension, Age Greater than 75, Diabetes, and Prior Stroke or Transient Ischemic Attack (CHADS2), have been used to identify the best candidates for anticoagulation. Antithrombotic drugs are the mainstay of therapy for embolic prevention. The clinical use of these drugs is based on the risk–benefit ratio, where benefit is the reduction of stroke and systemic embolic events and risk is mostly driven by the increase in bleeding events. Generally, antiplatelets are indicated for low-risk patients in light of the fact anticoagulants are the drug of choice for moderate- or high-risk patients. Vitamin K antagonists have been the only option for oral anticoagulation for the last 50 years. However, these drugs have many pharmacodynamic and pharmacokinetic problems. The problems of anticoagulation with vitamin K antagonists have led to the investigation of new drugs that can be administered orally and have a better dose–response relationship, a shorter half-life and, in particular, higher efficacy and safety without the need for frequent anticoagulation controls. The drugs that have been studied most thoroughly in patients with AF are inhibitors of the activated coagulation factor X and inhibitors of coagulation factor II (thrombin), including ximelagatran and dabigatran. In addition, non-pharmacological therapies have been developed to prevent recurrent embolism in certain patient populations.

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