scholarly journals Predictors of Bleeding in the Perioperative Anticoagulant Use for Surgery Evaluation Study

2020 ◽  
Vol 9 (19) ◽  
Author(s):  
Alfonso J. Tafur ◽  
Nathan P. Clark ◽  
Alex C. Spyropoulos ◽  
Na Li ◽  
Eric Kaplovitch ◽  
...  
Keyword(s):  
Elective Surgery ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Univariate Analysis ◽  
Area Under The Curve ◽  
Bleeding Risk ◽  
Evaluation Study ◽  
Nonvalvular Atrial Fibrillation ◽  
Perioperative Bleeding ◽  
Management Protocol

Background In the PAUSE (Perioperative Anticoagulant Use for Surgery Evaluation) Study, a simple, standardized, perioperative interruption strategy was provided for patients with nonvalvular atrial fibrillation taking direct oral anticoagulants (DOACs). Our objective was to define the factors associated with perioperative bleeding. Methods and Results We analyzed bleeding as the composite of major and clinically relevant nonmajor bleeding. Putative predictors of bleeding, and preoperative DOAC level were prospectively collected during recruitment. We used stratified logistic regression models for analysis. All statistical analyses were performed in R version 3.6.0. There were 3007 patients requiring perioperative DOAC interruption. More than one third of the included patients underwent a high bleeding risk procedure. The 30‐day rates of major and clinically relevant nonmajor bleeding were 3.02% in apixaban (n=1257), 2.84% in dabigatran (n=668), and 4.16% for rivaroxaban (n=1082). Multivariate analysis stratified by region found more bleeding for hypertension (odds ratio [OR], 1.79; 95% CI 1.07‐2.99; P =0.027), and prior bleeding (OR, 1.71; 95% CI, 1.08‐2.71; P =0.021). Surgical bleed risk classification (high‐ versus low‐risk) as a predictor of bleeding was only significant in the univariate analysis. The prediction model for major and clinically relevant nonmajor bleeding had an area under the curve of 0.71, and the preoperative DOAC level did not improve the area under the curve of the model. Conclusions In patients treated with DOACs who required an elective surgery/procedure and were managed with standardized DOAC interruption and resumption, there we did not find reversible risk factors for bleeding, suggesting that adjustment of the PAUSE management protocol to mitigate against bleeding is not needed.

scholarly journals Use of Idarucizumab to Revert the Anticoagulant Effect of Dabigatran in Heart Transplant Surgery: An Institutional Experience

2020 ◽  
Vol 2020 ◽  
pp. 1-3
Author(s):  
Álvaro Herrera-Escandón ◽  
Orlando Castaño-Cifuentes ◽  
Carlos A. Plata-Mosquera
Keyword(s):  
Heart Transplant ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Previous History ◽  
Waiting List ◽  
Anticoagulant Effect ◽  
Nonvalvular Atrial Fibrillation ◽  
Reversal Agent ◽  
Perioperative Bleeding ◽  
Congestive Liver

Heart transplant is a surgical procedure with a high risk of perioperative bleeding in patients with a previous history of sternotomy, congestive liver disease, and/or use of oral anticoagulants. Anticoagulation is usually done with coumarin agents (warfarin, acenocoumarol), while on the waiting list, vitamin K is available allowing for partial reversal of the anticoagulant effect, although with variable INR and risk of uncontrolled bleeding. Direct oral anticoagulants have emerged as an alternative to the use of coumarins in patients with nonvalvular atrial fibrillation (NVAF). The main disadvantage of this group of drugs is that there was no specific reversal agent available that would allow an urgent reversal of the anticoagulant effect. The recent commercialization of idarucizumab (specific reversal agent) has allowed patients with NVAF on the waiting list for heart transplant to be treated with dabigatran. We present the case of a patient with advanced chronic heart failure and NVAF anticoagulated with dabigatran, who underwent urgent heart transplant after administration of idarucizumab, without complications derived from its use or from anticoagulation.

scholarly journals Safety and Efficacy of Direct Oral Anticoagulants for Atrial Fibrillation in Patients with Renal Impairment

Pharmacy ◽  
2020 ◽  
Vol 8 (1) ◽  
pp. 30 ◽  
Author(s):  
Soo Min Jang ◽  
Khaled Bahjri ◽  
Huyentran Tran
Keyword(s):  
Atrial Fibrillation ◽  
Renal Impairment ◽  
Stroke Prevention ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Bleeding Risk ◽  
Bleeding Events ◽  
Nonvalvular Atrial Fibrillation ◽  
Efficacy Data ◽  
Safety And Efficacy

Direct oral anticoagulants (DOACs) are gaining popularity for patients with nonvalvular atrial fibrillation (AF) for stroke prevention. Less bleeding risk with comparable stroke prevention compared to warfarin was shown. DOACs have predictable anticoagulant effects, infrequent monitoring requirements and less drug-food interactions compared to warfarin. However, safety and efficacy data of DOACs in patients with chronic kidney disease (CKD) are limited. This is a retrospective study to evaluate thromboembolic and bleeding events in patients with AF (with/without CKD) in October 2010 and July 2017. A total of 495 patients were included and only 150 patients had CKD. Our study found that patients with renal impairment on a DOAC do not have a higher incidence of bleeding events. It showed significant increase in thromboembolic events in CKD patients with dabigatran compared to CKD patients with apixaban with odds ratio of 6.58 (95%CI 1.35–32.02, p = 0.02).

The perioperative management of new direct oral anticoagulants: a question without answers

2013 ◽  
Vol 110 (09) ◽  
pp. 515-522 ◽  
Author(s):  
Jordi Castillo ◽  
José de Andrés ◽  
Carmen Gomar ◽  
Aurelio Gómez-Luque ◽  
Francisco Hidalgo ◽  
...  
Keyword(s):  
Emergency Surgery ◽  
Elective Surgery ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Perioperative Period ◽  
Bleeding Risk ◽  
Secondary Prophylaxis ◽  
Rescue Treatment ◽  
Prevention Of Thromboembolic Events ◽  
Hip And Knee Arthroplasty

SummaryNew direct oral anticoagulant agents (DOAC) are currently licensed for thromboprophylaxis after hip and knee arthroplasty and for longterm prevention of thromboembolic events in non-valvular atrial fibrillation as well as treatment and secondary prophylaxis of venous thromboembolism. Some other medical indications are emerging. Thus, anaesthesiologists are increasingly likely to encounter patients on these drugs who need elective or emergency surgery. Due to the lack of experience and data, the management of DOAC in the perioperative period is controversial. In this article, we review available information and recommendations regarding the periprocedural management of the currently most clinically developed DOAC, apixaban, dabigatran, and rivaroxaban. We discuss two trends of managing patients on DOAC for elective surgery. The first is stopping the DOAC 1–5 days before surgery (depending on the drug, patient and bleeding risk) without bridging. The second is stopping the DOAC 5 days preoperatively and bridging with low-molecular-weight heparin. The management of patients on DOAC needing emergency surgery is also reviewed. As no data exist for the use of haemostatic products for the reversal of the anticoagulant effect in these cases, rescue treatment recommendations are proposed.

Comparison of Bleeding Risk Scores in Patients With Nonvalvular Atrial Fibrillation Starting Direct Oral Anticoagulants

2017 ◽  
Vol 70 (10) ◽  
pp. 878-880
Author(s):  
César Caro Martínez ◽  
José Manuel Andreu Cayuelas ◽  
Pedro José Flores Blanco ◽  
Mariano Valdés ◽  
José Luis Bailén Lorenzo ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Bleeding Risk ◽  
Risk Scores ◽  
Nonvalvular Atrial Fibrillation

Perioperative Management of Patients Receiving New Anticoagulants

2019 ◽  
Vol 25 (19) ◽  
pp. 2149-2157 ◽  
Author(s):  
Massimo Lamperti ◽  
Andrey Khozenko ◽  
Arun Kumar
Keyword(s):  
Vitamin K ◽  
Elective Surgery ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Oral Intake ◽  
Bleeding Risk ◽  
Dietary Vitamin ◽  
Reversal Agent ◽  
Onset Of Action ◽  
Reversal Agents

There is an increased use of oral anticoagulants for the prevention of venous and arterial thrombosis. Vitamin-K antagonists have been used for decades as the main oral anticoagulants but they have the draback a complex therapeutic management, slow onset of action and by a different oral intake caused by dietary vitamin K intake. New non-vitamin K antagonist oral anticoagulants (NOACs) have been developed to overcome the limitations of warfarin. Their management is easier as it requires a fixed daily dose without coagulation monitoring. Although their therapeutic profile is safe, proper attention should be paid in case of unexpected need for the reversal of their coagulation effect and in case a patient needs to have a scheduled surgery. For non-acute cardiac surgery, discontinuation of NOACs should start at least 48 hours prior surgery. Intracranial bleedings associated with NOACs are less dangerous comparing to those warfarin-induced. NOACs need to be stopped ≥24 hours in case of elective surgery for low bleeding-risk procedures and ≥48 hours for high bleeding-risk surgery in patients with normal renal function and 72 hours in case of reduced CrCl < 80. The therapy with NOACs should be resumed from 48 to 72 hours after the procedure depending on the perceived bleeding, type of surgery and thrombotic risks. There are some available NOAC reversal agents acting within 5 to 20 minutes. In case of lack of reversal agent, adequate diuresis, renal replacement therapy and activated charcoal in case of recent ingestion should be considered.

scholarly journals Novel bleeding risk score for patients with atrial fibrillation on oral anticoagulants, including direct oral anticoagulants

2021 ◽  
Author(s):  
Luise Adam ◽  
Martin Feller ◽  
Lamprini Syrogiannouli ◽  
Cinzia Del‐Giovane ◽  
Jacques Donzé ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Risk Score ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Bleeding Risk
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