scholarly journals Perioperative management of anticoagulant therapy

2019 ◽  
Vol 4 (4) ◽  
pp. 144-151
Author(s):  
Johanna Wagner ◽  
Johan F. Lock ◽  
Carolin Kastner ◽  
Ingo Klein ◽  
Katica Krajinovic ◽  
...  
Keyword(s):  
Anticoagulant Therapy ◽  
Oral Anticoagulant ◽  
Oral Anticoagulant Therapy ◽  
Invasive Procedure ◽  
Bleeding Risk ◽  
Coumarin Derivative ◽  
Bridging Therapy ◽  
Perioperative Bleeding ◽  
Increased Risk ◽  
Risk For Bleeding

AbstractAbout 10% of patients taking a chronic, oral anticoagulant therapy require an invasive procedure that can be associated with an increased risk for peri-interventional or perioperative bleeding. Depending on the risk for thromboembolism and the risk for bleeding, the physician has to decide whether the anticoagulant therapy should be interrupted or continued. Patient characteristics such as age, renal function and drug interactions must be considered. The perioperative handling of the oral anticoagulant therapy differs according to the periprocedural bleeding risk. Patients requiring a procedure with a minor risk for bleeding do not need to pause their anticoagulant therapy. For procedures with an increased risk for perioperative bleeding, the anticoagulant therapy should be adequately paused. For patients on a coumarin derivative with a high risk for a thromboembolic event, a perioperative bridging therapy with a low molecular weight heparin is recommended. Due to an increased risk for perioperative bleeding in patients on a bridging therapy, it is not recommended in patients with a low risk for thromboembolism. For patients taking a non-vitamin K oral anticoagulant, a bridging therapy is not recommended due to the fast onset and offset of the medication.

Bleeding risk assessment during oral anticoagulant therapy initiation

2012 ◽  
Vol 5 (2) ◽  
pp. 125-127
Author(s):  
Alejandro Lazo-Langner ◽  
Michael J Kovacs ◽  
Martha Louzada
Keyword(s):  
Risk Assessment ◽  
Anticoagulant Therapy ◽  
Oral Anticoagulant ◽  
Oral Anticoagulant Therapy ◽  
Bleeding Risk ◽  
Therapy Initiation

The association between atrial fibrillation and pulmonary embolism

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
E Svennberg ◽  
L Friberg
Keyword(s):  
Atrial Fibrillation ◽  
Pulmonary Embolism ◽  
Risk Factor ◽  
Anticoagulant Therapy ◽  
Oral Anticoagulant ◽  
Oral Anticoagulant Therapy ◽  
Funding Source ◽  
Anticoagulant Treatment ◽  
Oral Anticoagulant Treatment ◽  
Increased Risk

Abstract Background and objectives Previous studies have suggested that atrial fibrillation is a risk factor for pulmonary embolism. Oral anticoagulant therapy is the mainstay of treatment for atrial fibrillation and pulmonary embolism. We wanted to investigate if atrial fibrillation remained associated with the development of pulmonary embolism if oral anticoagulant treatment was accounted for. Method In this retrospective registry study a random sample of 20% of the adult Swedish population comprising approximately 1.5 million individuals were included during 2010–2017 in a cohort analysis. The endpoint was acute pulmonary embolism. In the cohort study, patients were analysed according to oral anticoagulant treatment and presence of atrial fibrillation at baseline. Results The group with atrial fibrillation was >25 years older than the group without and had almost three times higher incidence of pulmonary embolism (2.91 vs 1.09 /1000 year at risk, p<0.001). Individuals with atrial fibrillation on oral anticoagulant therapy had a lower risk of pulmonary embolism in multi-variable analysis (HR 0.59, CI 0.45–0.77). In the unadjusted analysis participants with atrial fibrillation without oral anticoagulant therapy showed an increased risk of pulmonary embolism (HR 3.33, CI 3.05–3.63). However, after multi-variable adjustment this association disappeared (HR 0.98, CI 0.89–1.07). In the entire atrial fibrillation cohort, no association was seen with the development of pulmonary embolism after multi-variable adjustment (HR 0.92, CI 0.84–1.01). The higher rate of pulmonary embolism among patients with atrial fibrillation can be fully explained by differences in age and co-morbidity. Conclusion Atrial fibrillation does not appear to be a clinically relevant risk factor for pulmonary embolism. Oral anticoagulant therapy protects against the development of pulmonary embolism in patients with atrial fibrillation. Associations with pulmonary embolism Funding Acknowledgement Type of funding source: Other. Main funding source(s): The main author has received funding from Stockholm County Council (Clinical postdoctorial appointment)

scholarly journals Differences in Perceived and Predicted Bleeding Risk in Older Adults With Atrial Fibrillation: The SAGE‐AF Study

2021 ◽  
Author(s):  
Benita A. Bamgbade ◽  
David D. McManus ◽  
Robert Helm ◽  
Jordy Mehawej ◽  
Jerry H. Gurwitz ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Native American ◽  
Anticoagulant Therapy ◽  
Oral Anticoagulant ◽  
Risk Perceptions ◽  
Oral Anticoagulant Therapy ◽  
Bleeding Risk ◽  
Systematic Assessment ◽  
Patient Reported ◽  
History Of

Background Little research has evaluated patient bleeding risk perceptions in comparison with calculated bleeding risk among oral anticoagulant users with atrial fibrillation. Our objective was to investigate underestimation of bleeding risk and to describe the characteristics and patient‐reported outcomes associated with underestimation of bleeding risk. Methods and Results In the SAGE‐AF (Systematic Assessment of Geriatric Elements in Atrial Fibrillation) study, a prospective cohort study of patients ≥65 years with atrial fibrillation, a CHA 2 DS 2 ‐VASc risk score ≥2 and who were on oral anticoagulant therapy, we compared patients’ self‐reported bleeding risk with their predicted bleeding risk from their HAS‐BLED score. Among the 754 participants (mean age 74.8 years, 48.3% women), 68.0% underestimated their bleeding risk. Participants who were Asian or Pacific Islander, Black, Native American or Alaskan Native, Mixed Race or Hispanic (non‐White) (adjusted OR [AOR], 0.45; 95% CI, 0.24–0.82) and women (AOR, 0.62; 95% CI, 0.40–0.95) had significantly lower odds of underestimating their bleeding risk than respective comparison groups. Participants with a history of bleeding (AOR, 3.07; 95% CI, 1.73–5.44) and prior hypertension (AOR, 4.33; 95% CI, 2.43–7.72), stroke (AOR, 5.18; 95% CI, 1.87–14.40), or renal disease (AOR, 5.05; 95% CI, 2.98–8.57) had significantly higher odds of underestimating their bleeding risk. Conclusions We found that more than two‐thirds of patients with atrial fibrillation on oral anticoagulant therapy underestimated their bleeding risk and that participants with a history of bleeding and several comorbid conditions were more likely to underestimate their bleeding risk whereas non‐Whites and women were less likely to underestimate their bleeding risk. Clinicians should ensure that patients prescribed oral anticoagulant therapy have a thorough understanding of bleeding risk.

Duration of Oral Anticoagulant Therapy after Proximal Deep Vein Thrombosis: a Decision Analysis

1994 ◽  
Vol 71 (03) ◽  
pp. 286-291 ◽  
Author(s):  
François P Sarasin ◽  
Henri Bounameaux
Keyword(s):  
Deep Vein Thrombosis ◽  
Decision Analysis ◽  
Anticoagulant Therapy ◽  
Oral Anticoagulant ◽  
Oral Anticoagulant Therapy ◽  
Oral Anticoagulants ◽  
Bleeding Risk ◽  
Lower Limbs ◽  
Vein Thrombosis ◽  
Deep Vein

SummaryThe optimal duration of oral anticoagulant therapy following proximal deep vein thrombosis (DVT) in the lower limbs remains controversial. To compare the risk benefit tradeoffs for different treatment durations (6 to 24 weeks) we constructed a Markov-based decision analysis model which explicitly balances the time-dependent declining risk of recurrent thrombosis and pulmonary embolism against the risk of major hemorrhagic complications. Specifically, we determined the threshold below which the risk of recurrent DVT exceeds the risk of major hemorrhage if anticoagulant therapy is discontinued, and above which the benefits provided by oral anticoagulants are outweighed by their risk.Our model shows that for patients with a low hemorrhagic risk (0.5%/month), the benefit yielded by oral anticoagulants breaks off beyond the 4th month of therapy, while patients with moderate (1%/month) to high (2%/month) bleeding risk will no longer benefit from the therapy after 3 or 2.5 months, respectively.In conclusion, our model supports the validity of the usually recommended duration of 3 months of oral anticoagulation after proximal vein thrombosis in the lower limbs, but suggests that this duration should be modulated between 2.5 and 4 months depending upon individual bleeding risk. Since clinical trials can hardly handle the complexity of the addressed issue, such a model may prove very helpful in daily clinical practice.

A Comparison of the Safety and Efficacy of Oral Antiocoagulation for the Treatment of Venous Thromboembolic Disease in Patients with or without Malignancy

2000 ◽  
Vol 84 (11) ◽  
pp. 805-810 ◽  
Author(s):  
Cristina Legnani ◽  
Agnes Lee ◽  
Cesare Manotti ◽  
Jack Hirsh ◽  
Armando D’Angelo ◽  
...  
Keyword(s):  
Cancer Patients ◽  
Anticoagulant Therapy ◽  
Oral Anticoagulant ◽  
Oral Anticoagulant Therapy ◽  
Current Evidence ◽  
Recurrent Thrombosis ◽  
Bleeding Rate ◽  
Patients With Cancer ◽  
Increased Risk ◽  
Long Term Treatment

SummaryThe optimal long-term treatment of acute venous thromboembolism (VTE) in patients with malignancy remains undefined. In particular, based on current evidence, it is uncertain whether secondary prophylaxis using standard intensity oral anticoagulant therapy is associated with higher risks of bleeding and recurrent thrombosis in patients with cancer than in those without cancer. This study compared the outcome of anticoagulation courses in 95 patients with malignancy with those of 733 patients without malignancy. All patients were participants in a large, nation-wide population study and were prospectively followed from the initiation of their oral anticoagulant therapy.Based on 744 patient-years of treatment and follow-up, the rates of major (5.4% vs 0.9%), minor (16.2% vs 3.6%) and total (21.6% vs 4.5%) bleeding were statistically significantly higher in cancer patients compared with patients without cancer. Bleeding was also a more frequent cause of early anticoagulation withdrawal in patients with malignancy (4.2% vs. 0.7%; p <0.01; RR 6.2 (95%CI 1.95-19.4). There was a trend towards a higher rate of thrombotic complications in cancer patients (6.8% vs. 2.5%; p = 0.058; RR 2.5 [CI 0.96-6.5]) but this did not achieve statistical significance. In the group of patients with cancer, the bleeding rate was high across the different INR categories and was independent of the temporally associated International Normalized Ratio (INR). In contrast, the bleeding rate was increased only with INR values greater than 4.5 in the group of patients without cancer. The rate of thrombotic events was significantly higher in both cohorts when the INR was less than 2.0.In conclusion, patients with malignancy treated with oral anticoagulants have a higher rate of bleeding and possibly an increased risk of recurrent thrombosis compared with patients without malignancy. Safer and more effective anticoagulant therapy is needed for this challenging group of patients.

Reduced stroke risk without increased bleeding risk in patients with atrial fibrillation and complicated liver cirrhosis treated with oral anticoagulation

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
K Steensig ◽  
M Pareek ◽  
A.L Krarup ◽  
P Sogaard ◽  
M Maeng ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Liver Cirrhosis ◽  
Anticoagulant Therapy ◽  
Oral Anticoagulation ◽  
Oral Anticoagulant ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Bleeding Risk ◽  
Increased Risk ◽  
First Time

Abstract Introduction Patients with atrial fibrillation (AF) have an increased risk of thromboembolic events (TE), while patients with complicated liver cirrhosis have an increased risk of both TE and bleeding. Oral anticoagulation reduces the risk of TE in the general group of patients with AF but its use in patients with liver cirrhosis is obscured by their imbalance between endogenous procoagulants and anticoagulants, as well as the lack of data from randomized controlled trials. Purpose To examine the risks of TE and bleeding in patients with AF and complicated liver cirrhosis according to whether oral anticoagulation is initiated. Methods We conducted a nationwide registry-based study of anticoagulant-naive patients with complicated liver cirrhosis and first-time AF diagnosed between 2010–2017. Complicated liver cirrhosis was defined as liver cirrhosis plus one of the following: alcoholism, esophageal varices, ascites or hepatorenal syndrome. Patients were followed for a maximum of 5 years. TE was defined as a composite of ischemic stroke, transient ischemic attack or systemic thromboembolism; and the bleeding endpoint was defined as gastrointestinal, cerebral or urogenital bleeding requiring hospitalization, or any hospital contact with epistaxis. TE risk was estimated by use of the CHA2DS2-VASc score, while bleeding risk was estimated by use of the HAS-BLED score. Outcomes were stratified according to whether an oral anticoagulant (vitamin K antagonists [VKA] or direct oral anticoagulants [DOAC]) was initiated. Results We identified 770 patients with complicated liver cirrhosis and first-time AF. TE events occurred in 7.0% (n=25/359) of patients with a CHA2DS2-VASc score ≤2 versus 20.7% (n=85/411) of patients with a CHA2DS2-VASc score &gt;2. Among 411 patients with a high CHA2DS2-VASc score, 111 (27.0%) were prescribed an oral anticoagulant (OAC+; VKA, n=53 [47.7%], DOAC, n=58 [52.3%]), while 300 (73.0%) were not treated with oral anticoagulation (OAC−). These two groups had comparable baseline data, including HAS-BLED (OAC+ 3.0 [2.5–4.0] versus OAC− 3.0 [2.0–4.0]) and CHA2DS2-VASc (OAC+ 4.0 [3.0–5.0] versus OAC− 4.0 [3.0–5.0]) scores. The 5-year TE risk among patients receiving anticoagulant therapy was 14.4% (n=16/111) versus 23.0% (n=69/300) in patients not treated with anticoagulant therapy (hazard ratio (HR) 0.55 [0.32–0.95]). The difference in bleeding risk was insignificant between the two groups (HR 0.67 [0.35–1.30]). Adjusting for CHA2DS2-VASc, HAS-BLED and prior bleeding requiring hospitalization did not significantly change the HR estimate, and no significant interactions were found. Conclusion TE risk was significantly lower in AF patients with complicated liver cirrhosis treated with oral anticoagulation, without a significantly increased bleeding risk. However, the majority of AF patients with complicated liver cirrhosis are not treated with anticoagulant therapy, indicating a potential for reducing the TE burden in this population. Funding Acknowledgement Type of funding source: None

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