scholarly journals Current therapeutic approaches to haemostasis correction in covid-19: a systematic review

2021 ◽  
Vol 28 (4) ◽  
pp. 72-84
Author(s):  
V. N. Antonov ◽  
M. V. Osikov ◽  
G. L. Ignatova ◽  
S. О. Zotov
Keyword(s):  
Oral Anticoagulants ◽  
Russian Language ◽  
Medical Community ◽  
Therapeutic Value ◽  
Anticoagulant Drug ◽  
Potential Benefits ◽  
Downstream Analysis ◽  
Randomised Controlled ◽  
Direct Acting ◽  
Drug Efficiency

Background. The coronavirus disease 2019 (COVID-19) caused by the SARS-CoV-2 virus has swept across countries worldwide. Despite an unprecedented volume of research, few drug therapies have been proved effective. The lack of evidence-based strategies entailed many practical treatments. Hypercoagulability observed in COVID-19 patients has sparked a debate in the medical community on therapeutic value of anticoagulants.Objectives. A review of up-to-date evidence supporting the therapeutic effect of unfractionated and low molecular-weight heparin as anticoagulant in treatment for COVID-19. Methods. Russian-language and foreign literature was mined in the RSCI, Scopus, PubMed, medRxiv and eLibrary databases for the years 2020–2021, with considering selected impactive publications within 1991–2019 as well. The query keywords were COVID-19, heparin [гепарин], hemostasis [гемостаз], thromboembolism [тромбоэмболия]. Peer-reviewed scientific journals received priority. Content and descriptive analytics were used as research tools.Results. The review surveyed 84 literature sources, with 51 articles selected for downstream analysis. We highlight usage of heparin and its fractions in treatment for COVID-19 and preclinical evidence verifying the antiviral and anti-inflammatory properties of heparin and synthetic heparin-like drugs in COVID-19. The known and plausible side effects demanding additional prospective randomised controlled trials on anticoagulant application in COVID-19 are reviewed, with an assessment of oral direct-acting anticoagulant drug efficiency.Conclusion. Drug-based therapies for haemostasis correction in COVID-19 are currently limited. The paucity of evidence warrants heparin usage as a safer therapy in acute COVID-19 compared to oral anticoagulants. However, the balance of its potential benefits vs. risks must be observed. The benefits and risk uncertainty in heparin treatment require randomised clinical trials and further studies to evaluate safety of direct-acting oral anticoagulants after the patient’s discharge in COVID-19.

Safety and efficacy of direct acting oral anticoagulants and vitamin K antagonists in nonvalvular atrial fibrillation – a network meta-analysis of real-world data

VASA ◽  
2019 ◽  
Vol 48 (2) ◽  
pp. 134-147 ◽  
Author(s):  
Mirko Hirschl ◽  
Michael Kundi
Keyword(s):  
Real World ◽  
Meta Analysis ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Efficacy And Safety ◽  
Nonvalvular Atrial Fibrillation ◽  
Real World Data ◽  
Hazard Ratios ◽  
Direct Acting ◽  
Event Rates

Abstract. Background: In randomized controlled trials (RCTs) direct acting oral anticoagulants (DOACs) showed a superior risk-benefit profile in comparison to vitamin K antagonists (VKAs) for patients with nonvalvular atrial fibrillation. Patients enrolled in such studies do not necessarily reflect the whole target population treated in real-world practice. Materials and methods: By a systematic literature search, 88 studies including 3,351,628 patients providing over 2.9 million patient-years of follow-up were identified. Hazard ratios and event-rates for the main efficacy and safety outcomes were extracted and the results for DOACs and VKAs combined by network meta-analysis. In addition, meta-regression was performed to identify factors responsible for heterogeneity across studies. Results: For stroke and systemic embolism as well as for major bleeding and intracranial bleeding real-world studies gave virtually the same result as RCTs with higher efficacy and lower major bleeding risk (for dabigatran and apixaban) and lower risk of intracranial bleeding (all DOACs) compared to VKAs. Results for gastrointestinal bleeding were consistently better for DOACs and hazard ratios of myocardial infarction were significantly lower in real-world for dabigatran and apixaban compared to RCTs. By a ranking analysis we found that apixaban is the safest anticoagulant drug, while rivaroxaban closely followed by dabigatran are the most efficacious. Risk of bias and heterogeneity was assessed and had little impact on the overall results. Analysis of effect modification could guide the clinical decision as no single DOAC was superior/inferior to the others under all conditions. Conclusions: DOACs were at least as efficacious as VKAs. In terms of safety endpoints, DOACs performed better under real-world conditions than in RCTs. The current real-world data showed that differences in efficacy and safety, despite generally low event rates, exist between DOACs. Knowledge about these differences in performance can contribute to a more personalized medicine.

Reversal of DIRECT-ACTING Oral Anticoagulants in Urgent Surgery of the Proximal Aorta: case Series and Review of the literature

2019 ◽  
Vol 24 (38) ◽  
pp. 4534-4539 ◽  
Author(s):  
Eric Zimmermann ◽  
Fawzi Ameer ◽  
Berhane Worku ◽  
Dimitrios Avgerinos
Keyword(s):  
Oral Anticoagulants ◽  
Aortic Surgery ◽  
Management Strategies ◽  
Case Series ◽  
Published Data ◽  
Review Of Literature ◽  
Clotting Factors ◽  
Urgent Surgery ◽  
Direct Acting ◽  
Direct Acting Oral Anticoagulants

Introduction: Proximal aorta interventions impose significant bleeding risk. Patients on concomitant anticoagulation regimens compound the risk of bleeding in any surgery, but especially cardiothoracic interventions. The employment of direct-acting oral anticoagulants (DOAC), namely those that target clotting factors II or X, has expanded at a precipitous rate over the last decade. The emergence of their reversal agents has followed slowly, leaving clinicians with management dilemmas in urgent surgery. We discuss current reversal strategies based on the available published data and our experience with proximal aortic surgery in patients taking DOACs. Literature Search: We performed a review of literature and present three cases from our experience to offer insight into management strategies that have been historically successful. A review of literature was conducted via PubMed with the following search string: (NOAC or DOAC or TSOAC) and (aorta or aortic or (Stanford and type and a)). Case Presentation: We present three case presentations that illustrate the importance of DOAC identification and offer management strategies in mitigating associated bleeding risks in urgent or emergent surgeries. Conclusion: Treatment teams should be aware of the technical limitations of identifying and reversing DOACs. In view of the tendency toward publishing positive outcomes, more scientific rigor is required in the area of emergency DOAC reversal strategies.

scholarly journals The use of direct acting oral anticoagulants in patients with COVID-19 infection

2021 ◽  
Vol 11 (2) ◽  
pp. 184-186
Author(s):  
Ragia Aly ◽  
Sachin Gupta ◽  
Balraj Singh ◽  
Parminder Kaur ◽  
Kunhwa Kim ◽  
...  
Keyword(s):  
Oral Anticoagulants ◽  
Direct Acting ◽  
Direct Acting Oral Anticoagulants

scholarly journals 306 The Changing Face of Stroke in the DOAC Era

2019 ◽  
Vol 48 (Supplement_3) ◽  
pp. iii17-iii65
Author(s):  
Recie Davern ◽  
Helena Hobbs ◽  
Hannah Murugan ◽  
Paul Cotter
Keyword(s):  
Atrial Fibrillation ◽  
Oral Anticoagulants ◽  
P Value ◽  
Stroke Management ◽  
Medicines Management ◽  
First Line ◽  
Stroke Registry ◽  
Multiple Factors ◽  
Direct Acting ◽  
Anticoagulated Patients

Abstract Background Patients prescribed oral anticoagulants (OAC) for atrial fibrillation (AF) can still present with stroke. The mechanism for stroke in these patients can be due to multiple factors including subtherapeutic dosing and non-compliance. With the increasing use of direct-acting OACs (DOACs) in favour of warfarin, it is unclear if the incidence of stroke in those already taking OAC has reduced. Methods Data was extracted from our unit’s stroke registry, a prospectively maintained database, for patients who presented with stroke while receiving OAC for AF from 2013 to 2017. Type of OAC, type of stroke, OAC dosing at time of event including non-compliance, stroke management and outcome were recorded. Results 67 patients were included for analysis, with 55 ischaemic and 12 haemorrhagic strokes. 52 patients were receiving warfarin at the time of their stroke vs. 15 receiving DOACs. 33/55 (60%) of ischaemic strokes occurred in patients taking warfarin with a sub-therapeutic INR. In 3/55 (5%) of ischaemic strokes, the OAC was held for a procedure while in 6/55 cases (11%) the OAC had been stopped for another reasons e.g. bleeding. 5/55 (7%) were due to non-compliance. 1 ischaemic stroke was due to under-dosing of a DOAC (dabigatran). 16 strokes were recorded in 2013 for patients prescribed OAC vs. 3 in 2017. Overall the number of ischaemic strokes due to subtherapeutic OAC decreased from 14 in 2013 to 1 in 2017 (p value 0.06). Conclusion The majority of strokes occurring in anticoagulated patients are related to warfarin use. We observed an almost significant reduction in the proportion of ischaemic strokes due to under-dosing of OAC over the study period. Warfarin continues to be recommended as the first line anticoagulant for stroke prevention in atrial fibrillation by the HSE Medicines Management Programme, a decision which we would argue warrants review.

scholarly journals A randomised controlled clinical trial comparing the effectiveness of bandaging compared to the JuxtaCures™ device in the management of people with venous ulceration: Feasibility study

2021 ◽  
pp. 026835552098822
Author(s):  
Philip Stather ◽  
Carroll Petty ◽  
Helen Langthorne ◽  
Emma Rayner ◽  
Jufen Zhang ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Feasibility Study ◽  
Multicentre Trial ◽  
Compression Therapy ◽  
Controlled Clinical Trial ◽  
Venous Ulceration ◽  
Significant Difference ◽  
Potential Benefits ◽  
Randomised Controlled

Introduction The mainstay of treatment for venous ulceration remains compression therapy. Velcro Wrap devices are being increasingly used in these patients despite limited evidence. This feasibility study aimed to compare standard bandaging to the JuxtaCures™ Velcro wrap device. Methods A single centre, unblinded RCT compared participants with venous ulceration randomised to either the JuxtaCures™ device or short stretch bandaging. Participants were followed up for 26 weeks. Results 160 participants were screened with 40 randomised. 3 participants in bandaging and 1 in JuxtaCures™ didn’t complete the study. 60% in JuxtaCures™ healed v 55% in bandaging despite larger ulcers in the JuxtaCures™ arm (9.33 cm2 v 6.97 cm2). There was no significant difference in time to healing (12.17 v 13.64 weeks). JuxtaCures™ showed improved ulcer reduction for those that didn’t heal (14.91–5.00 cm2 v 14.20–8.62 cm2; P = 0.06). JuxtaCures™ had more consistent sub-bandage pressure dropping from 39–36 mmHg versus 41–25 mmHg in bandaging between application and removal (P < 0.001). Quality of life (EQ5D) was improved in JuxtaCures at 3 months (mean difference 0.14, p = 0.04), but not at 1 and 6 months, or in disease specific quality of life. Cost was lower in JuxtaCures™ £842.47 v £1064.68. Duration of appointment was significantly shorter in JuxtaCures™ (41 minutes v 53 minutes; P = 0.003). Conclusion This study has shown the feasibility and necessity of running a multicentre trial to evaluate the use of Velcro wrap devices for venous ulceration. It highlights the potential benefits of more consistent pressure, increased self-care, and potential with regards to ulcer healing, cost, nursing resource and quality of life.

scholarly journals Stroke Prevention: Little-Known and Neglected Aspects

2021 ◽  
pp. 1-14
Author(s):  
M. Reza Azarpazhooh ◽  
Chrysi Bogiatzi ◽  
J. David Spence
Keyword(s):  
Stroke Prevention ◽  
Oral Anticoagulants ◽  
Blood Pressure Reduction ◽  
The Elderly ◽  
Lipid Lowering ◽  
Lipid Lowering Therapy ◽  
Enteric Coating ◽  
Asymptomatic Carotid ◽  
Lowering Therapy ◽  
Direct Acting

Combining available therapies has the potential to reduce the risk of stroke by 80% or more. A comprehensive review of all aspects of stroke prevention would be very lengthy; in this narrative review, we focus on some aspects of stroke prevention that are little-known and/or neglected. These include the following: (1) implementation of a Mediterranean diet; (2) B vitamins to lower homocysteine; (3) coordinated approaches to smoking cessation; (4) intensive lipid-lowering therapy; (5) lipid lowering in the elderly; (6) physiologically individualized therapy for hypertension based on renin/aldosterone phenotyping; (7) avoiding excessive blood pressure reduction in patients with stiff arteries; (8) treatment of insulin resistance with pioglitazone in stroke patients with prediabetes and diabetes; (9) impaired activation of clopidogrel in patients with variants of CYP2C19; (10) aspirin pseudoresistance due to enteric coating; (11) rationale for anticoagulation in patients with embolic stroke of unknown source; (12) pharmacologic properties of direct-acting oral anticoagulants that should be considered when choosing among them; (13) the identification of which patients with asymptomatic carotid stenosis are at a high enough risk to benefit from carotid endarterectomy or stenting; and (14) the importance of age in choosing between endarterectomy and stenting. Stroke prevention could be improved by better recognition of these issues and by implementation of the principles derived from them.

Direct-Acting Oral Anticoagulants in Critically Ill Patients

CHEST Journal ◽  
2019 ◽  
Vol 156 (3) ◽  
pp. 604-618 ◽  
Author(s):  
Parth Rali ◽  
Andrew Gangemi ◽  
Aimee Moores ◽  
Kerry Mohrien ◽  
Lisa Moores
Keyword(s):  
Critically Ill ◽  
Critically Ill Patients ◽  
Oral Anticoagulants ◽  
Direct Acting ◽  
Direct Acting Oral Anticoagulants

A Review of Direct Oral Anticoagulants in Patients With Stage 5 or End-Stage Kidney Disease

2021 ◽  
pp. 106002802110400
Author(s):  
Jessica A. Starr ◽  
Nathan A. Pinner ◽  
Melanie Mannis ◽  
Mary Katherine Stuart
Keyword(s):  
Kidney Disease ◽  
Data Extraction ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Cochrane Library ◽  
End Stage Kidney Disease ◽  
Vein Thrombosis ◽  
Study Selection ◽  
Direct Acting ◽  
End Stage

Objective: To evaluate the role of oral anticoagulation in patients with stage 5 chronic kidney disease (CKD-5) or end-stage kidney disease (ESKD). Data Sources: A literature search of PubMed (January 2000 to July 1, 2021), the Cochrane Library, and Google Scholar databases (through April 1, 2021) was performed with keywords DOAC (direct-acting oral anticoagulant) OR NOAC or dabigatran OR rivaroxaban OR apixaban OR edoxaban AND end-stage kidney disease combined with atrial fibrillation (AF) or venous thromboembolism (VTE) OR pulmonary embolism OR deep-vein thrombosis. Study Selection and Data Extraction: Case-control, cohort, and randomized controlled trials comparing DOACs to an active control for AF or VTE in patients with CKD-5 or ESKD and reporting outcomes of stroke, recurrent thromboembolism, or major bleeding were included. Data Synthesis: Nine studies were included. Efficacy data supporting routine use of warfarin or DOACs in CKD-5 or ESKD are limited. Rivaroxaban and apixaban may provide enhanced safety compared to warfarin in patients with AF. Data for VTE are limited to 1 retrospective study. Relevance to Patient Care and Clinical Practice: Because of the paucity of rigorous, prospective studies in CKD-5 or ESKD, OACs should not be broadly used in this population. It is clear that data regarding efficacy of DOACs cannot be reliably and safely extrapolated from the non-ESKD population. Therefore, use of OACs in this population should be individualized. Conclusions: If OACs for stroke prevention with AF are deemed necessary, apixaban or rivaroxaban can be considered. DOACs cannot currently be recommended over warfarin in patients with CKD-5 or ESKD and VTE.

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