scholarly journals Severe gastrointestinal bleeding in patients with atrial fibrillation receiving oral anticoagulants (based on REGistry of long-term AnTithrombotic TherApy – REGATTA)

2021 ◽  
Vol 93 (9) ◽  
pp. 1037-1043
Author(s):  
Ekaterina S. Kropacheva ◽  
Mariia B. Khakimova ◽  
Elena N. Krivosheeva ◽  
Oksana A. Zemlyanskaya ◽  
Elizaveta P. Panchenko
Keyword(s):  
Atrial Fibrillation ◽  
Gastrointestinal Bleeding ◽  
Antithrombotic Therapy ◽  
Oral Anticoagulants ◽  
Clinical Predictors ◽  
Gastrointestinal Ulcer ◽  
Hemorrhagic Complications ◽  
Life Threatening ◽  
History Of

Background. The rate of major bleeding in patients with atrial fibrillation receiving oral anticoagulants is 25% per year. Gastrointestinal bleedings are at least a half of major hemorrhagic complications. Currently, there is no optimal scale to calculate the risk of bleeding, and therefore the search for clinical predictors of gastrointestinal bleeding remains relevant. Aim. To assess the frequency and structure of large gastrointestinal bleeding, as well as to identify clinical predictors of their development based on long-term prospective observation of patients with atrial fibrillation receiving oral anticoagulants. Materials and methods. Data were obtained from single center prospective REGistry of long-term AnTithrombotic TherApy (REGATTA NCT043447187). Investigation based on a 20-year follow-up with 510 patients with atrial fibrillation with a high thromboembolic risk (median CHA2DS2-VASc was 4 points). The REGATTA registry assessed the frequency and structure of major gastrointestinal bleeding. Predictors of the development of 32 large gastrointestinal bleeding were identified based on the analysis of pairs with univariate and multivariate analyses. Results. The frequency of major gastrointestinal bleeding in patients with atrial fibrillation receiving oral anticoagulants at 1 year was 1.42 per 100 patients; the predominant localization was upper gastrointestinal tract. Predictors of the development of major gastrointestinal bleeding according to multiple regression data analysis were hemoglobin level 14.55 g/dL, body mass index 28.4 kg/m2, gastrointestinal ulcer or erosive lesion and major hemorrhagic complications in history of disease. In 1/2 cases the sourse of bleeding remained unclear. Conclusion. Searching for clinical predictors of gastrointestinal bleeding can identify patients receiving oral anticoagulants who is need of intensive monitoring risk factors to prevent the development of life-threatening bleeding and to provide with adequate anticoagulant therapy.

scholarly journals COVID-19 Pneumonia in Patients with Chronic Myocarditis (HBV-Associated with InfarctLike Debute): Specifics of the Diseases Course, the Role of the Basic Therapy (Part II)

2020 ◽  
Vol 16 (5) ◽  
pp. 730-736
Author(s):  
O. V. Blagova ◽  
N. V. Varionchik ◽  
M. M. Beraia ◽  
V. A. Zaidenov ◽  
E. A. Kogan ◽  
...  
Keyword(s):  
Immunosuppressive Therapy ◽  
Troponin T ◽  
Oral Anticoagulants ◽  
Adverse Outcomes ◽  
Interleukin 17 ◽  
Chronic Myocarditis ◽  
Life Threatening ◽  
History Of ◽  
Therapy Withdrawal

Chronic infectious-immune myocarditis of severe course can potentially be considered as a factor that aggravates the course of new coronavirus disease (COVID-19) and increases the risk of adverse outcomes. The interaction of chronic myocarditis and COVID-19 during long-term immunosuppressive therapy has not been studied. We present a description of a 35-year-old female patient with chronic infectious-immune myocarditis (morphologically confirmed, with a history of infarction-like onset and thromboembolic complications), who had continuous immunosuppressive therapy with methylprednisolone and mycophenolate mofetil. The patient also received new oral anticoagulants and tenofovir (for chronic HBV infection). COVID-19 (SARS-Cov-2 RNA+) was diagnosed in May 2020. Risk factors for the adverse course of coronavirus infection included severe obesity, heart failure, and life-threatening ventricular arrhythmias. Correction of immunosuppressive therapy (withdrawal of the cytostatic agent, administration of hydroxychloroquine) and therapy with levofloxacin, an interleukin-17 inhibitor (netakimab) were performed. The severity of pneumonia and respiratory failure was moderate despite high fever and high levels of inflammatory markers in the blood (including interleukin-6). Signs of exacerbation of myocarditis, increased levels of troponin T and anticardial antibodies (compared with the initial ones) were not found. It can be assumed that supportive immunosuppressive therapy for myocarditis has a positive effect on the course of coronavirus pneumonia and avoids exacerbation of myocarditis. Careful continuation of immunosuppressive therapy with temporary withdrawal of aggressive cytostatics can be recommended in chronic myocarditis. Further study of the features of the course of previous myocarditis and COVID-19 pneumonia is necessary.

P471Experience with the use of non-vitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation and a high risk of hemorrhagic complications

EP Europace ◽  
2020 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
E Emelina ◽  
G Gendlin ◽  
I Nikitin
Keyword(s):  
Atrial Fibrillation ◽  
Anterior Chamber ◽  
Oral Anticoagulants ◽  
Lymphocytic Leukemia ◽  
Hemorrhagic Complication ◽  
Minimum Dose ◽  
Gingival Bleeding ◽  
Life Threatening ◽  
History Of ◽  
Persistent Thrombocytopenia

Abstract Background. The use of NOACs in patients with chronic lymphocytic leukemia (CLL) is a difficult task due to the tendency to hemorrhage in these patients associated with CLL. The use of targeted ibrutinib (Ib) therapy in the treatment of CLL patients increases the risk of bleeding due to thrombocytopathy. A feature of targeted Ib therapy is the need for daily and lifelong use. One of the cardiotoxic effects of Ib is the development of atrial fibrillation (AF). Some patients receiving Ib have a history of AF. Warfarin is contraindicated in patients taking Ib, so all patients received NOACs. Purpose. To evaluate the possibility of using NOACs in CLL patients receiving Ib, taking into account the frequency and severity of hemorrhagic manifestations, the need to cancel, reduce the dose and replace with another NOACs. Methods. We examined and observed the dynamics of 224 patients with CLL receiving Ib from 5 to 56 months at a dose of 420 mg per day as 1, 2, 3, and 4 lines of CLL therapy. Patients with CLL aged 32 to 91 years (66.0 (59.0-72.0) years) were Included, of whom 82 are women aged 39 to 83 years (64.0 (54.0-71.0 ) years) and 142 men aged 32 to 91 years (66.0 (60.0-72.0) years). All hemorrhagic manifestations in patients receiving Ib and NOACs were evaluated, taking into account the glomerular filtration rate and platelet count. Results. AF were revealed in 51 patients with CLL receiving Ib. AF was registered in 32 patients during the treatment with Ib, in 19 patients AF was before prescribing of Ib. The need for NOACs because of AF arose in 38 patients with CLL who were prescribed rivaroxaban (n = 11), dabigatran (n = 6), apixaban (n = 21). Hemorrhages were observed in 88.2% of patients receiving NOACs and Ib, represented by hematomas (n = 32), petechiae (n = 4), nosebleeds (n = 6), gingival bleeding (n = 7), hemorrhage in the anterior chamber of the eye (n = 1), hemorrhage in the sclera of the eye (n = 3) and macrohematuria (n = 4). A combination of several hemorrhagic manifestations (combined hemorrhages) was observed in 40.7% of CLL patients receiving NOACs. 10 patients were transferred to the minimum dose of apixaban 2.5 mg twice a day due to the development of recurring nosebleeds (n = 5), macrohematuria (n = 3), large, recurring hematomas with localization on the neck and face (n = 1 ), hemorrhages in the anterior chamber of the eye (n = 1). Cancellation of NOACs in 1 patient was associated with recurrent macrohematuria. Rivaroxaban 20 mg per day was canceled in 6 patients due to the development of persistent thrombocytopenia of less than 50 × 109/L. Conclusions. There were no life-threatening hemorrhages. The main reason for the withdrawal of NOACs was persistent thrombocytopenia. Due to hemorrhagic complication, NOACs was canceled only in 1 patient, 10 patients (26.3%) required a transfer to the minimum dose of apixaban. The arising hemorrhages did not require hospitalization of patients.

scholarly journals Atherothrombotic stroke in non-valvular atrial fibrillation

2019 ◽  
Vol 11 (3S) ◽  
pp. 78-81 ◽  
Author(s):  
I. S. Yavelov ◽  
E. Yu. Okshina
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K ◽  
Antithrombotic Therapy ◽  
Detection Rate ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Low Risk ◽  
Antiplatelet Drugs ◽  
Hemorrhagic Complications ◽  
Poor Outcomes

The review analyzes data on the detection rate of and the abilities to predict and prevent non-cardioembolic strokes in non-valvular atrial fibrillation. According to accumulated facts, vitamin K antagonists in non-valvular atrial fibrillation are noted to be inferior to antiplatelet drugs in efficiency in preventing non-cardioembolic (atherothrombotic in particular) strokes, and the widespread use of oral anticoagulants in combination with antiplatelet drugs does not generally reduce the incidence of poor outcomes, markedly increasing the risk of serious bleeding. Nevertheless, it is conceivable that this combination antithrombotic therapy may be useful for certain categories of patients at the highest risk for atherothrombotic stroke and at relatively low risk for hemorrhagic complications. Cohorts of patients, to whom such an approach should be reasonable considered to be applied, have not yet been identified.

scholarly journals Antithrombotic Therapy in Patients with Atrial Fibrillation after Myocardial Infarction: Clinical Guidelines and Actual Practice

2019 ◽  
Vol 14 (6) ◽  
pp. 858-863 ◽  
Author(s):  
K. G. Pereverzeva ◽  
S. S. Yakushin ◽  
A. E. Pripadcheva ◽  
N. P. Agaltsova
Keyword(s):  
Myocardial Infarction ◽  
Atrial Fibrillation ◽  
Antithrombotic Therapy ◽  
Oral Anticoagulants ◽  
Antiplatelet Agent ◽  
Final Diagnosis ◽  
Hospital Treatment ◽  
Median Score ◽  
University Hospitals ◽  
Hemorrhagic Complications

Aim. To study the frequency of oral anticoagulants (ОАС) prescription for patients with atrial fibrillation (AF) after myocardial infarction (MI). Material and methods. The study includes 106 patients (60 men, 55.6%) with a previously established diagnosis of AF, who were on hospital treatment in the period 2016-2017 years in one of the university hospitals of the city and having at the time of discharge from the hospital the final diagnosis of МI. The median age was 70.0 (61.0;78.0) years. Patients with the first and only paroxysm of AF were excluded from the analysis and all further calculations were performed for 104 patients. In 64 (60.2%) of cases, AF was presented by paroxysmal form, while in 2 (1.9%) cases this paroxysm was the first and only, in 20 (18.9%) cases – persistent AF and in 20 (18.9%) – pernanent. Results. While assessing the risk of thromboembolic complications on the CHA2DS2-VASc scale, the median score for all patients was 5.0 (4.0;6.0) points. While assessing the risk of hemorrhagic complications on the HAS-BLED scale, the median score for all patients was 2.0 (2.0;3.0) points. HAS-BLED≤2 value had 71 (68.3%) patients, HAS-BLED≥3 – 33 (31.7%). Only one antiplatelet agent was prescribed to 4 (3.8%) patients. Aspirin was the only antiplatelet agent in 3 cases and clopidogrel – in one case. In 80 (76.9%) cases, patients were prescribed dual antiplatelet therapy, in 17 (16.3%) – ОАС therapy, among which 7 (6.7%) cases – a triple antithrombotic therapy (ATT), 9 (8.7%) cases – a double ATT (ОАС+ antiplatelet agent) and 1 (1.0%) case – a monotherapy. Among all cases of OAC prescription warfarin was prescribed in 11 (64.7%) cases and rivaroxaban – in 6 (35.3%). Conclusion. In real clinical practice, the prescription or refusal of ОАС occurs without taking into account the risk of thromboembolic and hemorrhagic complications according to appropriate scales.

scholarly journals Antithrombotic therapy in patients with coronary heart disease and atrial fibrillation after direct myocardial revascularization

2020 ◽  
Vol 35 (4) ◽  
pp. 49-56
Author(s):  
M. A. Kirgizova ◽  
O. R. Eshmatov ◽  
Yu. I. Bogdanov ◽  
R. E. Batalov ◽  
S. V. Popov
Keyword(s):  
Atrial Fibrillation ◽  
Coronary Heart Disease ◽  
Heart Disease ◽  
Antithrombotic Therapy ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Pulmonary Veins ◽  
Myocardial Revascularization ◽  
Small Sample ◽  
Hemorrhagic Complications

Aim. To evaluate the clinical efficacy and safety of direct oral anticoagulants versus warfarin as part of antithrombotic therapy (ATT), namely, to study the frequency of bleeding and thromboembolic complications in patients with atrial fibrillation (AF) after direct myocardial revascularization in combination with radiofrequency isolation of pulmonary veins.Material and Methods. A total of 44 patients (36 men) aged 44–77 years (average age of 63.5 ± 7.8 years) with coronary heart disease, indications for direct myocardial revascularization, and AF were included in the study from 2014 to 2016. The observation period was 24 months.Results. Warfarin was one of the components of ATT in 20 patients (48%). However, the target values of international normalized ratio (INR) within the therapeutic range for over 70% of the time were achieved only in seven patients. Two patients who were taking warfarin without achieving target INR values for 24 months suffered from ischemic stroke. One patient taking warfarin (without regular INR control) had gastrointestinal bleeding requiring hospitalization and conservative therapy; ten patients had minor bleedings (nasal and gingival bleeding). All patients, who suffered from thromboembolic and hemorrhagic complications and had inadequate warfarin intake, were recommended to switch to direct oral anticoagulants (DOAC). Thirteen patients (29%) were administered with DOAC: five patients took rivaroxaban 20 mg/day, four patients took dabigatran 300 mg/day, and four patients took apixaban 10 mg/day. DOAC therapy was administered in combination with one of the antiplatelet drugs (aspirin or clopidogrel). In the case of DOAC administration, only minor bleedings were observed: one patient had hemorrhoidal bleeding and four patients had nasal bleedings, which did not require hospitalization, medical intervention, or suspension of anticoagulant therapy. There were no other adverse events in patients taking DOAC.Conclusions. Patients administered with DOAC as a part of antithrombotic therapy after coronary bypass surgery and surgical epicardial radiofrequency isolation of the pulmonary veins had lower incidence rates of thromboembolic and hemorrhagic complications compared with the rates in patients taking warfarin. However, no statistically significant differences were found between the groups due to the small sample size.

A Review on the Use of Reversal Agents of Direct Oral Anticogulant Drugs in Case of Gastrointestinal Bleeding

2020 ◽  
Vol 15 ◽  
Author(s):  
Veronica Ojetti ◽  
Angela Saviano ◽  
Mattia Brigida ◽  
Luisa Saviano ◽  
Alessio Migneco ◽  
...  
Keyword(s):  
Gastrointestinal Bleeding ◽  
Major Bleeding ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Medical Emergency ◽  
Management Approach ◽  
Emergency Setting ◽  
Reversal Agents ◽  
Life Threatening ◽  
Andexanet Alfa

Background : Major bleeding is a life-threatening condition and a medical emergency with high mortality risk. It is often the complication of anticoagulant’s intake. Anticoagulants are commonly used for the prevention and the treatment of thrombotic events. The standard therapy with vitamin K antagonist (warfarin) has been frequently replaced by direct oral anticoagulants (DOACs). The latter agents (rivaroxaban, apixaban, edoxaban, dabigatran, betrixaban) showed a better efficacy and safety compared to standard warfarin treatment and they are recommended for the reduction of ischemic stroke. Literature data reported a high risk of gastrointestinal bleeding with DOACs, in particular with dabigatran and rivaroxaban. In case of life-threatening gastrointestinal bleeding, these patients could benefit from the use of reversal agents. Methods: We performed an electronic search on PUBMED of the literature concerning reversal agents for DOACs and gastrointestinal bleeding in the Emergency Department from 2004 to 2020. AIM: This review summarizes the current evidences about three reversal agents idarucizumab, andexanet alfa and ciraparantag, and the use of the first two in the emergency setting in patients with an active major bleeding or who need urgent surgery to offer physicians indications for a better management approach in order to increase patient’s safety. Conclusion: Although these agents have been marketed for five years (idarucizumab) and two years (andexanet alfa) respectively, and despite guidelines considering antidotes as first-line agents in treating life-threatening hemorrhage when available, these antidotes seem to gain access very slowly in the clinical practice. Cost, logistical aspects and need for plasma level determination of DOAC for an accurate therapeutic use probably have an impact on this phenomenon.. An expert multidisciplinary bleeding team should be established so as to implement international guidelines based on local resources and organization.

scholarly journals Impact of atrial fibrillation pattern on outcomes after left atrial appendage closure: lessons from the prospective LAARGE registry

2021 ◽  
Author(s):  
Shinwan Kany ◽  
Johannes Brachmann ◽  
Thorsten Lewalter ◽  
Ibrahim Akin ◽  
Horst Sievert ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Left Atrial Appendage ◽  
Systemic Embolism ◽  
Long Term Outcomes ◽  
Increased Risk ◽  
History Of ◽  
One Year ◽  
The One

Abstract Background Non-paroxysmal (NPAF) forms of atrial fibrillation (AF) have been reported to be associated with an increased risk for systemic embolism or death. Methods Comparison of procedural details and long-term outcomes in patients (pts) with paroxysmal AF (PAF) against controls with NPAF in the prospective, multicentre observational registry of patients undergoing LAAC (LAARGE). Results A total of 638 pts (PAF 274 pts, NPAF 364 pts) were enrolled. In both groups, a history of PVI was rare (4.0% vs 1.6%, p = 0.066). The total CHA2DS2-VASc score was lower in the PAF group (4.4 ± 1.5 vs 4.6 ± 1.5, p = 0.033), while HAS-BLED score (3.8 ± 1.1 vs 3.9 ± 1.1, p = 0.40) was comparable. The rate of successful implantation was equally high (97.4% vs 97.8%, p = 0.77). In the three-month echo follow-up, LA thrombi (2.1% vs 7.3%, p = 0.12) and peridevice leak > 5 mm (0.0% vs 7.1%, p = 0.53) were numerically higher in the NPAF group. Overall, in-hospital complications occurred in 15.0% of the PAF cohort and 10.7% of the NPAF cohort (p = 0.12). In the one-year follow-up, unadjusted mortality (8.4% vs 14.0%, p = 0.039) and combined outcome of death, stroke and systemic embolism (8.8% vs 15.1%, p = 0.022) were significantly higher in the NPAF cohort. After adjusting for CHA2DS2-VASc and previous bleeding, NPAF was associated with increased death/stroke/systemic embolism (HR 1.67, 95% CI 1.02–2.72, p = 0.041). Conclusion Atrial fibrillation type did not impair periprocedural safety or in-hospital MACE patients undergoing LAAC. However, after one year, NPAF was associated with higher mortality. Graphic abstract

scholarly journals The Risk of Gastrointestinal Bleeding between Non-Vitamin K Antagonist Oral Anticoagulants and Vitamin K Antagonists in the Asian Atrial Fibrillation Patients: A Meta-Analysis

2020 ◽  
Vol 18 (1) ◽  
pp. 137
Author(s):  
Kuang-Tsu Yang ◽  
Wei-Chih Sun ◽  
Tzung-Jiun Tsai ◽  
Feng-Woei Tsay ◽  
Wen-Chi Chen ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Gastrointestinal Bleeding ◽  
Vitamin K ◽  
Meta Analysis ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Vitamin K Antagonist ◽  
Cochrane Library ◽  
Secondary Outcome ◽  
Optimal Dosage

Background: Non-vitamin K antagonist oral anticoagulants (NOACs) are more commonly used to prevent atrial fibrillation (AF) patients from thromboembolic events than vitamin K antagonists (VKAs). However, the gastrointestinal bleeding (GIB) risk in the Asian AF patients associated with NOACs in comparison with VKAs remained unaddressed. Materials and Methods: A systematic search of studies on NOACs and VKAs in the Asian AF patients was conducted in PubMed, Cochrane Library, and ClinicalTrials.gov. The primary outcome was the hazard ratio (HR) of any GIB associated with NOACs versus VKAs. The secondary outcome was the GIB risks in different kinds of NOACs compared with VKAs. Results: This meta-analysis included two randomized controlled trials (RCTs) and four retrospective studies, comprising at least 200,000 patients in total. A significantly lower HR of GIB risks was found in all kinds of NOACs than VKAs in the Asian AF patients (HR: 0.633; 95% confidence interval: 0.535–0.748; p < 0.001). Additionally, the GIB risks of different NOACs were apixaban (HR: 0.392), edoxaban (HR: 0.603), dabigatran (HR: 0.685), and rivaroxaban (HR: 0.794), respectively. Conclusions: NOACs significantly reduced the risk of GIB in the Asian AF patients compared with VKAs. In the four NOACs compared with VKAs, apixaban probably had a trend of the least GIB risk. We need further head-to-head studies of different NOACs to confirm which NOAC is the most suitable for Asian AF patients and to know the optimal dosage regimen of different NOACs.

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