Vitamin K Antagonists
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2021 ◽  
Vol 8 ◽  
Eve Cariou ◽  
Kevin Sanchis ◽  
Khailène Rguez ◽  
Virginie Blanchard ◽  
Stephanie Cazalbou ◽  

Background: Atrial arrhythmia (AA) is common among patients with cardiac amyloidosis (CA), who have an increased risk of intracardiac thrombus. The aim of this study was to explore the prognostic impact of vitamin K-antagonists (VKA) and direct oral anticoagulants (DOAC) in patients with CA.Methods and Results: 273 patients with CA and history of AA with long term anticoagulation−69 (25%) light chain amyloidosis (AL), 179 (66%) wild-type transthyretin amyloidosis (ATTRwt) and 25 (9%) variant transthyretin amyloidosis (ATTRv)–were retrospectively included between January 2012 and July 2020. 147 (54%) and 126 (46%) patients received VKA and DOAC, respectively. Patient receiving VKA were more likely to have AL with renal dysfunction, higher NT-proBNP and troponin levels. Patients with ATTRwt were more likely to receive DOAC therapy. There were more bleeding complications among patients with VKA (20 versus 10%; P = 0.013) but no difference for stroke events (4 vs. 2%; P = 0.223), as compared to patients with DOAC. A total of 124 (45%) patients met the primary endpoint of all-cause mortality: 96 (65%) and 28 (22%) among patients with VKAs and DOACs, respectively (P < 0.001). After multivariate analysis including age and renal function, VKA was no longer associated with all-cause mortality.Conclusion: Among patients with CA and history of AA receiving oral anticoagulant, DOACs appear to be at least as effective and safe as VKAs.

2021 ◽  
Vol 9 (11) ◽  
pp. 602-607
Benyamna I. ◽  
Bouzid F. ◽  
El Mousadik A. ◽  
Alif N. ◽  

Because of their cost and the large amount of experience, vitamin k antagonists are widely prescribed in the world for the prevention and treatment of thrombosis. However, cases of resistance to VKA exist, although they are difficult to authenticate. Direct oral anticoagulants DOA represent a good alternative. We report a case of true hemodynamic and genetic resistance to VKA in which rivaroxaban was the solution.

2021 ◽  
Vol 10 (23) ◽  
pp. 5526
Mattia Manfredini ◽  
Pier Paolo Poli ◽  
Luca Creminelli ◽  
Alberto Porro ◽  
Carlo Maiorana ◽  

Objectives: A wide variety of approaches have been proposed to manage anticoagulant drugs in patients undergoing dental surgery; vitamin K antagonists and novel direct oral anticoagulants have been used. The present study aims to explore the existing evidence concerning the management of patients in anticoagulant therapy undergoing oral surgery procedures and to give suggestions related to peri- and post-operative measures. Materials and methods: A comprehensive search of databases was conducted to identify studies that evaluated the relationship between direct oral anticoagulants and dental procedures. The present scoping review was realized in adherence with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. The publications varied from randomized controlled trials (RCT) to cohort trials. Only articles written in English language and published between 2000 to 2020 were screened. The studies were included if discussing the management of a patient in anticoagulant therapy (warfarin or direct oral anticoagulants) scheduled for tooth extraction. Results: 33 studies were selected and included in the qualitative review. Nineteen considered anticoagulant therapy with warfarin, six considered anticoagulant therapy with new oral anticoagulants and eight compared patients taking warfarin with patients taking direct oral anticoagulants. Conclusions: No case of extractive surgery should alter the posology of the drug: thromboembolic risks derived from discontinuation are heavier than hemorrhagic risks. Clinical relevance: direct oral anticoagulants are safer in terms of bleeding and manageability and bleeding episodes are manageable with local hemostatic measures.

Reem Bahmaid ◽  
Filwah Almarzouq ◽  

Background: The SAMe-TT2 R2 Score was developed to identify vitamin K antagonists control outliers before non-valvular atrial fibrillation (AF) patients start treatment. SAMe-TT2 R2 Score was derived and validated using a primarily white Caucasian population to predict TTR. Given that non-Caucasian race already confers 2 points in this score, the SAMe-TT2 R2 score requires validation and/or re-calibration despite race of population. Method: We conducted a cohort retrospective study that included all non-valvular atrial fibrillation patients who were on warfarin therapy from January to December 2019. Then we calculated the modified SAMe-TT2 R2 and SAMe-TT2 R2 for all study populations and we correlated the result with patients' TTR. The TTR was calculated through the Rosendaal's method. Results: We had 662 patient using warfarin therapy, among those 662, 60.9% were under cardiology and using it for cardiac indication, and only 18.1% diagnosed to have non-valvular AF. Modified SAMe-TT2 R2 score has good relation to original SAMe-TT2 R2 score as showed 75.71% (95% CI. 63.99 to 85.17%), 100% (95% CI. 92.89 to 100%) and 15% (95% CI. 3.21 to 77.95%); accuracy, sensitivity and specificity in relation to SAMe-TT2 R2 respectively. In addition to that in this small cohort we found that there is universal relationship between SAMe-TT2 R2 score, Modified SAMe-TT2 R2 score and TTR; TTR >=65% associate with low score (<2) of both SAMe-TT2 R2 , Modified SAMe-TT2 R2 score. Conclusion: The use of Modified SAMe-TT2 R2 score allows clinicians to make an informed decision on whether to start vitamin K antagonist or other non-vitamin K antagonist oral anticoagulant despite the race of the patients.

2021 ◽  
Petar Stanković ◽  
Stephan Hoch ◽  
Stefan Rudhart ◽  
Danilo Obradović ◽  
Nikolaos Dagres ◽  

2021 ◽  
Vol 2021 ◽  
pp. 1-3
Ayrton Bangolo ◽  
Trupti Waykole ◽  
Bilal Niazi ◽  
Chandini Sajja ◽  
Mahabuba Akhter ◽  

Factor X deficiency is a rare coagulopathy that can be inherited or acquired. Acquired factor X deficiency has been associated with plasma cell dyscrasias, amyloids, and use of vitamin K antagonists. Of plasma cell dyscrasias, most cases in the literature have been associated with multiple myeloma with or without concomitant AL amyloidosis. Here, we present a rare case of acquired isolated factor X deficiency in an elderly patient with immunoglobulin A (Ig A) monoclonal gammopathy of undetermined significance (MGUS). Herein, we highlight a rare cause of acquired factor X deficiency, and we hope to contribute to the growing literature of plasma cell dyscrasias associated with factor X deficiency.

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 1066-1066
Chantal Visser ◽  
Joseph S. Biedermann ◽  
Melchior C. Nierman ◽  
Felix J. M. Van der Meer ◽  
Anouk J. W. Gulpen ◽  

Abstract Background: In January 2021, the Dutch vaccination programme against SARS-CoV-2 was started. Clinical studies have shown that systemic reactions occur in up to 50% of vaccine recipients. Therefore, COVID-19 vaccination could affect anticoagulation control, potentially leading to an increased risk of thrombotic events and bleeding complications. Aims: To investigate whether the BNT162b2 vaccine affects anticoagulation control in outpatients using Vitamin K antagonists (VKAs). Methods: A case-crossover study was performed in a cohort of outpatient VKA users from four Dutch anticoagulation clinics who received a BNT162b2 vaccine. INR results and VKA dosages before the first vaccination, the reference period, were compared with those after the first and second vaccination. Results: A total of 3148 outpatient VKA users were included, with a mean age (standard deviation (SD)) of 86.7 (8.7) years, of whom 43.8% were male, 67.0% used acenocoumarol and 33.0% phenprocoumon. We observed a decrease of 8.9% of INRs within range in the standard intensity group (target INR 2.0-3.0). There was both an increased risk of supratherapeutic [OR=1.34 (95% CI 1.08-1.67)] and subtherapeutic levels [OR=1.40 (95% CI 1.08-1.83)] after first vaccination. In the high-intensity group (target INR 2.5-3.5), the risk of a supratherapeutic INR was 2.3 times higher after first vaccination [OR=2.29 (95% CI 1.22-4.28)] and 3.3 times higher after second vaccination [OR 3.25 (95% CI 1.06-9.97). Conclusion: BNT162b2 was associated with an immediate negative effect on anticoagulation control in patients treated with vitamin K antagonists, so it is advisable to monitor the INR short after vaccination, even in stable patients. Figure 1 Figure 1. Disclosures Kruip: Daiichi Sankyo: Research Funding; Bayer: Honoraria, Research Funding.

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 2135-2135
Maha AT Elsebaie ◽  
Zoe Alexandra Wickham ◽  
Stephanie Debragga ◽  
Juan Li ◽  
Manila Gaddh

Abstract Introduction Antiphospholipid syndrome (APS) is a major acquired thrombophilia in which vascular thrombosis (venous or arterial) and/or pregnancy losses occur. Despite the use of vitamin K antagonists (VKAs), the annual risk for recurrent thrombosis among APS patients ranges between 2-5% (Crowther et al. NEJM 2003). The evidence for direct oral anticoagulants (DOAC) use in APS patients is still lacking. Therefore, we conducted a retrospective cohort study to explore the efficacy and safety of DOACs vs. VKAs in this patient population. Methods The electronic medical records at Emory University Hospitals were queried for patients ≥18 years old with APS diagnosis, according to the Sydney international census criteria (Miyakis et al. JTH 2006). Included patients must have experienced acute thrombosis between 01/01/2012 and 12/31/2018 and started anticoagulation therapy with DOACs or VKAs. We reviewed patient charts from the index thrombosis date till the end of the study period (12/31/2019). Clinical endpoints were: recurrent vascular thrombosis, clinically relevant bleeding (CRB), which included major and non-major bleeding events as defined by the ISTH society, and composite outcome of thrombosis and bleeding (Kaatz et al. JTH 2015). Patients presenting with pregnancy complications only during the identification period were excluded. Results A total of 153 patients with confirmed APS diagnosis were included in the study. Mean age was 51 (range, 18-79 y.o.). 94 patients (61.4%) were females and 80 patients (52.3%) were white. The most common sites of index thrombosis were pulmonary embolism (N=62, 40.5%), proximal lower extremity deep venous thrombosis (N=49, 32%), and stroke/TIA (N=29, 19%). The majority of patients had a single positive antiphospholipid antibody (aPL) (N=83, 54.2%). 35 (22.9%) had double positive and 24 (15.7%) had triple positive disease. Following index thrombosis, 75 patients started DOAC, whereas 72 started warfarin. Six patients started subcutaneous heparin for a short duration before starting an oral form of anticoagulation. Of those on DOAC, 50 started rivaroxaban while 22 started apixaban. After a mean of 19.8 months (range, 0.68 - 69.8) from the index thrombosis, 62 patients (40.5%) switched to a different class of anticoagulation. The most common reasons for switching therapy were recurrent thrombosis (N=16, 25.8%), followed by patient preference (N=13, 20.9%), side effects including bleeding (N=9, 14.5%), and other reasons, such as confirmed APS diagnosis or renal insufficiency (N=12, 19.3%). We found no statistically significant differences in risk of recurrent thrombosis or CRB events among patients who were started on DOAC vs. VKAs (Figure). The number of arterial thrombosis events was minimal and similar in both treatment groups: N=3 in DOAC group vs. N=5 in the VKA group. Patients treated with rivaroxaban had a similar risk of recurrent thrombosis (log rank, p-value=0.629) and CRB events (log rank, p-value=0.631) compared to those treated with apixaban. The risk of recurrent thrombosis was not affected by degree of aPL positivity or previous history of arterial thrombosis in multivariate models (HR 0.791, 95% CI 0.357 - 1.751) (Table). Discussion and Conclusion Our experience suggests that DOACs -particularly rivaroxaban / apixaban- could be an effective and safe alternative to warfarin in APS patients. We realize that patients with triple aPL positivity constitute a special population with a substantial risk of arterial and venous thrombosis. Given the retrospective nature of our data and that triple aPL positive patients compromised only 15% of our patient population, we conclude that the use of DOACs in these high risk patients remains uncertain. Prospective and large-scale multicenter studies are highly encouraged to explore DOAC use in APS patients with various background profiles. We build on our current experience by starting a multicenter collaboration that will facilitate meaningful subgroup comparisons in APS patients. Figure 1 Figure 1. Disclosures Gaddh: Agios: Consultancy, Other: Advisory board.

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