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Anticoagulant restart

Truman J Milling, Alex C Spyropoulos
Direct oral anticoagulants (DOACs) are a relatively recent addition to the oral anticoagulant armamentarium, and provide an alternative to the use of vitamin K antagonists such as warfarin. Regardless of the type of agent used, bleeding is the major complication of anticoagulant therapy. The decision to restart oral anticoagulation following a major hemorrhage in a previously anticoagulated patient is supported largely by retrospective studies rather than randomized clinical trials (mostly with vitamin K antagonists), and remains an issue of individualized clinical assessment: the patient's risk of thromboembolism must be balanced with the risk of recurrent major bleeding...
September 28, 2016: American Journal of Emergency Medicine
Truman J Milling, Alex C Spyropoulos
Direct oral anticoagulants (DOACs) are a relatively recent addition to the oral anticoagulant armamentarium, and provide an alternative to the use of vitamin K antagonists such as warfarin. Regardless of the type of agent used, bleeding is the major complication of anticoagulant therapy. The decision to restart oral anticoagulation following a major hemorrhage in a previously anticoagulated patient is supported largely by retrospective studies rather than randomized clinical trials (mostly with vitamin K antagonists), and remains an issue of individualized clinical assessment: the patient's risk of thromboembolism must be balanced with the risk of recurrent major bleeding...
November 2016: American Journal of Medicine
Thomas C Sauter, Sina Blum, Michael Nagler, Fabian L Schlittler, Meret E Ricklin, Aristomenis K Exadaktylos
Background. Immediate reversal of anticoagulation is essential when facing severe bleeding or emergency surgery. Although idarucizumab is approved for the reversal of dabigatran in many countries, clinical experiences are lacking, particularly in special patient-populations such as sepsis and impaired renal function. Case Presentation. We present the case of a 67-year-old male septic patient with a multilocular facial abscess and chronic kidney disease (GFR 36.5 mL/min). Thrombin time (TT) and activated partial thromboplastin time (aPTT) 15 hours after the last intake of 150 mg dabigatran were both prolonged (>120 sec, resp...
2016: Case Reports in Emergency Medicine
Maria Sorbera, Tina Joseph, Robert V DiGregorio
We describe a 70-year-old Haitian man who had been taking warfarin for 5 years for atrial fibrillation and pulmonary hypertension. This patient had his international normalized ratio (INR) checked in the pharmacist-run anticoagulation clinic and was followed monthly. Prior to the interaction, his INR was therapeutic for 5 months while taking warfarin 10.5 mg/d. The patient presented with an INR > 8.0. Patient held 4 days of warfarin and restarted on warfarin 8.5 mg/d. Two weeks later, his INR was 2.5. After continuing dose, patient presented 2 weeks later and INR was 4...
August 19, 2016: Journal of Pharmacy Practice
Alberto Alonso-Fernández, Angela García Suquia, Mónica de la Peña, Raquel Casitas, Javier Pierola, Antonia Barceló, Joan B Soriano, Carmen Fernández-Capitán, Elizabet Martinez-Ceron, Miguel Carrera, Francisco García-Río
BACKGROUND: Obstructive sleep apnea (OSA) is a risk factor for a first episode of pulmonary embolism (PE), although its impact on the risk of thromboembolism recurrence is uncertain. Our objective was to explore the prognostic value of OSA after discontinuing oral anticoagulation (OAC) in patients with a first episode of PE. METHODS: In 120 consecutive patients who had stopped OAC for a first episode of PE, we performed a home respiratory polygraphy and recorded sleep characteristics, classical risk factors for PE, blood pressure, spirometric parameters, physical activity and levels of D-dimer and prothrombin fragment 1+2...
July 21, 2016: Chest
Geoffrey D Barnes, Brian Kurtz
Since 2009, four direct oral anticoagulants (DOACs) have been introduced for treatment of venous thromboembolism and stroke prevention in non-valvular atrial fibrillation. While they are currently first-line therapy for a majority of patients, there are a number of clinical situations where warfarin is preferable. In both randomised trials and real-world populations, use of DOACs significantly reduces the risk of intracranial haemorrhage as compared with warfarin. While drug-specific reversal agents are currently only available for dabigatran, andexanet alpha is pending approval for reversal of factor Xa inhibitors, reducing concerns about major bleeding for many patients and providers...
October 15, 2016: Heart: Official Journal of the British Cardiac Society
Hironori Kitade, Azusa Hiromasa-Yamasaki, Kengo Hokkoku, Mitsue Mori, Michio Watanabe, Masuo Nakai, Seiji Yano
BACKGROUND: Regorafenib and its metabolites may inhibit the activities of several CYP or UDP-glucuronosyltransferase isoforms, including that of CYP2C9. Therefore, pharmacological agents that are CYP2C9 substrates may show elevated circulating levels and enhanced drug efficacy when concurrently used with regorafenib. Previous studies showed that the area under the plasma concentration-time curve of warfarin, which is the substrate for CYP2C9, increased upon co-administration of regorafenib...
2016: Journal of Pharmaceutical Health Care and Sciences
Fahad AlKherayf, Yan Xu, Esteban Gandara, Harrison Westwick, Ioana Doina Moldovan, Philip S Wells
BACKGROUND: While evidence supports resumption of vitamin K antagonists (VKAs) among mechanical heart valve (MHV) patients presenting with anticoagulant-associated intracranial hemorrhage (ICH), ideal timing of resumption is uncertain. OBJECTIVE: To determine the optimal timing of VKA re-initiation and its associated clinical outcomes. METHODS: We performed a systematic review and a meta-analysis of studies published from January 1950 to August 2015...
August 2016: Thrombosis Research
Jean-Claude Schwartz, Piotr P Skowronski
INTRODUCTION: The available options for post-mastectomy reconstruction in a patient requiring abbreviated operative times and immediate and sustained post-operative anticoagulation are limited. PRESENTATION OF CASE: A 50year old woman with a history of multiple deep venous thromboses (DVTs) and pulmonary embolisms (PEs) requested a bilateral prophylactic mastectomy and immediate reconstruction. She had a history of multiple breast biopsies demonstrating atypia and two sisters with premenopausal breast cancer...
2016: International Journal of Surgery Case Reports
Michael A Pizzi, David A Alejos, Jason L Siegel, Betty Y S Kim, David A Miller, William D Freeman
BACKGROUND: Cerebral venous thrombosis (CVT) is a rare cerebrovascular event that can present with headache, seizure, and focal neurological deficits. Approximately 30%-40% of patients with CVT also present with intracranial hemorrhage. Current guidelines recommend anticoagulation after CVT even in the setting of intracranial hemorrhage, but the timing of initiation is unclear. We present a case of CVT where timing of anticoagulation was unclear by current guidelines. METHODS: We conducted a literature search with search terms of "cerebral venous thrombosis," "intracranial hemorrhage," and "anticoagulation...
September 2016: Journal of Stroke and Cerebrovascular Diseases: the Official Journal of National Stroke Association
H Bart van der Worp
Guidelines for the management of non-variceal upper gastrointestinal haemorrhage recommend restarting anticoagulant therapy after treatment of the haemorrhage in patients with an indication for anticoagulation, such as atrial fibrillation. This recommendation is based on findings in retrospective observational studies, and probably also on common sense: if the cause of the haemorrhage has been treated, the chance of a life-threatening second gastrointestinal haemorrhage when anticoagulation is restarted is likely to be smaller than the chance of a serious thromboembolic complication if anticoagulation is stopped indefinitely...
2016: Nederlands Tijdschrift Voor Geneeskunde
Katharina Klee, Meinrad Gawaz, Christine Stefanie Meyer-Zürn
HISTORY AND ADMISSION FINDINGS: We report the case of a 30-year-old pregnant patient with mechanical valve replacement in mitral and aortic position. She had discontinued Phenprocoumon-treatment in the 5+4 week of pregnancy by herself. Because of rheumatic fever she had undergone a mechanical aortic and mitral valve replacement 12 years ago. Due to a thrombosis of the mitral valve, an acute reoperation had to be done 5 years later. 2 years ago, a partially re-thrombosis of the mechanical mitral valve was treated by intravenous thrombolysis...
March 2016: Deutsche Medizinische Wochenschrift
Marc Kohli, William Mayo-Smith, Ronald Zagoria, Kumar Sandrasegaran
Determining practice parameters for interventional procedures is challenging due to many factors including unreliable laboratory tests to measure bleeding risk, variable usage of standardized terminology for adverse events, poorly defined standards for administration of blood products, and the growing numbers of anticoagulant and antiplatelet medications. We aim to address these and other issues faced by radiologists performing invasive procedures through a review of available literature, and experiential guidance from three academic medical centers...
April 2016: Abdominal Radiology
Hans-Christoph Diener, James Aisenberg, Jack Ansell, Dan Atar, Günter Breithardt, John Eikelboom, Michael D Ezekowitz, Christopher B Granger, Jonathan L Halperin, Stefan H Hohnloser, Elaine M Hylek, Paulus Kirchhof, Deirdre A Lane, Freek W A Verheugt, Roland Veltkamp, Gregory Y H Lip
The choice of oral anticoagulant (OAC) for patients with atrial fibrillation (AF) may be influenced by individual clinical features or by patterns of risk factors and comorbidities. We reviewed analyses of subgroups of patients from trials of vitamin K antagonists vs. non-vitamin K oral anticoagulants (NOACs) for stroke prevention in AF with the aim to identify patient groups who might benefit from a particular OAC more than from another. In addition, we discuss the timing of initiation of anticoagulation. In the second of a two-part review, we discuss the use of NOAC for stroke prevention in the following subgroups of patients with AF: (vii) secondary stroke prevention in patients after stroke or transient ischaemic attack (TIA), (viii) patients with acute stroke requiring thrombolysis or thrombectomy, (ix) those initiating or restarting OAC treatment after stroke or TIA, (x) those with renal impairment on dialysis, (xi) the elderly, (xii) those at high risk of gastrointestinal bleeding, and (xiii) those with hypertension...
February 4, 2016: European Heart Journal
Dong Geum Shin, Tae Hoon Kim, Jae Sun Uhm, Joung Youn Kim, Boyoung Joung, Moon Hyoung Lee, Hui Nam Pak
PURPOSE: Compared with warfarin, novel oral anticoagulants (NOACs) are convenient to use, although they require a blanking period immediately before radiofrequency catheter ablation for atrial fibrillation (AF). We compared NOACs and uninterrupted warfarin in the peri-procedural period of AF ablation. MATERIALS AND METHODS: We compared 141 patients treated with peri-procedural NOACs (72% men; 58 ± 11 years old; 71% with paroxysmal AF) and 281 age-, sex-, AF type-, and history of stroke-matched patients treated with uninterrupted warfarin...
March 2016: Yonsei Medical Journal
Meera Sridharan, Waldemar E Wysokinski, Rajiv Pruthi, Lance Oyen, William D Freeman, Alejandro A Rabinstein, Robert D McBane
INTRODUCTION: Approximately 10% of chronically anticoagulated patients require an invasive procedure annually. One in 10 procedures is emergent and requires prompt anticoagulation reversal. The study objective is to determine the safety and efficacy of a 3 factor prothrombin complex concentrate (PCC) for periprocedural anticoagulation reversal. MATERIALS AND METHODS: Consecutive patients receiving 3 factor PCC for warfarin reversal for either urgent/emergent invasive procedures or major bleeding were analyzed...
March 2016: Thrombosis Research
George Ntaios, Gregory Y H Lip
PURPOSE OF REVIEW: A significant proportion of stroke patients is treated with anticoagulants for secondary stroke prevention. Often, in such patients, stroke physicians are required to make difficult clinical decisions when confronted with the dilemma to choose between the risk of thromboembolism and the risk of bleeding. This article focuses on three common anticoagulant-related situations, where the stroke physician needs to find the delicate balance between the two risks. RECENT FINDINGS: Three typical case vignettes are presented and the associated dilemmas are discussed: a patient with an anticoagulant-related intracranial hemorrhage: would you restart anticoagulation?, an anticoagulated patient with a previous stroke because of atrial fibrillation is scheduled for an elective polyp removal: how would you handle anticoagulation perioperatively?, and a patient presents with an ischemic stroke because of atrial fibrillation: how soon would you start anticoagulation for secondary stroke prevention? The article summarizes the related literature and discusses the pros and cons of each choice...
February 2016: Current Opinion in Neurology
Laila Staerk, Gregory Y H Lip, Jonas B Olesen, Emil L Fosbøl, Jannik L Pallisgaard, Anders N Bonde, Anna Gundlund, Tommi B Lindhardt, Morten L Hansen, Christian Torp-Pedersen, Gunnar H Gislason
STUDY QUESTION: What are the risks of all cause mortality, thromboembolism, major bleeding, and recurrent gastrointestinal bleeding associated with restarting antithrombotic treatment after gastrointestinal bleeding in patients with atrial fibrillation? METHODS: This Danish cohort study (1996-2012) included all patients with atrial fibrillation discharged from hospital after gastrointestinal bleeding while receiving antithrombotic treatment. Restarted treatment regimens were single or combined antithrombotic drugs with oral anticoagulation and antiplatelets...
2015: BMJ: British Medical Journal
Ángel Lanas
In the Digestive Disease Week in 2015 there have been some new contributions in the field of gastrointestinal bleeding that deserve to be highlighted. Treatment of celecoxib with a proton pump inhibitor is safer than treatment with nonselective NSAID and a proton pump inhibitor in high risk gastrointestinal and cardiovascular patients who mostly also take acetylsalicylic acid. Several studies confirm the need to restart the antiplatelet or anticoagulant therapy at an early stage after a gastrointestinal hemorrhage...
September 2015: Gastroenterología y Hepatología
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