Performing non-neuraxial bedside procedures on patients taking anticoagulants Blood&Clots Series: Performing non-neuraxial bedside procedures on patients taking anticoagulants - CanadiEM Blood&Clots Series: Performing non-neuraxial bedside procedures on patients taking anticoagulants In , by Calvin Yeh February 19, 2019 All the content from the Blood & Clots series can be found . CanMEDS Roles addressed: Medical expert Case Description You are assessing a patient in the emergency room who (...) is presenting with a unilateral large pleural effusion that is causing hypoxia and shortness of breath. She needs a thoracentesis but her INR is 3.0 due to the Warfarin she takes for atrial fibrillation. How can this procedure be performed safely? What about other common (non-neuraxial) bedside procedures (thoracentesis, NG tube, paracentesis, arthrocentesis) – when is it safe to perform these procedures while on anticoagulants (DOACs, Warfarin)? Main Text Thoracentesis-associated Risk Case series

Decreased risk of renal impairment in atrial fibrillation patients receiving non-vitamin K antagonist oral anticoagulants: A pooled analysis of randomized controlled trials and real-world studies Patients with warfarin have a potential risk of warfarin-related nephropathy, which could result in the discontinuation of anticoagulation therapy. The question of whether non-vitamin K antagonist oral anticoagulants (NOACs) use is associated with increased risk of renal impairment in atrial

Open-Label Randomized Trial Comparing Oral Anticoagulation With and Without Single Antiplatelet Therapy in Patients With Atrial Fibrillation and Stable Coronary Artery Disease Beyond 1 Year After Coronary Stent Implantation Despite recommendations in the guidelines and consensus documents, there has been no randomized controlled trial evaluating oral anticoagulation (OAC) alone without antiplatelet therapy (APT) in patients with atrial fibrillation and stable coronary artery disease beyond 1 (...) on Thrombosis and Haemostasis classification. Although the trial was designed to enroll 2000 patients during 12 months, enrollment was prematurely terminated after enrolling 696 patients in 38 months.Mean age was 75.0±7.6 years, and 85.2% of patients were men. OAC was warfarin in 75.2% and direct oral anticoagulants in 24.8% of patients. The mean CHADS2 score was 2.5±1.2. During a median follow-up interval of 2.5 years, the primary end point occurred in 54 patients (15.7%) in the OAC-alone group and in 47

Direct acting oral anticoagulants likely to be better than warfarin for people taking them for atrial fibrillation Direct acting oral anticoagulants likely to be better than warfarin for people taking them for atrial fibrillation Discover Portal Discover Portal Direct acting oral anticoagulants likely to be better than warfarin for people taking them for atrial fibrillation Published on 6 February 2018 doi: In people with atrial fibrillation needing anticoagulant treatment, deaths were fewer (...) in those who had direct acting oral anticoagulants compared with warfarin. The picture is less clear for the risk of stroke and complications such as bleeding in the brain or gut. Apixaban had the best efficacy and safety profile and was cost-effective compared with warfarin. This study pooled the data in all trials reporting efficacy, safety and cost of anticoagulant prevention of stroke events in people with atrial fibrillation. Researchers used a technique called network meta-analysis to compare

Screen reminders for GPs did not improve anticoagulant prescribing in atrial fibrillation Screen reminders for GPs did not improve anticoagulant prescribing in atrial fibrillation Discover Portal Discover Portal Screen reminders for GPs did not improve anticoagulant prescribing in atrial fibrillation Published on 18 July 2017 doi: General practice software that generated screen reminders for patients with atrial fibrillation did not increase the proportion taking oral anticoagulants (...) appropriately by six months. This NIHR-funded trial included GPs in 47 surgeries in England and found that at the start only 63% of eligible patients with atrial fibrillation were being prescribed anticoagulants. Six months later the rate had increased to 66% in intervention practices and 64% in those following usual practice, a non-significant difference between the groups. Use of the software was associated with increased diagnosis of transient ischemic attack, which could be due to improved detection

New generation anticoagulants may be safer than warfarin for people with chronic kidney disease New generation anticoagulants may be safer than warfarin for people with chronic kidney disease Discover Portal Discover Portal New generation anticoagulants may be safer than warfarin for people with chronic kidney disease Published on 26 April 2016 doi: Newer generation anticoagulants appear to reduce the risk of bleeding compared with older anticoagulants like warfarin, when used to prevent clots (...) in people who also have mild to moderate chronic kidney disease. This group of drugs, called direct oral anticoagulants, have been well researched in healthy people with atrial fibrillation or at risk of thromboembolism but this was the first review to look at their safety, in terms of bleeding and risk of bleeding within the brain, in people with kidney disease. As a group, these newer drugs appear safer than older anticoagulants such as warfarin. Evidence from the trials comparing individual new

An anticoagulant, bivalirudin, may not be safer than the alternative, heparin, when unblocking arteries in the heart An anticoagulant, bivalirudin, may not be safer than the alternative, heparin, when unblocking arteries in the heart Discover Portal Discover Portal An anticoagulant, bivalirudin, may not be safer than the alternative, heparin, when unblocking arteries in the heart Published on 14 June 2016 doi: Bivalirudin is currently recommended as an alternative option to heparin to prevent (...) procedures were carried out in the UK. It involves inserting a small tube called a stent into the heart’s arteries, to hold them open. Anticoagulant treatment is needed at the same time to reduce the risk of clotting during and after the procedure. Heparin is the long established anticoagulant, but newer bivalirudin may now be used as an alternative. To date, different trials have produced contradictory evidence comparing the safety and effectiveness of the two anticoagulants when given to patients

Extending anticoagulant treatment beyond three months reduces the risk of recurrent blood clots Extending anticoagulant treatment beyond three months reduces the risk of recurrent blood clots Discover Portal Discover Portal Extending anticoagulant treatment beyond three months reduces the risk of recurrent blood clots Published on 1 March 2016 doi: Warfarin, newer direct oral anticoagulants and aspirin all significantly reduced the rate of recurrent clots in patients treated for more than (...) the standard three months. Aspirin was the least effective and the number of major bleeds and deaths was low in all three groups. This review pooling seven trials found that between six and 36 months 28 in every 1000 people taking warfarin, direct oral anticoagulants or aspirin after a first blood clot developed a second clot. This was significantly fewer than the 97 per 1000 people who developed a second clot while taking placebo. The cost-effectiveness of extending treatment was not assessed. People who

The effective, safe and appropriate use of anticoagulation medicines: A systematic overview of reviews anticoagulation medicines 18 March 2019 Links Download reports (pdf) Evidence Summary Evidence Report The effective, safe and appropriate use of anticoagulation medicines: A systematic overview of reviews. What do we want to know? Anticoagulation drugs are used to prevent and treat irregular heartbeat (atrial fibrillation, AF), and clotting of blood in veins (venous thromboembolism, VTE (...) ). Until recently, warfarin was the only available drug to manage or prevent these conditions. Recently, novel oral anticoagulants (NOACs) have become available for prescription. To bring together current understanding about these treatments, we sought to address broad research questions: What evidence syntheses have been conducted to address the efficacy and safety of UK-approved oral anticoagulant therapy with respect to warfarin, novel oral anticoagulants, genotyping (i.e. using genetic information

Continued vs. interrupted direct oral anticoagulants at the time of device surgery, in patients with moderate to high risk of arterial thrombo-embolic events (BRUISE CONTROL-2) Guidelines recommend warfarin continuation rather than heparin bridging for pacemaker and defibrillator surgery, after the BRUISE CONTROL trial demonstrated an 80% reduction in device pocket haematoma with this approach. However, direct oral anticoagulants (DOACs) are now used to treat the majority of patients (...) -operation, interruption of anticoagulation, or prolonging hospital stay. In the continued arm, the median time between pre- and post-operative DOAC doses was 12 h; in the interrupted arm the median time was 72 h. Clinically significant haematoma occurred in of 7 of 328 (2.1%; 95% CI 0.9-4.3) patients in the continued DOAC arm and 7 of 334 (2.1%; 95% CI 0.9-4.3) patients in the interrupted DOAC arm (P = 0.97). Complications were uncommon, and included one stroke and one symptomatic pericardial effusion

Efficacy and safety of reduced-dose non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation: a meta-analysis of randomized controlled trials Non-vitamin K antagonist oral anticoagulants (NOACs) require dose reductions according to patient or clinical factors for patients with atrial fibrillation (AF). In this meta-analysis, we aimed to assess outcomes with reduced-dose NOACs when given as pre-specified in pivotal trials.Aggregated data abstracted from Phase III trials (...) , fatal bleeding, and death regardless of patient eligibility for NOAC dose reduction (interaction P > 0.05 for each).Patients eligible for reduced-dose NOACs were at elevated risk of thromboembolic and haemorrhagic complications when treated with anticoagulants. NOACs, when appropriately dose-adjusted, had an improved benefit-harm profile compared with warfarin. Our findings highlight the importance of prescribing reduced-dose NOACs for indicated patient populations.

Association of Oral Anticoagulants and Proton Pump Inhibitor Cotherapy With Hospitalization for Upper Gastrointestinal Tract Bleeding. Anticoagulant choice and proton pump inhibitor (PPI) cotherapy could affect the risk of upper gastrointestinal tract bleeding, a frequent and potentially serious complication of oral anticoagulant treatment.To compare the incidence of hospitalization for upper gastrointestinal tract bleeding in patients using individual anticoagulants with and without PPI (...) cotherapy, and to determine variation according to underlying gastrointestinal bleeding risk.Retrospective cohort study in Medicare beneficiaries between January 1, 2011, and September 30, 2015.Apixaban, dabigatran, rivaroxaban, or warfarin with or without PPI cotherapy.Hospitalizations for upper gastrointestinal tract bleeding: adjusted incidence and risk difference (RD) per 10 000 person-years of anticoagulant treatment, incidence rate ratios (IRRs).There were 1 643 123 patients with 1 713 183 new

The anticoagulant treatment for sepsis induced disseminated intravascular coagulation; network meta-analysis The benefits and harm caused by anticoagulant treatments for sepsis induced disseminated intravascular coagulation (DIC) remain unclear. Therefore, we performed a network meta-analysis to assess the effect of available anticoagulant treatments on patient mortality, DIC resolution and the incidence of bleeding complication in patients with septic DIC.We considered all studies from four (...) recent systematic reviews and searched the PubMed, MEDLINE, and Cochrane databases for other studies that investigated anticoagulant treatment for septic DIC using antithrombin, thrombomodulin, heparin, or protease inhibitors in adult critically ill patients. These four anticoagulants and placebo were compared. The primary outcome in this study was patient mortality, and the secondary outcomes were the DIC resolution rate and incidence of bleeding complications.The network meta-analysis included 1340

American Society of Hematology 2018 guidelines for management of venous thromboembolism: optimal management of anticoagulation therapy Clinicians confront numerous practical issues in optimizing the use of anticoagulants to treat venous thromboembolism (VTE).These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians and other health care professionals in their decisions about the use of anticoagulants in the management of VTE (...) . These guidelines assume the choice of anticoagulant has already been made.ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation

Who should get long-term anticoagulant therapy for venous thromboembolism and with what? After an initial 3 to 6 months of anticoagulation for venous thromboembolism (VTE), clinicians and patients face an important question: "Do we stop anticoagulants or continue them indefinitely?" The decision is easy in some scenarios (eg, stop in VTE provoked by major surgery). In most scenarios, which are faced on a day-to-day basis in routine practice, it is a challenging decision because of uncertainty (...) in estimates in the long-term risks (principally major bleeding) and benefits (reducing recurrent VTE) and the tight trade-offs between them. Once the decision is made to continue, the next question to tackle is "Which anticoagulant?" Here again, it is a difficult decision because of the uncertainty with regard to estimates of efficacy and the safety of anticoagulant options and the tight trade-offs between choices. We conclude with the approach that we take in our clinical practice.© 2018 by The American

Efficacy and safety of anticoagulant agents in patients with venous thromboembolism and cancer: A network meta-analysis Low-molecular-weight heparins (LMWHs) are the recommended treatment for cancer-associated venous thrombosis (CAT). Recent evidences suggest a role for direct-acting oral anticoagulants (DOACs) in this clinical setting.To evaluate the efficacy and safety of different anticoagulants we performed a network meta-analysis of RCTs including patients with CAT treated with LMWHs (...) , indirect and network meta-analyses.In patients with CAT, DOACs showed a good efficacy and safety profile compared to other anticoagulants and is candidates to be an alternative to LMWHs.Copyright © 2018 Elsevier Ltd. All rights reserved.

Periprocedural Outcomes of Direct Oral Anticoagulants vs. Warfarin in Non-Valvular Atrial Fibrillation: A Meta-analysis of Phase III Trials Direct oral anticoagulants (DOACs) are surpassing warfarin as the anticoagulant of choice for stroke prevention in nonvalvular atrial fibrillation. DOAC outcomes in elective periprocedural settings have not been well elucidated and remain a source of concern for clinicians. The aim of this meta-analysis was to evaluate the periprocedural safety and efficacy (...) of DOACs versus warfarin in patients with nonvalvular atrial fibrillation.We reviewed the literature for data from phase III randomized controlled trials comparing DOACs with warfarin in the periprocedural period among patients with nonvalvular atrial fibrillation. Substudies from 4 trials (RE-LY [Randomized Evaluation of Long-Term Anticoagulation Therapy], ROCKET AF [Rivaroxaban Once Daily Oral Direct Factor Xa Inhibitor Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial

Neuroimaging and clinical outcomes of oral anticoagulant-associated intracerebral hemorrhage Whether intracerebral hemorrhage (ICH) associated with non-vitamin K antagonist oral anticoagulants (NOAC-ICH) has a better outcome compared to ICH associated with vitamin K antagonists (VKA-ICH) is uncertain.We performed a systematic review and individual patient data meta-analysis of cohort studies comparing clinical and radiological outcomes between NOAC-ICH and VKA-ICH patients. The primary outcome

Impact of anticoagulant choice on hospitalized bleeding risk when treating cancer-associated venous thromboembolism Essentials Bleeding risk by anticoagulant choice for cancer-associated venous thrombosis (CA-VTE) is unknown. 26 894 people with CA-VTE were followed for bleeding in a claims database in the United States. Hospitalized bleeding risk was similar with direct acting oral anticoagulants vs. warfarin. Relative hospitalized bleeding risk varied by cancer type and anticoagulant choice (...) . SUMMARY: Background Direct acting oral anticoagulants (DOACs) are associated with less bleeding than traditional venous thromboembolism (VTE) treatments in the general population but are little studied in cancer-associated VTE (CA-VTE). Objective To determine whether different anticoagulation strategies for CA-VTE have different hospitalized bleeding rates. Patients/Methods We conducted a retrospective study of patients with CA-VTE, diagnosed between 2011 and 2015, in a large administrative database

Is the Risk of Bleeding Among Older Adults With Atrial Fibrillation Lower With Antiplatelet Compared With Oral Anticoagulants? TAKE-HOME MESSAGE Older adults have a lower risk of any severity of bleeding (includes both major and minor bleeding) when treated with aspirin or clopidogrel compared to warfarin. However, if minor bleeding is excluded, only the subgroup of patients aged 80 years or older demonstrate a lower risk the of major bleeding with antiplatelet agents. Is the Risk of Bleeding (...) Among Older Adults With Atrial Fibrillation Lower With Antiplatelet Compared With Oral Anticoagulants? EBEM Commentators Cameron Gettel, MD Elizabeth M. Goldberg, MD, ScM Department of Emergency Medicine Alpert Medical School of Brown University Providence, RI Results Commentary Several systematic reviews have previously shown that the risk of bleeding with long-term treatment with aspirin was lower than with warfarin. 2,3 It is common clinical practice to use antiplatelet agents as alternatives