|
| ||
|
|
||
Bleeding Risk (bleeding + risk)
Terms modified by Bleeding Risk Selected AbstractsAntiplatelet Therapy: Anti-Ischemic Benefits versus Bleeding RiskJOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 2008C. MICHAEL GIBSON M.D., F.A.C.C. Balance between efficacy and safety is a major concern in therapeutic interventions of patients with acute coronary syndromes. Identifying and managing the risks that may negatively affect this balance can potentially minimize the incidence of morbidity and/or mortality among patients with acute coronary syndromes. Unstable angina and non-ST-elevation myocardial infarction are potentially life-threatening disorders and a major cause of hospitalization and emergency medical care. At the time of presentation, the use of algorithms that provide reasonable assessment of a patient's risk of cardiovascular events, such as the Thrombolysis in Myocardial Infarction risk score, can help clinicians identify which patients will most likely benefit from a specific strategy. The ultimate goal of treatment for non-ST-elevation myocardial infarction is to reduce short- and long-term morbidity and mortality, as well as salvage myocardial cells and cardiac function. Pharmacologic intervention with antiplatelet and/or antithrombotic agents has proven to be effective in achieving this goal in numerous outcome studies. However, clinicians must balance anti-ischemic efficacy with the need to minimize the risk of serious bleeding complications (e.g., hemorrhage). Issues related to safety include timing of the dose, duration of infusion, drug compatibility, errors in estimating a patient's weight and/or age, failure to adjust the dosage based upon renal function, and errors in drug preparation. [source] Current Update on Glycoprotein IIb-IIIa and Direct Thrombin Inhibition in Percutaneous Coronary Intervention for Non-ST Elevation Acute Coronary Syndromes: Balancing Bleeding Risk and Antiplatelet EfficacyJOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 2 2008ANDREW T. KWA M.D. Appropriate pharmacologic treatment for patients with acute coronary syndromes (ACS) remains a matter of controversy. Additionally, a substantial gap exists between recommended guidelines and current clinical practice. Questions remain regarding which antiplatelet/antithrombotic treatment strategies are appropriate for individual patients, based on their risk. We explore the role of glycoprotein IIb-IIIa inhibitors and the direct thrombin inhibitor bivalirudin in ACS patients, and consider the difficulties involved in reducing ischemic events while limiting bleeding risks. In patients with ACS who are undergoing percutaneous coronary intervention, high levels of microembolization and myocardial necrosis are potential risk factors for adverse long-term outcomes. Intensive antiplatelet/antithrombotic regimens may substantially affect these factors. Determination of risk levels, with the goal of targeting aggressive antithrombotic and interventional therapies to patients at higher risk, will help physicians choose appropriate pharmacologic therapy for patients with ACS. [source] Bleeding risk with AZD6140, a reversible P2Y12 receptor antagonist, vs. clopidogrel in patients undergoing coronary artery bypass grafting in the DISPERSE2 trialINTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 4 2009S. Husted Summary AZD6140, the first reversible oral P2Y12 receptor antagonist, exhibits greater and more consistent inhibition of platelet aggregation than the irreversible thienopyridine clopidogrel. As a result of its reversible effect, AZD6140 may pose less risk for bleeding when antiplatelet treatment cannot be stopped at least 5 days before coronary artery bypass graft (CABG) surgery or other invasive procedures. The Dose conflrmation Study assessing anti-Platelet Effects of AZD6140 vs. clopidogRel in NSTEMI (DISPERSE2) trial showed overall comparable bleeding rates with antiplatelet treatment with AZD6140 90 mg twice daily or 180 mg twice daily vs. clopidogrel 75 mg once daily in 984 patients with non-ST-elevation acute coronary syndromes. A post hoc exploratory analysis of bleeding outcomes in the subset of 84 patients undergoing CABG in DISPERSE2 suggests reduced risk for total bleeding (41% and 58% vs. 62%), all major bleeding (38% and 50% vs. 62%), and life-threatening bleeding (22% and 38% vs. 54%) with AZD6140 90 mg (n = 32) and 180 mg (n = 26) vs. clopidogrel (n = 26) respectively. Trends suggested that major bleeding rates were reduced with AZD6140 (combined groups) vs. clopidogrel when treatment was stopped , 5 days prior to surgery (39% vs. 63%, p = 0.15) but not when treatment was stopped > 5 days before surgery (50% vs. 60%). This observation is consistent with the reversible binding of AZD6140 to the P2Y12 receptor. Further prospective studies are planned to assess the relationship between this potential clinical benefit of AZD6140 and the reversibility of its antiplatelet effects. [source] Which parameters differ in very old patients with chronic atrial fibrillation treated by anticoagulant or aspirin?FUNDAMENTAL & CLINICAL PHARMACOLOGY, Issue 5 2008Antithrombotic treatment of atrial fibrillation in the elderly Abstract The objective was to determine the main parameters taken into account for the decision of antithrombotic treatment of atrial fibrillation (AF) by vitamin K antagonist or aspirin. This was a prospective clinical study of four clinical services of geriatric medicine. Two hundred and nine inpatients, 84.7 ± 7 years (women 60.8%), with chronic AF were included. The patients were distributed into two groups (anticoagulant or aspirin) according to medical decision. All the decision criteria for treatment were recorded: cardiopathy, conditions of life, clinical examination (nutrition and autonomy, mini-mental state examination (MMSE), walking evaluation, comorbidity), subjective evaluation of risk of falls and glomerular filtration rate. The thromboembolic risk and the bleeding risk, evaluated subjectively for each patient, were compared with two scores of thrombo-embolic risk and bleeding risk. The evolution of the patients was recorded after 3 months. Student's t -test and chi-squared tests were used for statistical analysis. One hundred and two patients (48.8%) received anticoagulant and 107 patients received aspirin. Patients in the aspirin group were significantly older (86.5 ± 6.5 vs. 82.9 ± 7.1 years), with more frequent social isolation, higher systolic blood pressure, and had more important subjective bleeding risk and risk of falls. Patients in the anticoagulant group had significantly more valvulopathies and a more important subjective thromboembolic risk. Thrombo-phlebitis antecedents, dementia, denutrition and walking alterations were only slightly more frequent in patients in the aspirin group. Physicians underestimated thromboembolic risk (one-third of patients) and they overestimated bleeding risk (half of the patients). After 3 months, the two groups did not significantly differ for death, bleeding or ischaemic events. In common practice, the decision of antithrombotic treatment for AF should take into account not only cardiovascular but also geriatric criteria. [source] Efficacy of desmopressin as surgical prophylaxis in patients with acquired von Willebrand disease undergoing thyroid surgeryHAEMOPHILIA, Issue 2 2002M. FRANCHINI Coagulation abnormalities may occur in patients with thyroid diseases. We report on 14 patients undergoing thyroid surgery for a thyroid disease with an alteration of coagulation parameters resembling von Willebrand disease. Subcutaneous desmopressin was first tested and then used successfully in these patients as surgical prophylaxis, with no side-effects or bleeding complications during or after surgery. This study highlights the need for coagulation studies in patients with thyroid diseases undergoing thyroid surgery. Subcutaneous desmopressin may be used in these patients in order to prevent a surgically related bleeding risk. [source] Prevention of secondary stroke and transient ischaemic attack with antiplatelet therapy: the role of the primary care physician roleINTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 10 2007H. S. Kirshner Summary Background:, Stroke risk is heightened among patients who have had a primary stroke or transient ischaemic attack (TIA). The primary care physician is in the best position to monitor these patients for stroke recurrence. Because stroke recurrence can occur shortly after the primary event, guidelines recommend initiating antiplatelet therapy as soon as possible. Aspirin, with or without extended-release dipyridamole (ER-DP), and clopidogrel are options for such patients. Low-dose aspirin (75,150 mg/day) has the same efficacy as higher doses but with less gastrointestinal bleeding. Clopidogrel remains an option for prevention of secondary events and may benefit patients with symptomatic atherothrombosis, but its combined use with aspirin can harm patients with multiple risk factors and no history of symptomatic cerebrovascular, cardiovascular or peripheral vascular disease. Results:, Low dose aspirin is effective in secondary stroke prevention. Trials assessing aspirin plus ER-DP have shown that the combination is more effective than aspirin monotherapy in preventing stroke, with efficacy increasing among higher risk patients, notably those with prior stroke/TIA. Clopidogrel does not appear to have as much advantage over aspirin in secondary stroke prevention as aspirin plus ER-DP. Smoking cessation and cholesterol, blood glucose and blood pressure control are also important concerns in preventing recurrent stroke. In choosing pharmacological therapy, the physician must consider the individual patient's risk factors and tolerance, as well as other issues, such as use of aspirin among patients with ulcers. Conclusion:, Antiplatelet therapy is effective in secondary stroke prevention. Low dose aspirin can be used first-line, but aspirin plus ER-DP improves efficacy. Clopidogrel is another option in secondary stroke prevention, especially for aspirin-intolerant patients, but it appears to have less advantage over aspirin than aspirin plus ER-DP, and its combined use with aspirin has only marginally better efficacy and increased bleeding risk. [source] Comparison of two blood sampling methods in anticoagulation therapy: venipuncture and peripheral venous catheterJOURNAL OF CLINICAL NURSING, Issue 3 2008Neriman Zengin MScN Aim., To compare prothrombin time and activated partial thromboplastin time values in concurrent blood samples obtained by direct venipuncture and from a peripheral venous catheter. Method., Concurrent blood samples obtained from catheters and by direct venipuncture were studied. Venipuncture samples were labelled as the reference (control) group and the peripheral venous catheter samples as the experimental group. A 21-gauge needle was used in the venipuncture method and 18G, 20G, 22G catheters were used in the peripheral venous catheters method. In each case, after the blood samples were drawn by venipuncture and peripheral venous catheter the needles were drawn out, 1·8 ml of blood was added to 0·2 ml of citrate to give a 2 ml sample. The tube was shaken gently to mix the blood and citrate well. Results., No clinically significant difference between prothrombin time and activated partial thromboplastin time values were seen in the blood samples drawn by venipuncture and peripheral venous catheter methods. Discussion., It is recommended that peripheral venous catheter can be used for patients with high bleeding risk if they have a long hospital stay and frequent blood samples are needed. Relevance to clinical practice., In clinical applications, nurses may prefer the use of peripheral venous catheter to venipuncture both for the comfort of the patients who get anticoagulation therapy and for the prevention of the risks as a result of venipuncture. Application of peripheral venous catheter eliminates the risks of superficial bleeding, irritation, pain and anxiety caused by venipuncture. [source] Systematic review: Helicobacter pylori and the risk of upper gastrointestinal bleeding risk in patients taking aspirinALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 7 2010E. H. Fletcher Aliment Pharmacol Ther 2010; 32: 831,839 Summary Background, Aspirin is widely used to modify the risk of recurrent vascular events. It is, however, associated with increased upper gastrointestinal bleeding risk. The influence of Helicobacter pylori on this risk is uncertain. Aim, To determine the influence of H. pylori on upper gastrointestinal bleeding risk in patients taking aspirin. Methods, MEDLINE and EMBASE databases were searched. All studies providing data regarding H. pylori infection in adults taking aspirin and presenting with upper gastrointestinal bleeding were included. Results, A total of 13 studies that included 1 case,control, 10 cohort studies and 2 randomized-controlled trials (RCTs) were analysed. The case,control study (n = 245) determined H. pylori to be a significant independent risk factor for upper gastrointestinal bleeding. The cohort studies were heterogeneous, varying in inclusion criteria, doses and duration of aspirin used, mode of H. pylori testing and causative GI pathology considered. Comprising 5465 patients, H. pylori infection was tested for in 163 (0.03%) aspirin users with upper gastrointestinal bleeding. The RCTs yielded no significant results. Conclusions, The current data are not sufficient to allow meta-analyses. The widely held belief that H. pylori is a risk factor for upper gastrointestinal bleeding in regular aspirin users is not supported by the very limited evidence available. [source] Factor XI deficiency in animal modelsJOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 2009T. RENNÉ Summary., The blood coagulation system forms fibrin to limit blood loss from sites of injury, but also contributes to occlusive diseases such as deep vein thrombosis, myocardial infarction, and stroke. In the current model of a coagulation balance, normal hemostasis and thrombosis represent two sides of the same coin; however, data from coagulation factor XI-deficient animal models have challenged this dogma. Gene targeting of factor XI, a serine protease of the intrinsic pathway of coagulation, severely impairs arterial thrombus formation but is not associated with excessive bleeding. Mechanistically, factor XI may be activated by factor XII following contact activation or by thrombin in a feedback activation loop. This review focuses on the role of factor XI, and its deficiency states as novel target for prevention of thrombosis with low bleeding risk in animal models. [source] Warfarin for atrial fibrillation in community-based practiseJOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 10 2008A. J. ROSE Summary.,Background:,Previous studies of anticoagulation for atrial fibrillation (AF) have predominantly occurred in academic settings or randomized trials, limiting their generalizability.Objective:,To describe the management of patients with AF anticoagulated with warfarin in community-based practise.Methods:,We enrolled 3396 patients from 101 community-based practises in 38 states. Data included demographics, comorbidities, and International Normalized Ratio (INR) values. Outcomes included time in therapeutic INR range (TTR), stroke, and major hemorrhage.Results:,The mean TTR was 66.5%, but varied widely among patients: 37% had TTR above 75%, while 34% had TTR below 60%. The yearly rates of major hemorrhage and stroke were 1.90 per 100 person-years and 1.00 per 100 person-years. Four percent of patients (n = 127) were intentionally targeted to a lower INR, and spent 42.7% of time with an INR below 2.0, compared to 18.8% for patients with a 2.0,3.0 range (P < 0.001). Mean TTR for new warfarin users (57.5%) remained below that of prevalent users through the first six months. Patients with interruptions of warfarin therapy had lower TTR than all others (61.6% vs. 67.2%, P < 0.001), which corrected after deleting low peri-procedural INR values (67.0% vs. 67.4%, P = 0.73).Conclusions:,Anticoagulation control varies widely among patients taking warfarin for AF. TTR is affected by new warfarin use, procedural interruptions, and INR target range. In this community-based cohort of predominantly prevalent warfarin users, rates of hemorrhage and stroke were low. The risk versus benefit of a lower INR target range to offset bleeding risk remains uncertain. [source] A randomized clinical trial of high-intensity warfarin vs. conventional antithrombotic therapy for the prevention of recurrent thrombosis in patients with the antiphospholipid syndrome (WAPS),JOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 5 2005G. FINAZZI Summary.,Background:,The optimal intensity of oral anticoagulation for the prevention of recurrent thrombosis in patients with antiphospholipid antibody syndrome is uncertain. Retrospective studies show that only high-intensity oral anticoagulation [target international normalized ratio (INR) >3.0] is effective but a recent randomized clinical trial comparing high (INR range 3.0,4.0) vs. moderate (INR 2.0,3.0) intensities of anticoagulation failed to confirm this assumption. Methods:,We conducted a randomized trial in which 109 patients with antiphospholipid syndrome (APS) and previous thrombosis were given either high-intensity warfarin (INR range 3.0,4.5, 54 patients) or standard antithrombotic therapy (warfarin, INR range 2.0,3.0 in 52 patients or aspirin alone, 100 mg day,1 in three patients) to determine whether intensive anticoagulation is superior to standard treatment in preventing symptomatic thromboembolism without increasing the bleeding risk. Results:,The 109 patients enrolled in the trial were followed up for a median time of 3.6 years. Mean INR during follow-up was 3.2 (SD 0.6) in the high-intensity warfarin group and 2.5 (SD 0.3) (P < 0.0001) in the conventional treatment patients given warfarin. Recurrent thrombosis was observed in six of 54 patients (11.1%) assigned to receive high-intensity warfarin and in three of 55 patients (5.5%) assigned to receive conventional treatment [hazard ratio for the high intensity group, 1.97; 95% confidence interval (CI) 0.49,7.89]. Major and minor bleeding occurred in 15 patients (two major) (27.8%) assigned to receive high-intensity warfarin and eight (three major) (14.6%) assigned to receive conventional treatment (hazard ratio 2.18; 95% CI 0.92,5.15). Conclusions:,High-intensity warfarin was not superior to standard treatment in preventing recurrent thrombosis in patients with APS and was associated with an increased rate of minor hemorrhagic complications. [source] Non-fatal major bleeding during treatment with vitamin K antagonists: influence of soluble thrombomodulin and mutations in the propeptide of coagulation factor IXJOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 7 2004J. F. Van Der Heijden Summary., Background and objectives : The key complication of treatment with vitamin K antagonists (VKAs) is bleeding. The major determinant of VKA-induced bleeding is the intensity of anticoagulation. Individual patient characteristics may also influence bleeding risk. In addition, soluble thrombomodulin (s-TM) levels and mutations in the propeptide of factor (F)IX are important candidate risk factors in this respect. Patients and methods : A matched case,control study was designed to search for risk factors that predict bleeding during VKA treatment. We selected cases that had experienced major bleeding during treatment with VKA and matched controls without bleeding complications from the databases of two Thrombosis Services. The controls were matched for indication of treatment, age, gender, type of anticoagulant used and whether or not treatment with VKA was stopped. DNA and plasma were stored of all cases and controls. Results and conclusions : In total 110 patients and 220 controls consented to participate. The results indicate that s-TM levels, measured by ELISA, may be a risk indicator for bleeding [crude odds ratio 3.25 for the highest quartile vs. the lowest quartile (95% confidence interval 1.40, 7.51)]. Three novel mutations, determined by direct sequencing, in the gene portion encoding the propeptide of FIX were identified that do not seem to play an important role in bleeding risk during treatment with VKAs. [source] Individualized duration of oral anticoagulant therapy for deep vein thrombosis based on a decision modelJOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 12 2003R. Vink Summary.,Background:,The optimal duration of oral anticoagulant therapy for patients with a first episode of deep vein thrombosis (DVT) is still a matter of debate. However, according to the ACCP consensus strategy a limited stratification in treatment duration is advocated, i.e. 3 months for patients with a transient risk factor and 1 year or longer for patients with recurrent disease or a consistent risk factor such as thrombophilia or cancer. This consensus strategy is founded on the mean optimal duration of therapy obtained in large cohorts of patients and is mainly based on the risk of recurrent venous thromboembolism (VTE), with only minimal consideration for the patient's bleeding risk. Objective:,The aim of this study is to optimize the anticoagulant treatment strategy with vitamin K antagonists for the individual patient with DVT. Methods:,Based on an extensive literature study, a mathematical model was constructed to balance the risk of recurrent VTE against the risk of major hemorrhagic complications. The following parameters are incorporated in the model: baseline estimates and risk factors for recurrent VTE and bleeding, clinical course of DVT, and efficacy of treatment with vitamin K antagonists. With the use of these parameters, the risk for a recurrent VTE and a bleeding episode can be calculated for the individual patient. The optimal duration of anticoagulant therapy can be defined as the timepoint at which the benefit of treatment (prevention of VTE) is counterbalanced by its risk (bleeding). Results/conclusions:,How long a patient should receive anticoagulant treatment is a matter of balancing the benefits and risks of treatment. The model shows that the optimal treatment duration varies greatly from patient to patient according to the patient's unique bleeding and recurrence risk. [source] Does ageing influence deep brain stimulation outcomes in Parkinson's disease?MOVEMENT DISORDERS, Issue 10 2007Fabienne Ory-Magne MD Abstract We sought to define the influence of ageing in clinical, cognitive, and quality-of-life outcomes after subthalamic nucleus deep brain stimulation (STN-DBS) in Parkinson's disease (PD). We performed motor assessment (UPDRS), mood tests, cognitive, and quality of life evaluation (PDQ-39) on PD patients before surgery, and 12 and 24 months after, and we recorded adverse events. The variations of these parameters after surgery were correlated with age using regression statistical tests. Cerebral bleeding risk was evaluated by a nonparametric test. We enrolled 45 patients (mean age 60 ± 9 years, range 40,73). No significant correlation was found between age and motor scores and PDQ-39 improvements at 12 months. At 24 months, there was a significant negative correlation between age and the improvement of three dimensions of PDQ 39 (mobility, activities of daily life, and cognition). Cognitive impairment showed no correlation, but apathy and depression were positively correlated with age. Significant statistical difference was observed between cerebral bleeding and age. STN-DBS is an effective treatment for elderly patients with advanced PD. A longer follow-up duration and a larger population seem necessary to better assess the quality of life perception in elderly patients and to determinate the real risk of hemorrage. © 2007 Movement Disorder Society [source] Systemic AL amyloidosis with acquired factor X deficiency: A study of perioperative bleeding risk and treatment outcomes in 60 patients,AMERICAN JOURNAL OF HEMATOLOGY, Issue 3 2010Carrie A. Thompson Systemic light-chain (AL) amyloidosis may be associated with acquired factor X (FX) deficiency and optimal management of this coagulopathy is unknown. We reviewed our experience with 60 patients with isolated FX deficiency (,50%) due to AL amyloidosis that underwent an invasive procedure between 1975 and 2007. They were classified as having severe (<10%; n = 6), moderate (10,25%; n = 15), or mild (26,50%; n = 39) FX deficiency. The patients underwent a total of 112 procedures, 19 (17%) of which were managed with periprocedural treatment with one or more hemostatic agents. There were complications in 14 (13%) procedures (bleeding = 12, thrombosis = 1, death = 1). Baseline FX level was not predictive of bleeding risk; the only association with postintervention bleeding was central venous catheter placement. However, bleeding complications were relatively infrequent, particularly in patients with mild or moderate FX deficiency undergoing nonvascular procedures. Activated recombinant factor VII might be considered in patients undergoing major surgical procedures, but further experience is needed. Optimal management of AL patients with FX deficiency undergoing invasive procedures remains to be determined. Am. J. Hematol., 2010. © 2009 Wiley-Liss, Inc. [source] Utilization review of concomitant use of potentially interacting drugs in Thai patients using warfarin therapy,PHARMACOEPIDEMIOLOGY AND DRUG SAFETY, Issue 2 2007Surachai Kotirum PharmD Abstract Purpose In Thailand, there has been no study determining the concomitant use of medications, known to potentially interact with warfarin, in patients receiving warfarin therapy. This paper examined the frequency of which specific interacting drugs were concomitantly used in warfarin users. Methods We retrospectively examined the database of warfarin outpatient medical records from a regional 756-bed hospital located in the north of Thailand. All patients receiving warfarin from 10 June 1999 to 4 August 2004 were reviewed to identify all drugs possessing interaction potential with warfarin. The potential of significant interactions were divided into high, moderate and low, according to the extent of evidence documented in textbooks and literature. Results Among 1093 patients receiving warfarin therapy, 914 (84%) patients received at least one potentially interacting drug and half of them (457 patients) received at least one drug with high potential for interaction. The most frequently concomitant drug that increased INR was acetaminophen (63%, 316/457). Propylthiouracil was the most frequently concomitant drug that decreased INR response (4%, 19/457), while diclofenac was the most frequently concomitant drug that increased bleeding risk (16%, 73/457). Conclusions About a half of patients receiving warfarin therapy was prescribed concomitant drug(s) that has a high potential of interactions with warfarin. These patients should be closely monitored and counselled to watch for signs and symptoms of bleeding and thrombosis to avoid adverse events associated with drug interactions. Copyright © 2006 John Wiley & Sons, Ltd. [source] Efficacy and Safety of Anticoagulation With Heparin Versus Heparin Plus Epoprostenol in Patients Undergoing Extracorporeal Liver Support With PrometheusARTIFICIAL ORGANS, Issue 1 2010Peter Krisper Abstract Anticoagulation for extracorporeal liver support is delicate due to underlying coagulation disorders in patients with liver failure and to the associated elevated bleeding risk. To date, there has been no detailed report on anticoagulation issues in patients treated with Prometheus, a device based on the principle of fractionated plasma separation and adsorption. We studied 17 patients from two centers treated with Prometheus, comparing standard anticoagulation with heparin (15 treatments) and a combination of heparin and the synthetic prostacyclin epoprostenol (22 treatments). Standard coagulation tests, proteins C and S, and thrombin,antithrombin (TAT) complex were determined, and adverse events were recorded. All but two treatments could be completed as scheduled, although filter exchange due to filter clotting was required in 24% of the treatments. Three out of 17 patients developed severe bleeding complications within 24 h of treatment. There were no overt thrombotic events. Addition of epoprostenol neither reduced coagulation-related adverse events nor improved standard coagulation parameters. Protein C, but not protein S, showed a significant reduction (23 ± 18%) after Prometheus treatments, but levels rebounded to baseline within 18 h. TAT levels,a measure for activation of coagulation,were only altered by Prometheus in patients where TAT was already elevated before treatment. In conclusion, anticoagulation of Prometheus with heparin is feasible but still associated with a relatively high frequency of filter clotting and a considerable risk of severe bleeding in this high-risk patient population. As addition of epoprostenol did not prove beneficial, other strategies, such as regional anticoagulation with citrate, should be further evaluated. [source] Frequency and nature of drug,drug interactions in a Dutch university hospitalBRITISH JOURNAL OF CLINICAL PHARMACOLOGY, Issue 2 2009Jeannette E. F. Zwart-van Rijkom WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT , Drug,drug interactions (DDIs) may lead to often preventable adverse drug events and health damage. , In Dutch community pharmacies approximately 6% of all prescriptions generate a DDI alert. , Hospitalized patients may be especially at risk, as they are more severely ill and multiple medications may be prescribed simultaneously; however, only limited data are available on the frequency and nature of DDIs during hospitalization. WHAT THIS STUDY ADDS , In a Dutch university hospital 10% of all prescriptions generated a DDI alert; overall 25% of patients encountered at least one potential DDI. , Besides the risk of decreased effectiveness (25% of the DDIs), the most frequently occurring potential clinical consequence of the DDIs was an increased risk of side-effects, such as an increased bleeding risk (22% of DDIs), hypotension (15%) and nephrotoxicity (13%). , Almost half of the DDIs could be managed by monitoring laboratory values. AIM Drug,drug interactions (DDIs) may lead to often preventable adverse drug events and health damage. Especially within hospitals, this might be an important factor, as patients are severely ill and multiple medications may be prescribed simultaneously. The objective of this study was to measure the frequency and nature of DDI alerts in a Dutch university hospital. METHODS All patients hospitalized in the University Medical Centre Utrecht in 2006 who were prescribed at least one medication were included. The frequency of DDIs was calculated as: (i) the percentage of patients experiencing at least one DDI, and (ii) the percentage of prescriptions generating a DDI alert. Based on the national professional guideline, DDIs were classified into categories of potential clinical outcome, management advice, clinical relevance (A,F) and available evidence (0,4). RESULTS Of the 21 277 admissions included, 5909 (27.8%) encountered at least one DDI. Overall, the prescribing physician received a DDI alert in 9.6% of all prescriptions. The most frequently occurring potential clinical consequence of the DDIs was an increased risk of side-effects such as increased bleeding risk (22.0%), hypotension (14.9%), nephrotoxicity (12.6%) and electrolyte disturbances (10.5%). Almost half (48.6%) of the DDIs could be managed by monitoring laboratory values. CONCLUSIONS Computerized DDI alerts may be a useful tool to prevent adverse drug events within hospitals, but they may also result in ,alert fatigue'. The specificity of alerts could significantly improve by the use of more sophisticated clinical decision support systems taking into account, for example, laboratory values. [source] The influence of polymorphisms of VKORC1 and CYP2C9 on major gastrointestinal bleeding risk in anticoagulated patientsBRITISH JOURNAL OF HAEMATOLOGY, Issue 5 2008Ramón Montes Summary The VKORC1 c.,1639G>A and CYP2C9 c.430C>T and c.1075A>C polymorphisms have been associated with increased sensitivity to oral anticoagulants. However, their role in gastrointestinal bleeding is unknown. We studied the risk of gastrointestinal bleeding associated with these polymorphisms, and how this risk was influenced by the anticoagulant dose and the use of common drugs. Eighty-nine patients with gastrointestinal bleeding during acenocoumarol therapy and 177 patients free of bleeding during acenocoumarol therapy were studied. None of the three polymorphisms constituted a serious gastrointestinal bleeding risk factor. However, patients bearing at least one of these polymorphisms were at high risk, when they simultaneously met one of the following conditions: a weekly dose of acenocoumarol higher than 15 mg [adjusted Odds Ratio (OR) (95% confidence interval (CI) = 4·19 (1·59,11·04)]; amiodarone use [adjusted OR (95% CI) = 9·97 (1·75,56·89)]; or aspirin use [adjusted OR (95% CI) = 8·97 (1·66,48·34)]. The consumption of statins was associated with a lower risk of gastrointestinal bleeding [adjusted OR = 0·50 (0·26,0·99)]. The risk of gastrointestinal bleeding during acenocoumarol therapy in carriers of any of the studied polymorphisms is severely increased with exposure to weekly doses of acenocoumarol higher than 15 mg or the use of amiodarone or aspirin. [source] Overview of the 2006 Food and Drug Administration Circulatory System Devices Panel meeting on drug-eluting stent thrombosisCATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS, Issue 7 2007Tina L. Pinto Slottow Abstract Drug-eluting stents (DES) seemed likely to mitigate the problem of restenosis and have become the predominant stent deployed during percutaneous coronary intervention (PCI). Sustained concerns about the rate of stent thrombosis (ST), particularly very late ST (>1 year following PCI) led to a meeting of the Circulatory System Devices Advisory Panel to address "on-label" and "off-label" use as well as appropriate duration of dual antiplatelet therapy following DES. Over 40 presentations by members of the FDA, industry personnel, and leaders in the field of interventional cardiology helped set forth the body of data available on DES. Standardized definitions of ST created by the Academic Research Consortium were applied to existing randomized trials and registries. At the end of the 2-day session, the consensus of the panel was that "on-label" DES use is not associated with increased incidence of death and myocardial infarction (MI), although it is associated with increased rates of very late ST. "Off-label" use is associated with increased risk of death or MI when compared with "on-label" use. Insufficient data exist to determine the duration of clopidogrel that would minimize ST and bleeding risk, but the panel agreed with the current ACC/AHA/SCAI guidelines regarding dual antiplatelet therapy for at least 12 months in patients at low risk for bleeding, especially with "off-label" use. More data from trials designed with better control arms and prespecified analyses of complex patients and lesions subsets over longer periods of follow-up are needed. © 2007 Wiley-Liss, Inc. [source] Rare benign tumours of oral cavity , capillary haemangioma of palatal mucosa: a case reportINTERNATIONAL JOURNAL OF PAEDIATRIC DENTISTRY, Issue 2 2000Aydan Açikgözsurname Haemangiomas are benign tumours composed of blood vessels, they are probably developmental rather than neoplastic in origin. Haemangiomas are often present at birth but may become more apparent during life. The tumours appear as a flat or raised reddish-blue lesions and are generally solitary. They are occasionally seen on the palatal mucosa. Haemangiomas are classified on the basis of their histological appearance as capillary, mixed, cavernous or a sclerosing variety that tends to undergo fibrosis. Their differential clinical diagnosis is based on appearance. The tumours may be slowly progressive, involving extensive portions of the superficial and deep blood vessels. Function may be affected where development of the lesion is extra-invasive. Colour change on pressure is a common finding with return to the original colour on withdrawal of pressure. The case presented here was referred because of swelling and recurrent periodontal bleeding. The lesion was diagnosed as a capillary haemangioma through histopathology. Although different therapeutic procedures have been reported, in this case surgical excision was carried out under general anaesthesia following hospitalization. Despite their benign origins and behaviour, haemangiomas in the region of oral cavity are always of clinical importance to the dental profession and require appropriate clinical management. Dental practitioners and oral surgeons need to be aware of these lesions because they may pose serious bleeding risks. [source] Current Update on Glycoprotein IIb-IIIa and Direct Thrombin Inhibition in Percutaneous Coronary Intervention for Non-ST Elevation Acute Coronary Syndromes: Balancing Bleeding Risk and Antiplatelet EfficacyJOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 2 2008ANDREW T. KWA M.D. Appropriate pharmacologic treatment for patients with acute coronary syndromes (ACS) remains a matter of controversy. Additionally, a substantial gap exists between recommended guidelines and current clinical practice. Questions remain regarding which antiplatelet/antithrombotic treatment strategies are appropriate for individual patients, based on their risk. We explore the role of glycoprotein IIb-IIIa inhibitors and the direct thrombin inhibitor bivalirudin in ACS patients, and consider the difficulties involved in reducing ischemic events while limiting bleeding risks. In patients with ACS who are undergoing percutaneous coronary intervention, high levels of microembolization and myocardial necrosis are potential risk factors for adverse long-term outcomes. Intensive antiplatelet/antithrombotic regimens may substantially affect these factors. Determination of risk levels, with the goal of targeting aggressive antithrombotic and interventional therapies to patients at higher risk, will help physicians choose appropriate pharmacologic therapy for patients with ACS. [source] Body Mass Index and Effectiveness of Reperfusion Strategies: Implications for the Management of Patients with ST-Elevation Myocardial InfarctionJOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 1 2008M.S., RAJENDRA H. MEHTA M.D. Background:Fibrinolytic therapy has maximum dose limit in patients with ST-elevation myocardial infarction (STEMI). Consequently, obese patients receive lower dose of fibrinolytic per kg body weight compared to lower weight patients. Whether the relatively lower dose results in lower effectiveness of fibrinolytic agents versus primary percutaneous coronary interventions (PCI) in patients with higher body mass index (BMI) is not known. Methods:We analyzed 7,630 STEMI patients receiving primary PCI (46%) or fibrinolysis (54%) <24 hours of symptom onset from the MITRA PLUS registry. The relative effectiveness of the 2 reperfusion strategies on in-hospital death (adjusted with propensity scores) and bleeding were studied in 3 BMI groups: I-BMI 20,24.9 kg/m2 (n = 2,277), II-BMI 25,29.9 kg/m2 (n = 3,763), and III-BMI ,30 kg/m2 (n = 1,590). Results:BMI was inversely related to death, shock, stroke, and bleeding in patients treated with either reperfusion strategy. However, compared with primary PCI, fibrinolysis was associated with higher adjusted death with similar relative adjusted difference in all 3 groups (group I OR 1.69, 95% CI 1.19,2.44; group II OR 1.89, 95% CI 1.39,2.56; group III OR 1.85, 95% CI 1.08,3.22). Conclusions:Compared with primary PCI, fibrinolysis was associated with relatively similar higher risk of death in all 3 BMI groups. Whether the differences in death between fibrinolysis and primary PCI in the high-BMI categories can be reduced by higher fibrinolytic doses without increasing bleeding risks needs evaluation in future studies. [source] Heparin-induced thrombocytopenia: Current status and diagnostic challenges,AMERICAN JOURNAL OF HEMATOLOGY, Issue 9 2010Stavroula A Otis Heparin-induced thrombocytopenia (HIT) is a fairly common and potentially catastrophic complication of heparin therapy. Diagnosing HIT remains a challenge, as the patients at risk often have other reasons for thrombocytopenia and/or thrombosis. HIT is considered a clinicopathologic disorder whose diagnosis is generally made on the basis of both clinical criteria and the presence of "HIT antibodies" in the patient's serum or plasma. There are two basic laboratory approaches to detect HIT antibodies. The immunoassays detect antibodies based on their binding properties, whereas the functional assays detect antibodies based on their platelet-activating properties. Prompt and accurate diagnosis of HIT is imperative, as overdiagnosis exposes patients to alternative anticoagulants and their associated bleeding risks, whereas under- or delayed diagnosis leaves patients vulnerable to the thromboembolic sequelae of HIT, which can be life threatening. A critical interpretation of laboratory results by the clinician is an essential component of diagnosing HIT. This requires a keen understanding of the current concepts in the pathophysiologic mechanisms of the disease, and the application of these concepts when interpreting the results of both the functional and immunoassays. Equally important is an awareness of the strengths and weaknesses, as well as the current lack of standardization and proficiency testing, of these assays. Am. J. Hematol., 2010. © 2010 Wiley-Liss, Inc. [source] Safety of Selective Serotonin Reuptake Inhibitor Use Prior to Coronary Artery Bypass GraftingCLINICAL CARDIOLOGY, Issue 6 2010Glen L. Xiong MD Background Selective serotonin reuptake inhibitors (SSRIs) have been shown to increase bleeding risks. This study examined the association of perioperative coronary artery bypass grafting (CABG) bleeding risks and SSRI use prior to CABG. Hypothesis SSRI may be associated with increased bleeding risks after CABG resulting in elevated reoperation rates due to bleeding complications. Methods Patients who underwent CABG between 1999 and 2003 (n = 4794) were identified in a tertiary medical center. SSRI use (n = 246) was determined using inpatient pharmacy records. Outcomes included primary end point of reoperation due to bleeding complications and other secondary measures. Multivariate regression models were constructed to adjust for baseline differences between SSRI and control groups. Results Reoperation due to bleeding complications among SSRI users was not significantly different (odds ratio [OR]: 1.14 (0.52,2.47); P = 0.75) compared to the control group. Other secondary outcomes and 30-day mortality (2.0% in SSRI vs 2.1% in control group; P = 0.92) between the 2 groups were similar. However, the adjusted total volume of postoperative red blood cell (RBC) units transfused was higher in the SSRI group. Conclusion We conclude that there is no compelling evidence to limit the use of SSRIs among patients with coronary artery disease who undergo CABG given the current evidence. Further research may be needed on individual SSRI medications. Copyright © 2010 Wiley Periodicals, Inc. [source] | |||||||||||||||||||||||||