Anticoagulant Treatment In Patients Research Articles

Apixaban Plus Mono Versus Dual Antiplatelet Therapy in Acute Coronary Syndromes: Insights From the APPRAISE-2 Trial

BackgroundBleeding limits anticoagulant treatment in patients with acute coronary syndromes (ACS). ObjectivesWe investigated whether background concomitant antiplatelet therapy influences the effects of apixaban after ACS. MethodsThis study examined high-risk ACS patients who were treated with aspirin or aspirin plus clopidogrel and who were randomized to apixaban 5 mg twice daily or placebo. In a post-hoc analysis, we assessed whether the effect of apixaban on efficacy and safety outcomes varied by the concomitant antiplatelet regimen by using simple Cox modeling and marginal structural models with propensity scores and antiplatelet therapy as a time-dependent covariate. ResultsAt baseline, of 7,364 patients, 16.3% (n = 1,202) were on aspirin alone, and 79.0% (n = 5,814) were on aspirin plus clopidogrel. A total of 19.2% (n = 1,415) switched antiplatelet therapy during follow-up. No differential effect of apixaban versus placebo was observed for the composite endpoint of cardiovascular death, myocardial infarction, and ischemic stroke in patients taking aspirin (12.21 per 100 patient-years vs. 13.21 per 100 patient-years; adjusted hazard ratio [HR]: 0.91; 95% confidence interval [CI]: 0.62 to 1.32) or aspirin plus clopidogrel (13.22 vs. 14.24; adjusted HR: 0.95; 95% CI: 0.78 to 1.14; pinteraction = 0.84). Compared with placebo, apixaban increased Thrombolysis In Myocardial Infarction major bleeding in patients taking aspirin (1.48 vs. 0.25; adjusted HR: 6.62; 95% CI: 0.75 to 51.73) and in patients taking aspirin plus clopidogrel (2.58 vs. 1.02; adjusted HR: 2.44; 95% CI: 1.34 to 4.45; pinteraction = 0.41). Similar results were obtained with marginal structural models and in patients treated with and without percutaneous coronary intervention. ConclusionsPost-ACS treatment with apixaban versus placebo showed no efficacy, but it increased bleeding regardless of concomitant therapy with aspirin alone or aspirin plus clopidogrel. (Apixaban for Prevention of Acute Ischemic Events 2 [APPRAISE-2]; NCT00831441)

Anticoagulant Treatment in Patients with Atrial Fibrillation and Ischemic Stroke

Atrial fibrillation (AF) is the most common cardiac dysrhythmia, with a lifetime risk of 25%, and it is a well-known independent risk factor for ischemic stroke. Over the last 15years, efforts have been made to initiate relevant treatment in patients with AF. A retrospective study was set up to clarify whether this effort has resulted in a decreased proportion of patients with known AF experiencing an ischemic stroke. Patients admitted to the Department of Neurology, Vejle Hospital, Denmark, with ischemic stroke from January 1997 to December 2012 were included in the study. A total of 4134 patients were included in the study. Overall, the yearly proportion of patients with known AF varied between 9% and 18%. No significant change was observed (P=.511). The proportion of patients with known AF treated with anticoagulants at the time of the stroke and the proportion of newly discovered AF were significantly increasing during the study period (P=.002 and P=.035, respectively). Subgroup analysis of the patients aged 65-75years showed similar results. No significant reduction in the proportion of patients admitted with ischemic stroke and AF was observed. An explanation could be an increase in the prevalence of AF in the general population, leaving the proportion of patients admitted with ischemic stroke unchanged. Other risk factors have been sought reduced as well with the implementation ofnational guidelines regarding hypertension, hypercholesterolemia, and diabetes.

Rationale and design of a study exploring the efficacy of once-daily oral rivaroxaban (X-TRA) on the outcome of left atrial/left atrial appendage thrombus in nonvalvular atrial fibrillation or atrial flutter and a retrospective observational registry providing baseline data (CLOT-AF)

There are still many unresolved issues concerning patient outcomes and prognostic factors in patients with atrial fibrillation (AF) and left atrial/left atrial appendage (LA/LAA) thrombi. Rivaroxaban (Xarelto®), a potent and highly selective oral, direct factor Xa inhibitor, is a new therapeutic option in this setting. The planned study program will consist of a prospective interventional study (X-TRA) and a retrospective observational registry (CLOT-AF). The primary objective of the X-TRA study is to explore the efficacy of rivaroxaban in the treatment of LA/LAA thrombi in patients with nonvalvular AF or atrial flutter, scheduled to undergo cardioversion or AF ablation, in whom an LA/LAA thrombus has been found on transesophageal echocardiography (TEE) before the procedure. The primary end point is the complete LA/LAA thrombus resolution rate at 6 weeks of end of treatment confirmed by TEE. The secondary objectives are to describe categories of thrombus outcome in patients (resolved, reduced, unchanged, larger, or new) confirmed on TEE at the end of treatment (after 6 weeks of treatment), incidence of the composite of stroke and noncentral nervous system systemic embolism at the end of treatment and during follow-up, and incidence of all bleeding at the end of treatment and during follow-up. The objective of the CLOT-AF registry is to provide retrospective thrombus-related patient outcome data after standard-of-care anticoagulant treatment in patients with nonvalvular AF or atrial flutter, who have TEE-documented LA/LAA thrombi. The data will be used as a reference for the prospective X-TRA study. In conclusion, X-TRA and CLOT-AF will provide some answers to the many unresolved issues concerning patient outcomes and prognostic factors in patients with AF and LAA thrombi. Results from this study program would provide the first prospective interventional study (X-TRA) and a large international retrospective observational registry (CLOT-AF) on the prevalence and natural history of LA/LAA thrombi. Unique data on clot resolution with rivaroxaban in a prospective cohort would be obtained in X-TRA.

Aspirin and venous thromboses

The pharmacological prevention of venous thromboembolism (VTE) has so far been carried out mainly with classic (low-molecular-weight heparins, coumarins) or new direct oral anticoagulants (DOACs). The role of antiplatelet treatment with aspirin is controversial. New data, however, suggest a paradigm shift with the reassessment of aspirin as part of a multimodal antithrombotic approach. The article provides an up-to-date overview of the role of antiplatelet treatment with aspirin in the primary and secondary prevention of VTE. Primary prevention of surgery-related VTE with anticoagulants is effective but apparently not superior to a multimodal approach with aspirin, pneumatic compression, and early mobilization. Against this background, aspirin is now also included in the VTE prevention guidelines in the US (ACCP, AAOS) but not in the UK (NICE) and Germany (AMWF). A final evaluation of aspirin as compared to classic anticoagulants and DOACs in primary prophylaxis requires further randomized controlled, prospective trials. These should also consider the iatrogenic risk of bleeding as well as possible postoperative complications, such as retarded wound healing that might require prolonged hospitalization. After ending guideline-conforming anticoagulant treatment in patients with idiopathic VTE, administration of aspirin reduces the risk of recurrent VTE by about 40% without increasing the risk of severe bleeding (standardized INSPIRE evaluation of ASPIRE and WARFASA data). These data add to the current use of aspirin in the prevention of arterial thrombosis the new option of preventing spontaneous VTE. On the basis of new data from recent studies, an indication can be made for the use of aspirin, combined with other preventive measures, in the prevention of primary and secondary venous thromboses.

Status of oral anticoagulant treatment in patients with nonvalvular atrial fibrillation in Spain. REACT-AF study

Background and objectivesOral anticoagulant therapy is complex due to the need for control and the hemorrhagic risk the therapy entails. This study aims to determine the standard clinical practice in the treatment for preventing stroke in patients with nonvalvular atrial fibrillation (NVAF) in Spain. Patients and methodThe Real Evidence of Anti Coagulation Treatment in AF is a European, multicenter, multinational, observational, retrospectively monitored cohort of patients with NVAF. This study included patients recruited in Spain with at least one visit during the period of inclusion (May 2010/April 2012). The study evaluated the following: (a) persistence of oral anticoagulant treatment (time to discontinuation); (b) persistence rate (% of patients in treatment) at 6, 12 and 24 months and at 5 years; (c) therapeutic compliance (medication possession ratio); (d) the correlation between the treatment followed and that recommended by the European Society of Cardiology; and the incidence of stroke and hemorrhagic events. ResultsThe patients treated with oral anticoagulants (n=7526) had a median time to discontinuation of treatment of 1.99 years and a persistence rate at 5 years of 26% (discontinuation ≥3 months). The compliance (mean MPR) was 0.54±0.36. The incidence of stroke was 0.3/100 person-years, and the incidence of hemorrhagic events was 2.4/100 person-years. Fifty-eight percent of the patients with NVAF (n=12,514) followed the recommendations of the European Society of Cardiology. ConclusionForty-two percent of the patients with NVAF did not follow the recommendations of the European Society of Cardiology. We detected low persistence and treatment compliance rates for oral anticoagulants.

Reviewing a Clinical Decision Aid for the Selection of Anticoagulation Treatment in Patients With Nonvalvular Atrial Fibrillation: Applications in a US Managed Care Health Plan Database

PurposeThe Clinical Decision Aid was created to assist in selecting anticoagulant therapies for patients with nonvalvular atrial fibrillation. The aid incorporates a patient’s absolute risk for stroke and bleeding, relative stroke risk reduction, and increase in relative bleeding risk to identify the agent with the lowest net risk. We describe theoretical implications of utilizing the aid at a US managed care population level. MethodsThis retrospective study used claims data from a large US managed care database including enrollees in commercial and Medicare Advantage plans. The distribution of patients across each possible combination of scores on the HAS-BLED scale (evidence of hypertension, abnormal renal or liver function, stroke, bleeding, labile INR, age >65 years, and drugs or alcohol abuse or dependence) and the CHA2DS2-VASc scale (CHADS2 [congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism] with additional nonmajor stroke risk factors, including age 65–74 years, female sex, and vascular disease) was generated. We assessed the correlation between the HAS-BLED and CHA2DS2-VASc scores and derived the optimal treatment options based on various bleeding ratios. FindingsData from 48,260 patients were included in the analysis. The MAPD subset had a higher mean HAS-BLED score (2.17 vs 1.39; P < 0.001) and a higher mean CHA2DS2-VASc score (3.35 vs 2.05; P < 0.001) than did the commercial subset. Pearson coefficients suggested a moderate to strong positive correlation between the HAS-BLED and CHA2DS2-VASc scores among the commercial (0.730; P < 0.001) and MAPD (0.568; P < 0.001) enrollees. Based on a 2:1 bleeding-to-stroke risk ratio, 70.50% of patients would be recommended treatment with apixaban; 25.86%, no treatment; 3.62%, acetylsalicylic acid; and 0.01%, dabigatran 150 mg, if the Clinical Decision Aid were to be used for anticoagulant treatment selection. ImplicationsEvidence-based clinical decision–making tools utilizing risk assessment for recommending a treatment may be valuable for not only health care providers but also health care payers in optimizing care at the population level.

RELATIONSHIP OF DIETARY SODIUM INTAKES WITH HOMA-IR AND BLOOD PRESSURE IN CHILDREN WITH MENTAL HEALTH CONDITIONS

BACKGROUND: Using data from AMPLIFY, a phase III trial comparing apixaban with conventional anticoagulant treatment in patients with venous thromboembolism (VTE), we performed subgroup analyses to compare the efficacy and safety of these regimens in patients with and without active cancer at baseline. Active cancer was defined as cancer that was diagnosed or treated within the past 6 months. METHODS: Patients with symptomatic VTE were randomized to a 6-month course of apixaban (10mg BID for 7 days followed by 5mg BID) or conventional treatment consisting of enoxaparin (1mg/kg BID for at least 5 days) followed by doseadjusted warfarin (target INR, 2-3). Cancer patients for whom long-term low-molecular-weight heparin (LMWH) was planned were excluded. The primary efficacy outcome was symptomatic VTE or VTE-related death. The intent-to-treat efficacy analysis included all randomized subjects with a nonmissing primary endpoint. The primary safety outcome was ISTH-defined major bleeding up to 2 days after stopping study drug in all randomized subjects who received at least one dose of study medication. All outcomes were adjudicated by an independent committee blinded to treatment assignment. RESULTS: Of 5395 patients randomized, 169 (3.1%) had active cancer. Baseline characteristics in these patients were similar between the two treatment groups. The median duration of treatment was 167 and 168 days in the apixaban and warfarin groups, respectively. In patients with active cancer at entry, recurrent VTE occurred in 3 of 81 (3.7%) patients in the apixaban group and in 5 of 78 (6.4%) in the warfarin group (relative risk [RR], 0.56; 95% CI, 0.132.37); major bleeding occurred in 2 of 87 (2.3%) and 4 of 80 (5.0%) patients, respectively (RR, 0.45; 95% CI, 0.082.46). In patients without cancer at entry, recurrent VTE occurred in 56 of 2528 (2.2%) and in 66 of 2557 (2.6%) patients in the apixaban and warfarin group, respectively (RR, 0.86; 95% CI, 0.60-1.22), whereas major bleeding occurred in 13 of 2589 (0.5%) and in 45 of 2609 (1.7%) patients in the apixaban and warfarin group, respectively (RR, 0.29; 95% CI, 0.16-0.54). CONCLUSION: Although the number of cancer patients was small, the results in this pre-specified subgroup are consistent with the overall findings and suggest that apixaban is as effective as conventional therapy in VTE patients with active cancer, and is associated with less bleeding. Additional studies are needed to compare the efficacy and safety of apixaban and LMWH for VTE treatment in cancer patients. Pfizer, BMS

APIXABAN FOR THE TREATMENT OF VENOUS THROMBOEMBOLISM IN CANCER PATIENTS: DATA FROM THE AMPLIFY TRIAL

Using data from AMPLIFY, a phase III trial comparing apixaban with conventional anticoagulant treatment in patients with venous thromboembolism (VTE), we performed subgroup analyses to compare the efficacy and safety of these regimens in patients with and without active cancer at baseline. Active cancer was defined as cancer that was diagnosed or treated within the past 6 months.

Idiopathic versus secondary venous thromboembolism. Findings of the RIETE registry

Background and objectivesThe Computerized Registry of Patients with Venous Thromboembolism (RIETE) is a prospective registry that consecutively includes patients diagnosed with venous thromboembolism. We compared the clinical presentation and response to anticoagulant treatment in patients with idiopathic venous thromboembolism (IVT) versus secondary venous thromboembolism (SVT, associated with a risk factor). Patients and methodsWe analyzed the differences in clinical characteristics, comorbidity, treatment and events during the first 3 months after the diagnosis of venous thromboembolism in patients with IVT or SVT and according to their initial clinical presentation. ResultsA total of 39,921 patients with IVT (n=18,029; 45.1%) or SVT (n=21,892; 54.9%) were enrolled. The patients with IVT had a greater history of venous thromboembolism than those diagnosed with SVT (p<.001). The initial treatment was similar for the 2 groups, but more inferior vena cava filters were placed in the SVT group (p<.001). In the long term, low-molecular-weight heparin was used more often in the SVT group than in the IVT group. At 90 days, bleeding, death and the recurrence of venous thromboembolism were significantly more frequent in the SVT group. The multivariate analysis confirmed that IVT was associated with fewer major (OR, 0.60; 95% CI, 0.50–0.61; p<.001) and fatal (OR, 0.41; 95% CI, 0.29–0.62; p<.001) bleedings, fewer relapses (OR, 0.58; 95% CI, 0.39–0.78; p<.001) and fewer fatal pulmonary embolisms (OR, 0.29; 95% CI, 0.12–0.52; p<.001). These differences were maintained in patients whose venous thromboembolism started with a pulmonary embolism or with deep vein thrombosis. ConclusionsIVT has a better prognosis than SVT at 90 days of the diagnosis.

Enfermedad tromboembólica venosa idiopática versus secundaria. Hallazgos del registro RIETE

Background and objectivesThe Computerized Registry of Patients with Venous Thromboembolism (RIETE) is a prospective registry that consecutively includes patients diagnosed with venous thromboembolism. We compared the clinical presentation and response to anticoagulant treatment in patients with idiopathic venous thromboembolism (IVT) versus secondary venous thromboembolism (SVT, associated with a risk factor). Patients and methodsWe analyzed the differences in clinical characteristics, comorbidity, treatment and events during the first 3months after the diagnosis of venous thromboembolism in patients with IVT or SVT and according to their initial clinical presentation. ResultsA total of 39,921 patients with IVT (n=18,029; 45.1%) or SVT (n=21,892; 54.9%) were enrolled. The patients with IVT had a greater history of venous thromboembolism than those diagnosed with SVT (p<.001). The initial treatment was similar for the 2 groups, but more inferior vena cava filters were placed in the SVT group (p<.001). In the long term, low-molecular-weight heparin was used more often in the SVT group than in the IVT group. At 90days, bleeding, death and the recurrence of venous thromboembolism were significantly more frequent in the SVT group. The multivariate analysis confirmed that IVT was associated with fewer major (OR, 0.60; 95%CI, 0.50-0.61; p<.001) and fatal (OR, 0.41; 95%CI, 0.29-0.62; p<.001) bleedings, fewer relapses (OR, 0.58; 95%CI, 0.39-0.78; p<.001) and fewer fatal pulmonary embolisms (OR, 0.29; 95%CI, 0.12-0.52; p<.001). These differences were maintained in patients whose venous thromboembolism started with a pulmonary embolism or with deep vein thrombosis. ConclusionsIVT has a better prognosis than SVT at 90days of the diagnosis.

Bleeding complications during anticoagulant treatment in patients with cancer

Patients with cancer have an increased risk of bleeding complications, of which some are fatal. This risk is influenced by chemotherapy, cancer type and stage, thrombocytopenia, renal function, and previous bleeding. Since many cancer patients receive anticoagulant treatment for prophylaxis or treatment of venous thromboembolism (VTE), bleeding complications are a challenge in clinical practice. This review article focuses on the overall bleeding risk of cancer patients and the risk of major and clinically relevant bleeding associated with anticoagulant treatment, such as vitamin K antagonists, LMWH and the direct oral anticoagulants. It also describes strategies for individual risk assessments.

Prevalence of renal dysfunction according to the type of atrial fibrillation and anticoagulation treatment in patients who attended primary care in Spain.

To determine the prevalence of renal dysfunction according to the type of atrial fibrillation (AF) and anticoagulation treatment in patients attended in primary care in Spain. METHODS & PARTICIPANTS: The VAL-FAAP study was a national, descriptive, epidemiological and cross-sectional study that included patients of both sexes, ≥18 years of age, with a previous diagnosis of AF by an ECG, attended in a primary-care setting. Renal function was defined by estimated glomerular filtration rate (eGFR), calculated by the modification of diet in renal disease-4 formula. A total of 3287 patients with atrial fibrillation were included (mean age: 71.9 ± 10.1 years; 52.3% male). Overall, 31.6% of patients had an eGFR <60 ml/min/1.73m(2) and 1.6% <30 ml/min/1.73m(2). The proportion of patients with permanent AF increased as the eGFR decreased. Similarly, as congestive heart failure, hypertension, age ≥75 years (doubled), diabetes mellitus, stroke (doubled), vascular disease, age 65-74 years, sex category (CHA2DS2-VASc) increased, chronic kidney disease was more frequent. A third of patients with CHA2DS2-VASc ≥2 had moderate renal dysfunction; however, 35.5% of them did not receive anticoagulants (compared with 31.5% of those with CHA2DS2-VASc ≥2 and normal renal function). Chronic kidney disease is common in patients with AF, particularly in those patients with permanent AF or CHA2DS2-VASc ≥2. Although indicated, 35.5% of patients with AF, a CHA2DS2-VASc ≥2 and moderate renal dysfunction did not receive appropriate anticoagulation, despite the high risk of stroke.

Rivaroxaban as long term therapy of recurrent venous thromboembolism complicated with repeated skin necrosis

A 41-year-old woman with significant protein C deficiency (60%), antiphospholipid syndrome and recurrent venous thromboembolism (VTE), had experienced the first episode of lower limb deep vein thrombosis ten years previously. Subsequently, she suffered four VTE recurrences, including acute pulmonary embolism during pregnancy. She was successfully treated with a body weight-adjusted full dose of enoxaparin sc. In view of the potential lifelong anticoagulation, and significant subcutaneous haematomas at the injection sites after several years of anticoagulation with low molecular weight heparin sc, the patient was successfully switched to warfarin with more than a one month overlap period. She was advised to continue vitamin K antagonist (AVK) with a target international normalised ratio (INR) of 2.0–3.0. Approximately one year later, she was readmitted due to painful necrotic skin lesions of the buttock and left breast. They resolved completely after an unfractionated heparin injection followed by an intravenous infusion. Anticoagulation with warfarin was ceased and the patient was treated with nadroparin. However, she refused long term anticoagulation with subcutaneous drugs and was treated with warfarin instead, with a target INR of 3.0–3.5. Last year, she was admitted to our department once again because of recurrent episodes of necrotic skin lesions in the area over the right ilium (Fig. 1). On admission, INR was 1.8 because, by mistake, she had stopped taking warfarin two days earlier. We immediately ceased warfarin and administered unfractionated heparin in a bolus injection of 10,000 IU, continuing with an aPTT-adjusted infusion. Pending the complete regression of changes, low molecular weight heparin in a therapeutic dosage was recommended. After full regression of the skin lesions, we initiated treatment with rivaroxaban at 20 mg once a day. However, on the second day before scheduled dose of rivaroxaban we observed slight skin changes (Fig. 2), which disappeared spontaneously in a few hours after rivaroxaban administration. Therefore we established treatment with rivaroxaban at 15 mg twice a day. She was followed up for six months without any further complications, then we recommended 20 mg once a day. Skin necrosis during AVK treatment is a very rare complication and is usually associated with protein C deficiency, protein S deficiency or antiphospholipid syndrome. Initially, the skin becomes painful, erythematous and indurated, then skin necrosis develops due to thrombosis of subcutaneous venules. The lesions usually occur in the fatty areas of middle-aged women who have accidentally omitted the drug. They require an urgent bolus of unfractionated heparin followed by UFH infusion with an aPTT-adjusted dose or low molecular weight heparin in a therapeutic dosage. The reinstitution of AVK should be started with very low doses with simultaneous heparin anticoagulation. Rivaroxaban is a selective, direct factor Xa inhibitor. It seems to be useful in the chronic anticoagulant treatment of patients with protein C deficiency and recurrent venous thromboembolism, because it does not decrease this protein level. To the best of our knowledge, this is the first case of an effective treatment of a patient with protein C deficiency and antiphospholipid syndrome with rivaroxaban.

Should the presence of an antiphospholipid antibody affect the duration of anticoagulant treatment in patients with venous thromboembolism?

A 44-year-old otherwise healthy woman has completed 3 months of anticoagulation therapy for a first episode of unprovoked pulmonary embolism. At the time of diagnosis and before the initiation of anticoagulation, she was found to have an elevated IgG anticardiolipin antibody (ACLA), which was measured at 42 IgG phospholipid (GPL) units (reference range, <15 GPL units) with negative lupus anticoagulant (LAC) testing. Should this laboratory finding affect the recommended duration of anticoagulant therapy?

Anticoagulant treatment in patients with atrial fibrillation, according to risk factors for stroke

Atrial fibrillation (AF) is a common and serious condition in the elderly, concerning about 10% of people over 80. AF is a predictive factor for mortality in the elderly and a major risk factor for stroke. Approximately 15% of patients admitted for ischemic stroke have AF and the proportion increases with age, reaching about 40% in people over 80. Compared to patients with stroke unrelated to AF, patients with AF-associated stroke suffer from more severe strokes with an increased risk of remaining disabled after the event and have a higher risk of stroke recurrence. Although most ischemic strokes in AF patients are probably cardioembolic, due to migration of thrombi originating from the left atrial appendage, many elderly patients will be found to have other potential causes of stroke, such as extracranial or intracranial atherosclerotic stenosis, aortic arch atheroma, or small vessel disease. The absolute risk of stroke in patients with AF varies widely depending on associated risk factors, the most important being age over 75 and previous stroke or transient ischemic attack. Several scoring systems have been developed to help clinicians estimate the stroke risk on an individual basis and to guide the choice of the most appropriate preventive therapy. The management of AF in the elderly should involve a detailed evaluation of the patient's functional status and social situation. Specific precautions for treatment must be taken because of the co-morbidities and age-related changes in pharmacokinetics or pharmacodynamics. The benefits of VKAs have been largely shown in patients with AF and appear to be even more important among elderly people. Anticoagulants are recommended in patients with AF aged 75 years or above after assessing the bleeding risk. Novel oral anticoagulants (NOACs) are promising treatments, especially due to a lower risk of intracerebral haemorrhage. However, their prescriptions should take into account renal and cognitive functions.

Antithrombotic therapy in patients undergoing TAVI: an overview of Dutch hospitals

PurposeTo assess current antithrombotic treatment strategies in the Netherlands in patients undergoing transcatheter aortic valve implantation (TAVI).MethodsFor every Dutch hospital performing TAVI (n = 14) an interventional cardiologist experienced in performing TAVI was interviewed concerning heparin, aspirin, thienopyridine and oral anticoagulation treatment in patients undergoing TAVI.ResultsThe response rate was 100 %. In every centre, a protocol for antithrombotic treatment after TAVI was available. Aspirin was prescribed in all centres, concomitant clopidogrel was prescribed 13 of the 14 centres. Duration of concomitant clopidogrel was 3 months in over two-thirds of cases. In 2 centres, duration of concomitant clopidogrel was based upon type of prosthesis: 6 months versus 3 months for supra-annular and intra-annular prostheses, respectively.ConclusionsLeaning on a small basis of evidence and recommendations, the antithrombotic policy for patients undergoing TAVI is highly variable in the Netherlands. As a standardised regimen might further reduce haemorrhagic complications, large randomised clinical trials may help to establish the most appropriate approach.Electronic supplementary materialThe online version of this article (doi:10.1007/s12471-013-0496-6) contains supplementary material, which is available to authorized users.

Impact of chronic kidney disease on the risk of clinical outcomes in patients with cancer‐associated venous thromboembolism during anticoagulant treatment

Information on recurrent venous thromboembolic events (VTEs) and major bleeding risks during anticoagulant treatment in patients with cancer-associated VTEs and chronic kidney disease (CKD) is scarce, although it is of relevance in establishing better tailored management strategies in these patients. We compared risks of recurrent VTEs and major bleeds in cancer-associated VTE patients with and without CKD. A total of 1684 patients diagnosed with a cancer-associated VTE between 2001 and 2011 were followed for 180days after VTE diagnosis. Patients were treated mainly with low-molecular-weight heparin (LMWH) or vitamin-K antagonists (VKA). Primary outcomes were recurrent VTE and major bleeding. Secondary outcome was fatal bleeding. Recurrent VTEs occurred in 15.9/100 patient years (py) in patients without CKD (eGFR>60mL min(-1) ), 19.5/100py in those with CKD stage 3A (eGFR 45-60mL min(-1) ), 14.9/100py in those with CKD 3B (eGFR 30-45mL min(-1) ), and 6.8/100py in patients with CKD 4-5 (eGFR<30mL min(-1) ). Major bleeding occurred in 11.4/100 py in patients without CKD, 18.5/100 py in those with CKD stage 3A, 16.0/100 py in those with CKD 3B, and 40.8/100 py in patients with CKD 4-5. Fatal bleeding occurred in 1.1/100 py, 3.4/100 py, 6.3/100 py and 15.7/100 py, respectively. These increased bleeding risks in CKD patients were mainly observed in those on LMWH treatment, not VKA. The risk of major bleeding was increased in CKD patients with VTE and cancer, and was most prominent in those treated with LMWH and an eGFR<30mL min(-1) . These results indicate that LMWH should be used with caution in this specific population.

Factor Xa inhibitors versus vitamin K antagonists for preventing cerebral or systemic embolism in patients with atrial fibrillation

Factor Xa inhibitors versus vitamin K antagonists for preventing cerebral or systemic embolism in patients with atrial fibrillation

Identification of thrombus in left atrial appendage by 320-row ADCT is superior beyond CHADS2 score for initiating anticoagulation treatment in patients with atrial fibrillation

Identification of thrombus in left atrial appendage by 320-row ADCT is superior beyond CHADS2 score for initiating anticoagulation treatment in patients with atrial fibrillation

Personalizing oral anticoagulant treatment in patients with atrial fibrillation

For decades, warfarin has remained the standard oral anticoagulation for stroke prevention in atrial fibrillation (AF). Three novel oral anticoagulants (NOACs) have been recently approved for stroke prevention in non-valvular AF: dabigatran, rivaroxaban and apixaban. Better pharmacological and clinical profiles make these newcomers a preferable alternative over warfarin. Current AF guidelines do not endorse NOACs over warfarin, or one NOAC over another. Indeed, choice of the anticoagulation regimen should be personalized based on the relative efficacy and safety of different agents across subgroups stratified by thrombotic and bleeding risk, as well as on other clinical factors, including anticoagulation control on warfarin, drug interactions, compliance and need for coagulation monitoring. This review appraises i) the randomized evidence on approved NOACs versus warfarin in AF across subgroups stratified by risk factors of stroke and bleeding and by the anticoagulation level reached on warfarin; and ii) clinical factors impacting on the anticoagulation regimen selection.