Continuation Of Antithrombotic Therapy Research Articles

Management of antithrombotic therapy in patients undergoing dental procedures

A growing number of patients receiving antithrombotic therapy require dental procedures. Dental interventions in these patients can be challenging, as the risk of bleeding from the continuation of antithrombotic therapy needs to be weighed against the thromboembolic risk associated with drug interruption or de-escalation. Most minor dental procedures, including simple dental cleaning and filling, pose minimal bleeding risk, and antiplatelet or anticoagulation therapy can be continued without interruption. Local hemostatic measures, such as tranexamic mouthwash, can be used, as needed, to reduce bleeding events following these interventions. Managing antithrombotic therapy during more invasive dental interventions and oral surgeries with a higher risk of perioperative bleeding necessitates the consideration of specific factors influencing the bleeding risk and thromboembolism. In patients receiving antithrombotic therapy for primary prevention, temporary interruption is reasonable. In others, the decisions may be more complex and more nuanced. In this article, we review the current evidence for managing patients receiving oral antiplatelet or anticoagulant drugs scheduled for various dental procedures and present a practical approach for the periprocedural management of antithrombotic treatments.

Unintentional guideline deviations in hospitalized patients with two or more antithrombotic agents: an intervention study

PurposeTreatment schedules for antithrombotic therapy are complex, and there is a risk of inappropriate prescribing or continuation of antithrombotic therapy beyond the intended period of time. The primary aim of this study was to determine the frequency of unintentional guideline deviations in hospitalized patients. Secondary aims were to determine whether the frequency of unintentional guideline deviations decreased after intervention by a pharmacist, to determine the acceptance rate of the interventions and to determine the type of interventions.MethodsWe performed a non-controlled prospective intervention study in three teaching hospitals in the Netherlands. We examined whether hospitalized patients who used the combination of an anticoagulant plus at least one other antithrombotic agent had an unintentional guideline deviation. In these cases, the hospital pharmacist contacted the physician to assess whether this deviation was intentional. If the deviation was unintentional, a recommendation was provided how to adjust the antithrombotic regimen according to guideline recommendations.ResultsOf the 988 included patients, 407 patients had an unintentional guideline deviation (41.2%). After intervention, this was reduced to 22 patients (2.2%) (p < 0.001). The acceptance rate of the interventions was 96.6%. The most frequently performed interventions were discontinuation of an low molecular weight heparin in combination with a direct oral anticoagulant and discontinuation of an antiplatelet agent when there was no indication for the combination of an antiplatelet agent and an anticoagulant.ConclusionA significant number of hospitalized patients who used an anticoagulant plus one other antithrombotic agent had an unintentional guideline deviation. Intervention by a pharmacist decreased unintentional guideline deviations.

Arterial Thrombosis and Acute Limb Ischemia as a Complication of COVID-19 Infection.

COVID-19 refers to viral respiratory infections and is the predisposing factor for the development of venous and arterial thrombotic events due to a pronounced inflammatory response, platelet activation, endothelial dysfunction, and stasis. Recent studies have confirmed a high incidence of thromboembolic events, especially in the group of patients with severe coronavirus pneumonia. There have been an increasing number of reports of peripheral arterial thrombosis as well. Most cases of arterial thrombosis are noted in critical ill patients in intensive care setting. However, an increase of adverse arterial events was also noted in cases of asymptomatic or mild forms of COVID-19. Herein, we report a case of patient with asymptomatic SARS-CoV-2 infection, who developed a threatening lower limb ischemia. Our own clinical observation suggests that COVID-19-associated arterial thrombosis can be successfully treated by embolectomy, administration of in-hospital parenteral anticoagulation, and continuation of antithrombotic therapy with a "vascular" dose of rivaroxaban after discharge.

Safety of Inguinal Hernia Repair in the Elderly with Perioperative Continuation of Antithrombotic Therapy

Introduction: This study aimed to evaluate the safety of an inguinal hernia repair (IHR) under local anesthesia (LA) in the elderly with a perioperative continuation of antithrombotic therapy (AT). Methods: A total of 120 patients undergoing elective primary IHR between August 2018 and August 2019 at the West China Hospital of China were prospectively studied, among which 60 patients also had coexisting cardiovascular diseases and had a continuation of AT perioperatively (antithrombotic group); the other 60 patients were not on any prior AT (control group). The primary endpoints were intra- and postoperative hemorrhagic complications, the required interventions for complications based on the Clavien-Dindo classification, and postoperative thromboembolic complications. The secondary endpoints were nonhemorrhagic complications, intraoperative duration, and postoperative length of stay (LOS). Results: None of the patients in both groups had significant intraoperative bleeding >10 mL, and there were no significant differences between the 2 groups in terms of the postoperative hemorrhagic complications: bruising (2 vs. 0%, p = 1.000), serosanguinous soakage (7 vs. 3%, p = 0.679), and no hematoma was observed. Interventions required for encountered complications based on the Clavien-Dindo classification grade I (7 vs. 5%, p = 1.000) were assessed. There were no episodes of postoperative thromboembolic complications within 60 days in both groups. There were also no significant differences between the 2 groups in terms of nonhemorrhagic complications, intraoperative duration, and postoperative LOS (p > 0.05 in all). Conclusions: The perioperative continuation of AT did not increase the risk of intra- and postoperative hemorrhagic complications following IHR in the elderly. Thus, IHR under LA seems to be safe and feasible in this setting.

Risk of Gastrointestinal Endoscopic Procedure-Related Bleeding in Patients With or Without Continued Antithrombotic Therapy.

Prospective studies on bleeding risk during/after gastrointestinal endoscopic procedures are rare. We investigated the risk of endoscopic procedure-related bleeding in patients with biopsy and/or cold snare polypectomy (CSP) in relation to antithrombotic therapy. This prospective, observational single-center cohort study (NCT02594813) enrolled consecutive patients who underwent diagnostic esophagogastroduodenoscopy (EGD) or colonoscopy. The primary outcome measure was delayed bleeding in patients with biopsy and/or CSP who required endoscopic treatment within 2weeks post-procedure. The secondary outcomes were immediate bleeding and the number of hemostatic clips used during the procedure. From November 2015 to October 2018 at our institution, 3069 (mean age, 66years) and 37,887 (57years) patients underwent EGD with and without antithrombotic therapy, respectively. In addition, 1116 (72years) and 11,901 (65years) patients had colonoscopy with and without antithrombotic therapy, respectively. In the 3069 EGD patients receiving antithrombotic therapy, no delayed bleeding occurred, whereas immediate bleeding occurred in 9 of 141 patients (6.4%) with biopsy. Of the 1116 colonoscopy patients receiving antithrombotic therapy, delayed bleeding occurred in three of 228 (1.3%) following CSP. Immediate bleeding occurred in nine of 225 (4%) following biopsy and in 32 of 228 (14%) following CSP. Multivariate analysis following univariate analysis identified chronic kidney disease and CSP as factors significantly associated with procedure-related bleeding in patients taking antithrombotic agents. The risk of delayed bleeding in diagnostic EGD with biopsy or in colonoscopy with biopsy and/or CSP was low despite continuation of antithrombotic therapy.

Endoscopic transpapillary gallbladder drainage for acute cholecystitis is feasible for patients receiving antithrombotic therapy.

Patients with acute cholecystitis receiving antithrombotic therapy (ATT) have an increased risk of bleeding complications during surgery and percutaneous drainage. Endoscopic transpapillary gallbladder drainage (ETGBD) is recommended for such cases; however, evidence is limited. To investigate this issue further, we performed a retrospective multicenter study. One hundred thirty patients with acute cholecystitis who underwent ETGBD were enrolled. They were divided into an ATT group (continuation of ATT on the day of the procedure and/or heparin substitution) and a Non-ATT group (discontinuation or no use of ATT). The primary outcome was bleeding complication rate, and the secondary outcomes were technical success rate, clinical success rate and total complication rate. Eighty-three patients were enrolled in the ATT group, and 47 were enrolled in the Non-ATT group. In the ATT group, 42.2% continued multi-agent ATT. No bleeding complications occurred in either group. There were no significant differences between the ATT and Non-ATT groups in the technical success rate (84.3% vs 89.4%, P=0.426 respectively) or the clinical success rate (97.1% vs 100%, P=0.259, respectively). The overall early complication rate was 3.1% (4/130): mild pancreatitis (n=3) and cholangitis (n=1). Stent dysfunction was found in 10.9% of patients (at 196days on average), and the 12-month stent patency rate was 69.0%. No significant difference was found in the bleeding complication rate between ETGBD with and without ATT. ETGBD may be an ideal drainage method for patients with acute cholecystitis receiving ATT.

A Study on Inguinal Hernia Repair by Anterior Approach Method in Patients with Continuation of Antithrombotic Therapy

A Study on Inguinal Hernia Repair by Anterior Approach Method in Patients with Continuation of Antithrombotic Therapy

Feasibility of endoscopic ultrasound-guided gallbladder drainage for acute cholecystitis patients receiving antithrombotic therapy.

Background:Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) as a treatment for patients with acute cholecystitis has been shown to obtain high technical and clinical success rates and a low recurrence rate. However, the safety of EUS-GBD for patients receiving antithrombotic therapy (ATT) has not been proven. The aim was to evaluate the safety and efficacy of EUS-GBD in patients receiving ATT.Methods:Twelve patients with acute cholecystitis associated with gallstones who were receiving antithrombotic therapy and underwent EUS-GBD were enrolled in this retrospective study. Patients with grade II or III cholecystitis who had failed endoscopic transpapillary GBD (ETGBD) or developed recurrence after multiple ETGBD procedures underwent urgent drainage by EUS-GBD. The primary outcome was the rate of bleeding complications after the procedure and the secondary outcomes were the technical and clinical success rates, complications, and recurrence.Results:Eleven (91.6%) patients underwent EUS-GBD with continuation of ATT (at least 1 agent). Five of 12 patients (41.7%) were receiving more than 1 agent for ATT. The rate of bleeding complications was 0% and the technical success rate was 100%, even though some patients had high-grade (severe) cholecystitis and/or several underlying diseases. Early complications were found in 2 (16.7%) patients. The clinical success rate was 91.7% (11/12). There were no recurrences of cholecystitis during the follow-up period (mean 261 [range 5-650] days).Conclusions:EUS-GBD yielded high technical and clinical success rates and a low recurrence rate. No patients receiving ATT developed bleeding complications. EUS-GBD might be a good option for patients on ATT.

Continuation of antithrombotic therapy may be associated with a high incidence of colonic post-polypectomy bleeding.

Post-polypectomy bleeding (PPB) is the most common complication of endoscopic procedures. To reduce the risk of thromboembolic incidents, Japanese guidelines for gastroenterological endoscopy were revised to indicate that antithrombotic agents were not to be discontinued for endoscopic treatment. However, carrying out endoscopic procedures under antithrombotic medication potentially increases the incidence of hemorrhagic complications. The present study investigated the impact of the revised guidelines on the frequency of complications after colonoscopic procedures. The surveillance period comprised the year before the initiation of the new guidelines (2012), which served as a control period, and 2 years after initiation of the new guidelines (2013 and 2014). During the control period, 3955 cases were examined colonoscopically and 1601 lesions were treated endoscopically. During the 2-year period under the new guidelines, 8749 colonoscopies and 3768 endoscopic treatments were carried out. Changes in treatment methods and rates of complications were compared. PPB rate was not significantly different before and after the revision (0.87% vs 1.01%). With the new guidelines, PPB rates in antithrombotic non-users and users were 0.60% and 3.13%, respectively (OR 5.11, P = 0.000). Multivariable analysis showed that the risks for PPB were as follows: heparin bridging therapy (OR 6.34, P = 0.0002); low-dose aspirin (LDA) continuation (OR 5.30, P = 0.0079); and lesion size (OR 1.06, P < 0.0001). The present study showed that the overall PPB rate under the new guidelines was not significantly higher when compared with the previous data obtained before the new guidelines were introduced.

PWE-193 Antithrombotic therapy and cardiovascular outcomes following upper gastrointestinal bleeding – how are we doing?

<h3>Introduction</h3> Upper gastrointestinal bleeding (UGIB) is a recognised risk of antithrombotic therapy. We aimed to investigate whether patients admitted with UGIB whilst on antithrombotic therapy were continued on these following discharge, and to assess bleeding and cardiovascular outcomes. <h3>Method</h3> We performed a retrospective cohort study on consecutive inpatients referred to our university hospital for suspected UGIB over 18 months, who had been prescribed antithrombotic therapy at the point of admission. Patients were identified through our electronic database, and records were scrutinised for co-morbidities, antithrombotic indication (s), endoscopy findings, endotherapy and rebleeding. Primary outcomes included mortality and cardiovascular events at 1 year, whereas secondary outcomes included rebleed rates, and discontinuation of antiplatelet/anticoagulant therapy. Statistical analysis was performed using Fisher’s Exact test. <h3>Results</h3> 133 patients were included in the study, with a median age of 76 years (SD), of which 65.4% were male. Median follow-up was 255 days. Antithrombotic therapy consisted of aspirin monotherapy (44.4%), clopidogrel (9.7%), dual antiplatelet therapy (16.5%), anticoagulant (23.2%), with coronary artery disease (47.5%), atrial fibrillation (18.6%), cerebrovascular disease (9.3%) being the primary indications. Peptic ulcer disease was the commonest lesion on endoscopy (34%), followed by normal endoscopy (28.6%), gastritis (12.8%), and oesophagitis (7.5%). Intervention was performed in 30% of cases. Our 30-day rebleed rate was 5.2%. 30-day and 1-year all-cause mortality rates were 9.0% and 21.0% respectively. Antithrombotic therapy was at least partially discontinued in 55.2% of patients, with no concordance to Rockall scoring or endoscopic findings. Independent predictors of antithrombotic continuation included: metallic heart valve, coronary artery stenting within one year, and recent venous thromboembolism. At 1 year of follow-up, discontinuation of antithrombotic therapy was associated with increased cardiovascular mortality (RR 4.5, p = 0.036), increased all-cause mortality (RR 3.0, p = 0.003), and cardiovascular events (RR 6.1, p = 0.003). Continuation of antithrombotic therapy following haemostasis did not significantly increase bleeding-related mortality. <h3>Conclusion</h3> Patients with cardiovascular comorbidity are at high risk of developing ischaemic events following admission for UGIB. Clinicians should consider careful risk-benefit assessment prior to discontinuing established antithrombotic treatment. <h3>Disclosure of interest</h3> None Declared.

Periprocedural antithrombotic management

The periprocedural management of patients on long-term antithrombotic therapy (antiplatelet agents or vitamin K antagonists) who may require temporary disruption, given that an invasive procedure is always a dilemma for clinicians. Discontinuation of antithrombotic therapy can place patients at an increased risk of thromboembolic complications while the continuation of antithrombotic therapy can increase the procedure-related bleeding risk. Therefore, it is imperative for clinicians to be proficient in making thoughtful and individualized decisions on the appropriate management of periprocedural anticoagulants, drawing from recent evidence-based guidelines.

Guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment

Guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment have been produced by the Japan Gastroenterological Endoscopy Society in collaboration with the Japan Circulation Society, the Japanese Society of Neurology, the Japan Stroke Society, the Japanese Society on Thrombosis and Hemostasis and the Japan Diabetes Society. Previous guidelines from the Japan Gastroenterological Endoscopy Society have focused primarily on prevention of hemorrhage after gastroenterological endoscopy as a result of continuation ofantithrombotic therapy, without considering the associated risk of thrombosis. The new edition of the guidelines includes discussions of gastroenterological hemorrhage associated with continuation of antithrombotic therapy, as well as thromboembolism associated with withdrawal of antithrombotic therapy.

Commonly asked questions in the management of perioperative stroke

Certain surgical interventions increase stroke risk. Perioperative stroke significantly increases perioperative morbidity and mortality. Several interventions, such as perioperative continuation of antithrombotic therapy during selected surgical interventions, may decrease stroke risk without significantly increasing rates of adverse effects. Commonly asked questions in the management of perioperative stroke includes: What are the mechanisms of perioperative stroke? What are the stroke risk factors and perioperative risks? What is the perioperative stroke risk with discontinuation of antithrombotic medications? What risk modifications strategies can be implemented to decrease perioperative stroke risk? What is the role of neuroimaging in the management of perioperative stroke? What is the evidence for the management of perioperative acute ischemic stroke? This article provide an evidence-based review to these questions and comments on potential interventions in the management of these patients.

Peri-operative Management of Antithrombotic Therapy in Vitreoretinal Surgery

With an ageing population, it is increasingly common to encounter patients on anticoagulation or antiplatelet therapy in our practices. Vitreoretinal surgeons often have to balance the risks of sight-threatening peri-operative haemorrhage with continuing antithrombotic therapy against the systemic complications of stopping it. A recent survey showed marked variability in practice, reflecting individual surgeon preferences and the controversies surrounding the matter. In this article, we review current evidence for cessation or continuation of antithrombotic therapy and discuss important considerations for the safe peri-operative management of antithrombotics.

In reply.

In reply: Dr. Schreiber's letter draws attention to the lack of data regarding the optimal duration of antithrombotic therapy for prevention of venous thromboembolism (VTE) in the high-risk older surgical patient. Although the clinical practice guidelines1 refer to the use of warfarin, this issue applies to alternative therapies as well, including intermittent external pneumatic leg compression and low-dose unfractionated and low-molecular-weight heparins, although comparisons in efficacy between each are also not entirely clear. The risk for VTE increases with age.2, 3 Other risk factors include prolonged immobility or paralysis; prior VTE; cancer; major surgery (particularly operations involving the abdomen, pelvis, and lower extremities); obesity; varicose veins; congestive heart failure; myocardial infarction; stroke; fracture of the pelvis, hip, or leg; indwelling femoral vein catheter; inflammatory bowel disease; nephrotic syndrome; and estrogen use.4 The guideline recommends prophylactic antithrombotic therapy be continued for not less than 3 months or until the patient is ambulatory. Many older surgical patients regain ambulatory status during hospitalization or shortly thereafter. Those remaining bedfast pose the highest risk for VTE and continuation of antithrombotic therapy should be considered for them. As noted, several trials of antithrombotic therapy after hospitalization in patients undergoing hip replacement have found a significant incidence of asymptomatic DVT by venogram at 6 weeks in the placebo groups, with reduction in the incidence of VTE in the treated groups.5-8 One recent study of ardeparin prophylaxis for VTE in total hip and knee replacement patients, however, found that 6 weeks of postoperative therapy did not further reduce VTE incidence beyond that achieved with 4 to 10 days of therapy.9 Reduction in VTE risk must be weighed against the risk of bleeding with antithrombotic treatment. Bleeding risk is most closely associated with the intensity of therapy, which is usually lower for VTE prophylaxis. Additional risk factors include a history of gastrointestinal bleeding, cerebrovascular disease, and renal and hepatic disease.10 To provide some magnitude, the risk of intracranial hemorrhage is 0.3%/year and extracranial hemorrhage is 0.6%/year for warfarin prophylaxis of stroke in atrial fibrillation.11 In summary, it is difficult to extrapolate from currently available data what is the optimal duration of antithrombotic prophylaxis for VTE in non-ambulatory older patients following high-risk surgery; the potential benefit must be weighed against the risk for each patient.