Withdrawal Of Oral Anticoagulants Research Articles

Safety of Cold Snare Polypectomy for Small Colorectal Polyps in Patients Receiving Antithrombotic Therapy

Background and AimsRecent guidelines do not specify the bleeding risk of cold polypectomy. We investigated delayed postpolypectomy bleeding (DPPB) after cold snare polypectomy (CSP) for colorectal polyps in patients receiving antithrombotic (AT) therapy. MethodsA total of 4770 patients who underwent endoscopic resection of colorectal polyps between April 2017 and December 2019 were included. Of them, we analyzed 3600 patients and 10,152 polyps with a size of < 10 mm, including 640 patients who took AT drugs. The patients were subdivided into 3 groups according to AT drug use: 1) continued use, 2) withdrawal, and 3) no use. We compared DPPB rates between hot snare polypectomy (HSP) and CSP in each group. ResultsThe DPPB rates in the CSP group were approximately one-tenth lower than those in the HSP group (per-patient analysis: 0 (0/2598) vs 0.9% (9/1002), per-polyp analysis: 0.04 (3/7928) vs 0.58% (13/2224)). The DPPB rates of HSP were significantly different among the continued use, withdrawal, and no use groups (per-polyp analysis: 2.08 (6/289), 0 (0/159), and 0.40% (7/1771), P = 0.0015). However, the DPPB rates of CSP did not differ among groups (per-polyp analysis: 0 (0/983), 0.17 (1/591), and 0.03% (2/6348), P = 0.2087). No DPPB was observed after CSP in patients with continued use of thienopyridine, aspirin, cilostazol, direct oral anticoagulants, or warfarin; except for 1 patient with direct oral anticoagulant withdrawal. ConclusionThe DPPB of CSP in patients taking an AT drug was low and similar to that in patients not taking drugs. CSP could be a safe procedure for colorectal polyps, even with continued use of AT drugs.

Prevalence, outcome and management of patients with SLE and secondary antiphospholipid antibody syndrome after aPL seroconversion.

The withdrawal of oral anticoagulation (OAC) in patients with SLE and secondary aPL syndrome (SAPS) who become seronegative has not been clearly investigated to date. Our aim was to evaluate the prevalence of aPL seroconversion and the prognosis of SLE patients with SAPS who withdrew OAC after aPL negativization. We retrospectively analysed data of all SLE patients (ACR criteria) with SAPS (Sydney criteria) prospectively followed-up in our clinic. aPL seroconversion was defined as negativization of lupus anticoagulant, aCL, and anti-β2glycoprotein-1 antibodies on two or more consecutive measurements, at least 12 weeks apart. OAC discontinuation was defined as the definitive withdrawal of all anticoagulants. Fifty-five out of 513 (10.7%) SLE patients had vascular SAPS. Sixteen patients (29.1%) became aPL seronegative during follow-up. Immunosuppressive therapy predicted aPL negativization (odds ratio 5.211, 95%CI 1.341, 20.243), whereas APS diagnosis prior to that of SLE (odds ratio 0.078, 95%CI 0.008, 0.799) and triple-positive profile (odds ratio 0.264, 95%CI 0.115, 0.609) were negative predictors of aPL negativization. OAC was discontinued in 13/55 patients (23.6%), after a median follow-up of 45 months (range 1-276) from aPL seroconversion. SLE-related modifiable risk factors for thrombosis were observed in 10/13 patients (77%) at the time of the thrombotic event. No thrombotic recurrences were observed during a mean follow-up time of 44 (19) months from OAC discontinuation. Our results suggest that OAC can be safely discontinued in SLE patients who became persistently seronegative for aPL, at least when aPL-related thrombotic events occurred in presence of other thrombotic risk factors.

Incidence of oral anticoagulant interruption among stroke patients with atrial fibrillation and subsequent stroke.

We analyzed the incidence and causes of oral anticoagulant (OAC) cessation and subsequent stroke after OAC withdrawal in a cohort of Korean stroke patients with atrial fibrillation. The Korean Atrial Fibrillation Evaluation Registry in Ischemic Stroke patients (K-ATTENTION) is a multicenter cohort study, merging stroke registries from 11 tertiary centers in Korea. The number of OAC interruption episodes and the reasons were reviewed from hospital records. Stroke after OAC withdrawal was defined when a patient experienced ischaemic stroke within 31days after OAC withdrawal. Clinical variables were compared between patients who experienced stroke recurrence during OAC interruption and those who did not experience recurrence. Among 3213 stroke patients with atrial fibrillation, a total of 329 episodes of OAC interruption were detected in 229 patients after index stroke (mean age 72.9±8.3years, 113 female patients). The most frequent reason for OAC withdrawal was poor compliance [103 episodes (31.3%)] followed by extracranial bleeding [96 episodes (29.2%)]. Stroke after OAC withdrawal was noted in 13 patients. Mean age, vascular risk factor profile and mean CHA2 DS2 -VASc score were not significantly different between patients with and without recurrent stroke. A considerable number of stroke patients with atrial fibrillation experienced temporary interruption of OAC after index stroke, which was associated with stroke recurrence of 4.0 cases per 100 interruption episodes.

Circumstances of provoked recurrent venous thromboembolism: the Austrian study on recurrent venous thromboembolism

Patients with unprovoked deep-vein thrombosis (DVT) of the leg or pulmonary embolism (PE) have a high recurrence risk. How often these recurrences are provoked by a temporary risk condition is unknown. In a cohort of patients with unprovoked venous thromboembolism (VTE), we evaluated the clinical circumstances of recurrence. We studied patients with DVT of the leg and/or PE. End point was recurrence of objectively verified symptomatic VTE. Provoked recurrence was defined according to guidance criteria. 1188 patients were followed for a median of 8.9 years after withdrawal of oral anticoagulants. 312 patients had recurrent VTE, which was provoked in 42 (13%). Recurrence was related to a major risk factor in 19, to a minor risk factor in 22, and to a persistent risk factor in one patient(s). 14 recurrences occurred after major surgery and 5 during hospitalization. Ten recurrences occurred after minor surgery, eight after trauma and three during female hormone intake. Four recurrences occurred during heparin prophylaxis. The incidence of provoked VTE recurrence appears to be low. VTE can recur when prevention is stopped or even during thromboprophylaxis. Surgery and trauma are frequent risk factors.

Risk Factors for Delayed Bleeding after Therapeutic Gastrointestinal Endoscopy in Patients Receiving Oral Anticoagulants: A Multicenter Retrospective Study

Background/Aims: Delayed bleeding is among the adverse events associated with therapeutic gastrointestinal endoscopy. The aim of this study was to evaluate risk factors for delayed bleeding after gastrointestinal endoscopic resection in patients receiving oral anticoagulants as well as to compare the rates of occurrence of delayed bleeding between the oral anticoagulants used. Methods: We retrospectively analyzed a total of 772 patients receiving anticoagulants. Of these, 389 and 383 patients were receiving direct oral anticoagulants (DOACs) and warfarin, respectively. Therapeutic endoscopic procedures performed included endoscopic submucosal dissection (ESD), endoscopic mucosal resection, polypectomy, and cold polypectomy. Results: Delayed bleeding occurred in 90 patients (11.7%) with no significant difference between the DOAC and warfarin groups (9.5 and 13.8%, respectively). Delayed bleeding occurred significantly more frequently with apixaban than with rivaroxaban (13.5 vs. 6.4%; p < 0.05). A multivariate analysis identified continued anticoagulant therapy (OR 2.29), anticoagulant withdrawal with heparin bridging therapy (HBT; OR 2.18), anticoagulant therapy combined with 1 antiplatelet drug (OR 1.72), and ESD (OR 3.87) as risk factors for delayed bleeding. Conclusion: This study identified continued anticoagulant therapy, anticoagulant withdrawal with HBT, anticoagulant therapy combined with 1 antiplatelet drug, and ESD as risk factors for delayed bleeding after therapeutic endoscopy in patients receiving oral anticoagulants. Delayed bleeding rates were not significantly different between those receiving DOACs and warfarin. It was also suggested that the occurrence of delayed bleeding may vary between different DOACs and that oral anticoagulant withdrawal should be minimized during therapeutic gastrointestinal endoscopy, given the thromboembolic risk involved.

Abstract TP226: Impact of Non-Vitamin K Antagonist Oral Anticoagulant Withdrawal on Stroke Outcomes

Introduction: Discontinuation of antithrombotics can be associated with an increased risk of cardiovascular events and poor outcomes. Abrupt warfarin withdrawal may also induce a rebound or a paradoxical prothrombotic state, subsequently leading to an increased incident risk of stroke for up to 3 months. Hypothesis: Considering the potent anticoagulant effect of non-vitamin K oral anticoagulants (NOACs) on the suppression of thrombogenesis, NOAC withdrawal may be associated with profound hypercoagulable state, leading to severe stroke and poor outcomes in patients with non-valvular atrial fibrillation (NVAF) related stroke. The aim of this study was to compare the initial stroke severity and functional outcome associated with NOAC withdrawal to those associated with other prior medication statuses including warfarin withdrawal in patients with NVAF. Methods: A total of 719 patients with ischemic stroke or transient ischemic attack and NVAF who were admitted at five regional hospitals between January 2013 and December 2016 were included. Prior medication status was categorized into seven groups such as no antithrombotics, antiplatelet-only, warfarin with a subtherapeutic intensity, warfarin with a therapeutic intensity, NOAC, warfarin withdrawal, and NOAC withdrawal. We compared initial National Institute of Health Stroke Scale (NIHSS) scores between groups. Results: The mean age was 73.9 ±10.2 years, and 397 (55.2%) patients were men. Median CHA 2 DS 2 -VASc score was 4 (interquartile range [IQR] 3-5). Among 719 patients, the NOAC withdrawal group had the highest median NIHSS scores at stroke onset (16, interquartile range, IQR [4-20]), followed by the warfarin withdrawal group (11, IQR [3-17]), the no antithrombotic group (5, IQR [2-16]), and the warfarin with subtherapeutic intensity group (5, IQR [2-13]). Multivariable analysis demonstrated that NOAC withdrawal was independently associated with higher NIHSS scores at stroke onset (B 4.645, 95% CI 0.384-8.906, P=0.033). Conclusions: Stroke occurred after discontinuing oral anticoagulants, particularly NOAC, was independently associated with severe stroke severity.

Impact of Non-vitamin K Antagonist Oral Anticoagulant Withdrawal on Stroke Outcomes.

Introduction: Discontinuation of oral anticoagulants such as non-vitamin K antagonist oral anticoagulants (NOACs) may induce a hypercoagulable state, leading to severe stroke and poor outcomes. This study aimed to compare stroke outcomes between NOACs withdrawal and other prior medication statuses in patients with non-valvular atrial fibrillation (NVAF).Methods: Consecutive patients who had pre-existing NVAF and were admitted for an acute ischemic stroke or transient ischemic attack- at five hospitals between January 2013 and December 2016 were included. Prior medication status was categorized into seven groups such as no antithrombotics, antiplatelet-only, warfarin with subtherapeutic intensity, warfarin with therapeutic intensity, NOAC, warfarin withdrawal, and NOAC withdrawal. We compared initial National Institute of Health Stroke Scale (NIHSS) scores between groupsResults: Among 719 patients with NVAF, The median NIHSS score at admission was 5 (IQR 1-13). The NOAC withdrawal group had the highest median NIHSS scores at stroke onset [16, interquartile range, IQR (1–17)], followed by the warfarin withdrawal group [11, IQR (1–14, 18)], the no antithrombotic group [5, IQR (1–13, 18, 19)], and the warfarin with subtherapeutic intensity group [5, IQR (1–10, 18, 19)]. A Multivariable analysis demonstrated that NOAC withdrawal was independently associated with higher NIHSS scores at stroke onset (B 4.645, 95% confidence interval 0.384–8.906, P = 0.033). The median interval from drug withdrawal to ischemic stroke or TIA was 7 days (IQR 4-15) in the NOAC group.Conclusions: Stroke that occurred after stopping oral anticoagulants, especially NOAC, and was more severe at presentation and associated with poorer outcomes.

Withdrawal of oral anticoagulants 3 months after successful radiofrequency catheter ablation in patients with atrial fibrillation: A meta‐analysis

The best anticoagulation therapy for atrial fibrillation (AF) after radiofrequency catheter ablation (RFCA) remains a challenge. A systematic search of PubMed, Ovid, and Cochrane Library was conducted identifying at clinical trials which evaluated the differences between thromboembolism (TE) and hemorrhage in an off-oral anticoagulants (OACs) treatment group (the observation group) and an on-OACs treatment group (the control group), at 3 months after successful RFCA. Meta-analysis was performed using RevMan 5.3 software, and the fixed effect model was used as a relevant statistical model. χ2 test and I2 were used to test for the presence of heterogeneity. Subgroup analysis and sensitivity analysis were also performed. The results showed no significant differences between two groups in TE (relative risk [RR] 0.82, 95% confidence interval [CI], 0.51-1.33, P=0.42), and only mild heterogeneity (P=0.22, I2 =29%). No significant differences in TE between two subgroups were found according to<3 years and ≥ 3 years follow-up analyses (RR 0.58, 95% CI, 0.26-1.28, P=0.18; RR 1.00, 95% CI, 0.54-1.85, P=1.00). Furthermore, there was a lower risk of TE in the observation subgroup(<60 years) compared to the control group (RR 0.31, 95% CI, 0.12-0.78, P=0.01). Also, there were no significant differences in TE between two subgroups (≥ 60 years, RR 1.24, 95% CI, 0.67-2.28, P=0.49). The risk of hemorrhage in the observation group was significantly lower compared to the control group (RR 0.05, 95%CI, 0.02-0.14, P<0.00001). The withdrawal of OACs 3 months after successful radiofrequency catheter ablation for patients with AF may be safe and feasible. It needs to be tested by randomized controlled trial.

Effect of anticoagulants and NSAIDs on accuracy of faecal immunochemical tests (FITs) in colorectal cancer screening: a systematic review and meta-analysis.

Most colorectal cancer (CRC) screening programmes are nowadays based on faecal immunochemical testing (FIT). Eligible subjects often use oral anticoagulants (OACs) or non-steroidal anti-inflammatory drugs (NSAIDs), which could possibly stimulate bleeding from both benign and premalignant lesions in the colon. The aim of this meta-analysis was to study the effect of OACs and NSAIDs use on FIT performance. A systematic search was conducted until June 2017 to retrieve studies from PubMed, Embase, MEDLINE, Web of science, Cochrane Central and Google Scholar. Studies were included when reporting on FIT results in users versus non-users of OACs and/or NSAIDs in average risk CRC screening populations. Primary outcome was positive predictive value for advanced neoplasia (PPVAN) of FIT in relation to OACs/NSAIDs use. Values were obtained by conducting random-effect forest plots. Our literature search identified 2022 records, of which 8 studies were included. A total of 3563 participants with a positive FIT were included. Use of OACs was associated with a PPVAN of 37.6% (95% CI 33.9 to 41.4) compared with 40.3% (95% CI 38.5 to 42.1) for non-users (p=0.75). Pooled PPVAN in aspirin/NSAID users was 38.2% (95% CI 33.8 to 42.9) compared with 39.4% (95% CI 37.5 to 41.3) for non-users (p=0.59). FIT accuracy is not affected by OACs and aspirin/NSAIDs use. Based on the current literature, withdrawal of OACs or NSAIDs before FIT screening is not recommended. Future studies should focus on duration of use, dosage and classes of drugs in association with accuracy of FIT to conduct more specific guideline recommendations.

Risk factors for postoperative bleeding after gastric endoscopic submucosal dissection in patients under antithrombotics.

To evaluate the risk factors for postoperative bleeding after gastric endoscopic submucosal dissection (ESD) based on the latest guidelines. A total of 262 gastric neoplasms were treated by ESD at our center during a 2-year period from October 2012. We analyzed the data of these cases retrospectively to identify the risk factors for post-ESD bleeding. Of the 48 (18.3%) cases on antithrombotic treatment, 10 were still receiving antiplatelet drugs perioperatively, 13 were on heparin replacement after oral anticoagulant withdrawal, and the antithrombotic therapy was discontinued perioperatively in 25 cases. Postoperative bleeding occurred in 23 cases (8.8%). The postoperative bleeding rate in the heparin replacement group was 61.5%, significantly higher than that in the non-antithrombotic therapy group (6.1%). Univariate analysis identified history of antithrombotic drug use, heparin replacement, hemodialysis, cardiovascular disease, diabetes mellitus, elevated prothrombin time-international normalized ratio, and low hemoglobin level on admission as risk factors for post ESD bleeding. Multivariate analysis identified only heparin replacement (OR = 13.7, 95%CI: 1.2-151.3, P = 0.0329) as a significant risk factor for post-ESD bleeding. Continued administration of antiplatelet agents, based on the guidelines, was not a risk factor for postoperative bleeding after gastric ESD; however, heparin replacement, which is recommended after withdrawal of oral anticoagulants, was identified as a significant risk factor.

Trends in the Antiphospholipid Syndrome Criteria

Copyright: © 2013 Forastiero R. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. The Antiphospholipid Syndrome (APS) is an autoimmune disease characterized clinically by the occurrence of either venous or arterial thrombosis in different vascular beds, and/or recurrent miscarriages in the first trimester, or fetal death in the second or third trimesters, or severe pre-eclampsia requiring delivery of a premature infant before 34 weeks of gestation. Cerebrovascular infarction is the most common clinical feature within the arterial circulation, whereas lower limb deep venous thrombosis and pulmonary embolism are the main locations within the venous circulation [1]. The detection of persistently elevated levels of antiphospholipid antibodies (aPL) is a requisite laboratory feature for the diagnosis of APS. The positivity for at least one aPL test: lupus anticoagulant (LA) by clotting assays and/or IgG/IgM anticardiolipin (aCL) and/ or IgG/IgM anti-β2 glycoprotein I antibodies (aβ2GPI) by Enzyme-Linked Immunosorbent (ELISA) assays must be detected. aPL must be found on two or more occasions at least 12 weeks apart. In the 2006 updated APS criteria it is advised to classify APS patients in studies into one of the following categories: I, more than one laboratory criteria present (any combination); IIa, LA present alone; IIb, aCL present alone; IIc, aβ2GPI present alone [2]. aPL can occur in isolation or in association with other autoimmune conditions, particularly Systemic Lupus Erythematosus (SLE). The catastrophic APS is a rare variant of APS characterized by microthrombi in multiple organs. It is commonly triggered by several factors including infection, trauma, surgery, and the withdrawal of oral anticoagulation. Less than 1% of patients with the APS develop the catastrophic complication but it has a life-threatening clinical course. Sometimes aPL coagulopathy may start with a hemorrhagic syndrome when a severe thrombocytopenia, or an acquired thrombocytopathy, factor VIII inhibitor, or prothrombin deficiency is present.

Soluble p-selectin, D-dimer, and high-sensitivity C-reactive protein after acute deep vein thrombosis of the lower limb

Soluble p-selectin (sP-selectin), D-dimer, and C-reactive protein (CRP) are elevated in deep vein thrombosis (DVT), and may play a role as risk predictors of recurrent venous thromboembolism. However, these parameters have only been assessed at manifestation or at single time points after DVT so far. We therefore investigated the course of sP-selectin, D-dimer, and high-sensitivity (hs)-CRP after acute unprovoked DVT of the lower limb. In this prospective, longitudinal study, sP-selectin, D-dimer, and hs-CRP were determined by enzyme-linked immunosorbent assay, quantitative latex assay, and particle enhanced immunonephelometry, respectively, in 44 patients with sonographically confirmed acute DVT at the time of diagnosis, and 1, 3, 6, and 12 months later. sP-selectin and hs-CRP were also measured in 88 age- and gender-matched healthy controls. Further, color duplex sonography was performed in all patients at each time point. At DVT diagnosis, sP-selectin and hs-CRP were significantly higher in patients compared with healthy controls. From baseline to 1 month, both parameters decreased significantly. In patients with oral anticoagulation (OAC) for 6 months (n = 35), levels of sP-selectin increased significantly after cessation of anticoagulant therapy (P = .002), while sP-selectin was similar to healthy controls in patients with ongoing OAC (n = 9) at 12 months (P = .49). In contrast, hs-CRP in both subgroups remained constantly low at levels seen in healthy controls. The course of D-dimer was similar to sP-selectin. Color duplex sonography showed no ongoing thrombus formation in any patient. Thirty-four (77.3%), 29 (65.9%), 26 (59.1%), and 25 (56.8%) patients had residual thrombosis 1, 3, 6, and 12 months after the acute event, respectively. D-dimer was significantly higher in patients with residual thrombosis compared with patients without residual thrombosis 1 month after DVT (0.58 μg/mL [range, 0.2-9.67 μg/mL] vs 0.25 μg/mL [range, 0.2-0.62 μg/mL]; P = .02). At all other time points, the levels of D-dimer and sP-selectin did not differ significantly between patients without and with residual thrombosis (all P > .05). Concentrations of sP-selectin and D-dimer after acute DVT seem to be strongly influenced by treatment with vitamin K antagonists. After withdrawal of oral anticoagulation, they rise again and could therefore reflect a prothrombotic state, which is susceptible to pharmacologic therapy.

Seguridad del cateterismo diagnóstico transradial en pacientes anticoagulados de forma crónica con dicumarínicos

The aim of this study was to evaluate the safety of transradial catheterization without prior withdrawal of oral anticoagulation. In total, 183 patients on long-term acenocoumarol treatment who underwent transradial catheterization were included in a prospective study. In 135 patients, the coumarin derivative was continued without interruption before and during catheterization and, in 48, the drug was stopped 48 hours in advance. No severe thromboembolic or hemorrhagic complications occurred. At 7-day follow-up, the rate of occurrence of hematomas >3 cm in size was 5.5% in the group that continued anticoagulant treatment, and 10.4% in the group that stopped oral anticoagulation (P=.31). The transradial approach appears to be a safe option for patients receiving long-term coumarin treatment and could be the technique of choice because it avoids the drawbacks and complications associated with the withdrawal of oral anticoagulation.

Abnormally short activated partial thromboplastin time values are associated with increased risk of recurrence of venous thromboembolism after oral anticoagulation withdrawal

This study prospectively evaluated the relationship between activated partial thromboplastin time (aPTT) and risk of venous thromboembolism (VTE) recurrence after oral anticoagulant (OA) withdrawal in patients with a previous unprovoked VTE event. Six hundred twenty-eight patients (331 males; median age: 67 years) were followed after OA interruption (mean follow-up = 22 months). Three to four weeks from OA discontinuation patients were given a complete thrombophilic work-out, including aPTT (automated aPTT). Recurrent symptomatic VTE events (objectively documented) occurred in 71/628 (11.3%, 6.8/100 person-years) patients. The VTE recurrence rate was 17.5% and 7.5% in patients with aPTT in the lower (ratio < or =0.90) and in the upper (ratio >1.05) quartiles. The recurrence risk was more than twofold higher in patients with ratio < or =0.90 versus those of the reference category [Relative risk (RR): 2.38 (95% confidence interval (CI): 1.18-4.78)]. As expected, the increase in recurrence risk disappeared after adjustment for factor VIII, IX and XI levels [RR: 1.74 (95%CI: 0.43-2.76)]. In contrast, the risk was persistently increased in patients with a ratio < or =0.90 [RR: 2.07 (95%CI: 1.02-4.18)] after adjustment for age, gender and d-dimer level. The aPTT predictive value was independent of the presence of inherited thrombophilic alterations. In conclusion, abnormally short aPTT values are associated with a significantly increased risk of VTE recurrence.

Severe Left Atrial Edema and Heart Failure After Atrial Fibrillation Ablation

A 66-year-old woman with drug-refractory symptomatic paroxysmal atrial fibrillation presented for atrial fibrillation ablation. Before the procedure, she underwent a transthoracic echocardiogram and contrast-enhanced chest computed tomography (CT) scan (Figure, a) to define both her left atrial and pulmonary vein anatomy. Both structures were normal. The following day, a left atrial circumferential radiofrequency ablation throughout the atria was performed. The procedure was well tolerated, and she was discharged the …

Holmium Laser Enucleation of the Prostate in Patients on Anticoagulant Therapy or With Bleeding Disorders

We evaluated the safety and efficacy of HoLEP in patients on anticoagulation with significant obstructive symptoms secondary to BPH refractory to medical therapy. From May 1999 to October 2004, 83 patients with a mean age of 76.6 years who had symptomatic BPH and were on chronic oral anticoagulant therapy or had bleeding disorders underwent HoLEP. Mean preoperative prostate size estimated by transrectal ultrasound was 82.4 cc (range 25 to 222). A total of 14 patients underwent HoLEP without oral anticoagulant withdrawal, 34 underwent surgery with low molecular weight heparin substitution and 33 stopped anticoagulants before surgery, including 8 on antiplatelet therapy. All patients were assessed preoperatively, and 1, 3, 6 and 12 months after surgery. HoLEP was performed successfully in all patients with a mean enucleation time of 86.5 minutes (range 35 to 210). Mean morcellation time was 20.1 minutes (range 3 to 100). Peak urinary flow, post-void residual urine, International Prostate Symptom Score and quality of life score were significantly improved by 1 month after surgery and they continued to improve during subsequent followup. One patient required intraoperative platelet transfusion and 7 required blood transfusion early in the postoperative period due to hematuria coinciding with restarting oral anticoagulant therapy. Mean preoperative and postoperative hemoglobin was 13.5 (range 8.3 to 16.4) and 12.2 gm/dl (range 5.3 to15.4), respectively (p <0.0001). There were no major operative or postoperative complications, or thromboembolic events. HoLEP is a safe and effective therapeutic modality in patients on anticoagulation with symptomatic BPH refractory to medical therapy.

Family History for Venous Thromboembolism and the Risk for Recurrence

Purpose The relevance of a family history for venous thromboembolism with regard to the likelihood for recurrence is unknown. Subjects and methods We studied 826 patients for an average of 36 months after a first unprovoked venous thromboembolism and withdrawal of oral anticoagulation. Patients with cancer, lupus anticoagulant, or deficiency of antithrombin, protein C, or protein S were excluded. The study endpoint was objective evidence of recurrent symptomatic venous thromboembolism. Results Recurrence for venous thromboembolism was recorded in 23 of 190 patients (12.1%) with a family history (at least one affected first-degree family member) and in 79 of 636 patients (12.4%) without familial thrombosis (relative risk for recurrence 1.0; 95% confidence interval, 0.7-1.6; P = .9). At 5 years, the likelihood for recurrence was 20% among patients with a family history for venous thromboembolism and 18% among those without a family history for venous thromboembolism ( P = .9). Risk determinants for venous thromboembolism including factor V Leiden, factor II G20210A, and high factor VIII were not statistically different between the 2 groups. Conclusion A family history for venous thromboembolism does not segregate patients into high- or low-risk categories and is not suitable to identify patients at increased risk for recurrent venous thromboembolism.

High plasma levels of factor VIII and risk of recurrence of venous thromboembolism.

The aim of this study was to evaluate the relationship between factor VIII (FVIII) levels, measured by chromogenic and clotting assays, and risk of venous thromboembolism (VTE) recurrence. A total of 564 patients underwent clinical follow-up after oral anticoagulant withdrawal (total follow-up = 924.4 years). Recurrent VTE developed in 39 of 309 (12.6%) patients with a first idiopathic VTE and in 14 of 255 (5.5%) patients whose first event was secondary. In patients with a first idiopathic VTE, the risk of recurrence was more than fivefold higher in patients with FVIII levels exceeding the 90th percentile [chromogenic FVIII: relative risk (RR) 5.43 (95% CI 1.76-16.8); clotting FVIII: RR 6.21 (95% CI 1.57-24.5)] after adjustment for all possible confounding variables. In patients with a first secondary VTE, the risk of recurrence was slightly higher in patients with high FVIII levels [chromogenic FVIII: RR 2.62 (95% CI 0.34-19.9); clotting FVIII: RR 1.74 (95% CI 0.25-12.1)], but, given the low number of recurrences, the 95% CI were very large. In conclusion, this study shows that high FVIII levels are associated with increased risk of VTE recurrence in patients with a first idiopathic VTE. Although the measurement of FVIII levels by a specific chromogenic assay might, in principle, be preferred to avoid the risk of aspecific clotting effects, no significant differences in results obtained by chromogenic or clotting methods were found.

D-dimer levels and risk of recurrent venous thromboembolism.

Widespread screening of patients with venous thromboembolism (VTE) for thrombophilic risk factors has become common clinical practice. Because of the increasing number of risk factors, assessing the risk of recurrence in an individual patient is intricate; therefore, a laboratory method that measures multifactorial thrombophilia is required. To prospectively study the relationship between the risk of recurrent VTE and D-dimer, a global marker of coagulation activation and fibrinolysis. Prospective cohort study of 610 patients older than 18 years who were treated with oral anticoagulants for at least 3 months with a first spontaneous VTE, in whom D-dimer levels were measured shortly after discontinuation of oral anticoagulation. The study was conducted at the Department of Internal Medicine I, University Hospital, Vienna, Austria. Patients entered the study at time of discontinuation of oral anticoagulants and were observed at 3-month intervals during the first year and every 6 months thereafter from July 1992 to October 2002. Objectively documented symptomatic recurrent VTE. A total of 79 (13%) of 610 patients had recurrent VTE with a mean observation time of 38 months. Patients with recurrence had significantly higher D-dimer levels compared with those without recurrence (553 ng/mL vs 427 ng/mL, P =.01). Compared with patients with D-dimer levels of 750 ng/mL or higher, the relative risk (RR) of recurrence was 0.6 (95% confidence interval [CI], 0.3-1.4), 0.6 (95% CI, 0.3-1.2), and 0.3 (95% CI, 0.1-0.6) in patients with D-dimer levels of 500 to 749 ng/mL, 250 to 499 ng/mL, and less than 250 ng/mL, respectively. The cumulative probability of recurrent VTE at 2 years was 3.7% (95% CI, 0.9%-6.5%) among patients with D-dimer levels of less than 250 ng/mL compared with 11.5% (95% CI, 8.0%-15.0%) among patients with higher levels (P =.001). Patients with D-dimer levels of less than 250 ng/mL had a 60% lower RR of recurrence compared with patients with higher levels (RR, 0.4; 95% CI, 0.2-0.8). Patients with a first spontaneous VTE and a D-dimer level of less than 250 ng/mL after withdrawal of oral anticoagulation have a low risk of VTE recurrence.

The risk of recurrent venous thromboembolism: the Austrian Study on Recurrent Venous Thromboembolism.

Venous thromboembolism (VTE) is a chronic disease. After withdrawal of oral anticoagulation at least a third of patients will experience a subsequent episode of venous thrombosis. Of these patients, approximately 5% will die from pulmonary embolism. The Austrian Study on Recurrent Venous Thromboembolism (AUREC) is a prospective cohort study aiming to investigate the overall rate of recurrent VTE, the predictive value of laboratory assays, the importance of acquired or congenital risk factors for thrombosis and the impact of extended or modified secondary thromboprophylaxis on the risk of recurrence among high-risk patients. So far, the AUREC investigators have identified subgroups of patients with a particular high risk of recurrence: patients with a history of venous thrombosis, elevated levels of coagulation factors VIII, IX and XI, pulmonary embolism or superficial venous thrombosis and a history of venous thrombosis and hyperhomocysteinemia. Patients with a history of venous thrombosis and mutations in genes encoding for coagulation factors (factor V Leiden, factor II, G20210A) do not have an enhanced risk of recurrence and, thus, do not qualify for extended secondary thromboprophylaxis. At present, interventional trials are in progress in patients with high factor VIII or hyperhomocysteinemia in order to investigate if these patient groups might benefit from extended oral anticoagulation or vitamin supplementation, respectively.