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Respiratory Disease
Published in John S. Axford, Chris A. O'Callaghan, Medicine for Finals and Beyond, 2023
Ian Pavord, Nayia Petousi, Nick Talbot
Anticoagulation: The mainstay of treatment, aimed at preventing propagation of existing thrombus and formation of new clots. Options include low molecular weight heparin, warfarin or direct oral anticoagulants (DOACs). Duration of therapy for provoked DVT/PE (e.g. postoperative) is normally 3 months. For unprovoked DVT, therapy may be continued for longer.
Atrial fibrillation
Published in Henry J. Woodford, Essential Geriatrics, 2022
The main adverse effect of anticoagulation is an elevated bleeding tendency. The rapid reversal of anticoagulation following bleeding is discussed on page 219. Traditionally quoted contraindications to anticoagulation include recent bleeding, multiple falls, inability to consistently take the prescribed dose, uncontrolled hypertension and excessive alcohol intake. However, risks to older people have probably been over-estimated in the past.24 Falling, in particular, does not seem to be an important factor in deciding whether someone should be anticoagulated.25 Current accepted risk factors for haemorrhage are as shown in the HAS-BLED assessment (seeTable 19.2). Data extraction from major trials is consistent with a lower risk of bleeding with NOAC drugs compared to warfarin; this is shown in Table 19.3.26
Critical Care and Anaesthesia
Published in Tjun Tang, Elizabeth O'Riordan, Stewart Walsh, Cracking the Intercollegiate General Surgery FRCS Viva, 2020
Rajkumar Rajendram, Alex Joseph, John Davidson, Avinash Gobindram, Prit Anand Singh, Animesh JK Patel
How do you treat thrombophilia?If thrombophilia is acquired, treat cause if possibleConsider primary anticoagulation or prophylaxis in patients at riskPrimary prophylaxis − prolonged hospitalisation postoperatively, immobilisation and in patients with active cancer.Long-term prophylaxis − complex assessment of all risk factors; liaise with haematology colleagues Benefits of anticoagulation must outweigh the risk of bleeding, especially in elderly patients.
Adherence to protocols for the use of reversal agents in patients treated with direct oral anticoagulants
Published in Current Medical Research and Opinion, 2023
Darko Mitrovic, Margriet van Elp, Loes Visser, Nienke van Rein, Patricia van den Bemt, Marinus van Hulst, Albert Dreijer, Heleen Lameijer, Nic Veeger, Karina Meijer, Eric van Roon
As with all antithrombotic agents, patients using direct oral anticoagulants (DOAC) are at risk of bleeding complications. For various mild and moderate bleeding events, DOAC withdrawal and a “wait and support” policy are sufficient. The bleeding event will eventually be resolved without further complications. In case of planned procedures with an increased risk of complications due to extensive bleeding, DOAC therapy may be interrupted before the procedure to consider the DOAC type, the risk of bleeding during the procedure, and renal function. In patients with life-threatening bleeding or in need of an urgent procedure, an immediate reversal of anticoagulation is required1. Together with other medical treatment options, reversal agents such as prothrombin complex concentrate (PCC; registered for vitamin K antagonist and recommended for Xa inhibitor bleeding reversal), idarucizumab (registered for life-threatening bleeding and urgent procedures under dabigatran), and andexanet alfa (registered only for life-threatening bleeding under rivaroxaban and apixaban) are currently available to treat this group of patients. Considering the specific indications and the fact that some agents reverse only dabigatran (idarucizumab) or the anti-Xa DOACs (andexanet alfa), these agents need to be incorporated into local, regional, or national anticoagulation reversal protocols and guidelines.
Three cases of spontaneous major bleeding in patients with a COVID-19 infection
Published in Acta Chirurgica Belgica, 2023
Cornelis G. Vos, Joost Gravendeel, B. Paul J. A. Keller
The presented cases all illustrate the increased risk of bleeding in patients with therapeutic levels of anticoagulation. No iatrogenic punctures, local trauma or coughing preceded any of these bleeding complications. Furthermore, these major bleedings occurred in 3 patients admitted shortly after each other for PCR-proven COVID-19 disease suggesting a correlation between COVID-19 associated coagulopathy and increased bleeding risk. Of course, this observation is limited due to the small number of observations. Moreover, for the first case reported one could speculate whether this patient is not suffering from a to date still unidentified preexisting coagulopathy, when considering his medical history with pulmonary embolism and episodes of gastro-intestinal bleeding starting already one year before his SARS-CoV-2 infection.
Drugs in phase I and II clinical development for the prevention of stroke in patients with atrial fibrillation
Published in Expert Opinion on Investigational Drugs, 2021
Robert Bentley, Lewis J. Hardy, Laura J Scott, Parveen Sharma, Helen Philippou, Gregory Y. H. Lip
AF is the most common sustained arrhythmia. It is associated with significant patient morbidity and mortality chiefly because of the increased risk of associated thromboembolic complications. Patients with AF have a 5-fold increased risk of stroke; in fact, 20–30% of all strokes are attributed to this arrhythmia. Therapeutic anticoagulation offers clinical benefits to patients; however, these benefits are associated with significant adverse effects. Initiation and continuation of anticoagulation therapy thus requires routine screening, but this can significantly impact healthcare systems and service providers and the patient quality of life. Consequently, research is directed toward safer pharmacological approaches than those offered currently. A lower risk of adverse effects and a similar efficacy to current agents is desired, as is observed with VKAs and NOACs.