Tag Archives: bleeding

Introduction Anticoagulant therapy is an essential component in the treatment and prevention of venous and arterial thromboembolic events. In recent years, direct-acting oral anticoagulants (DOACs) have replaced vitamin K antagonists (VKAs) for many of these indications, due to their more favourable risk-benefit profile.1 Despite this, bleeding remains a significant concern with DOACs, especially in patients at high risk, such as those with an indication for concurrent antiplatelet therapy, and may lead to poor adherence or undertreatment.2–4 Safer anticoagulation that spares haemostasis without compromising efficacy is, therefore, desirab

Introduction Bleeding post cardiac surgery carries significant patient mortality and morbidity including resternotomy, increased hospital stays, and blood product transfusion.1,2 Bleeding is more severe in patients who are taking pre-operative antiplatelet or anticoagulation medications that have not been stopped sufficiently in advance to minimise such risks. Current guidelines across Europe recommend stopping such agents at least two to five days prior to surgery; they also recommend delaying urgent surgery so that the risk of perioperative bleeding is minimised.3 However, this is not always possible in the setting of urgent and emergency c

Introduction Atrial fibrillation (AF) more than doubles the five-year risk of stroke in middle-aged men and women.1 Prior cerebrovascular disease markedly amplifies the risk of recurrent stroke in patients with or without AF.1,2 Figure 1 shows the influence of AF and prior cerebrovascular disease (stroke or transient ischaemic attack [TIA]) on the estimated five-year risk of a composite of stroke, systemic thromboembolism, or TIA (most events were ischaemic strokes) for a 60-year-old individual, from a large cohort study conducted in the UK.1 These observations demonstrate the need for long-term treatment to reduce the risk of stroke in thes

European Society of Cardiology congress 2018, held in Munich The principal safety outcome of major bleeding also showed no significant difference between the rivaroxaban and placebo groups. Rivaroxaban, however, did reduce the rate of symptomatic VTE only, and symptomatic VTE and all-cause mortality, compared to placebo. On leaving hospital, the rate of symptomatic VTE more than doubles over the first 21 days and is associated with a five-fold increased risk of fatal pulmonary embolism (PE) within 30 days post-discharge. The MARINER trial investigated whether continuing thromboprophylaxis with an oral anticoagulant after discharge could reduc

Dr Matthew Fay, a Bradford GP and specialist member of the committee that developed the standard, said: “This quality standard brings into sharp focus the key issue of stroke prevention. In doing so it continues to highlight the need for a change in practice so that everyone with AF is considered for anticoagulation and the quality of that anticoagulation is always kept under review by clinicians and commissioning groups.” The quality standard includes six statements aimed at healthcare professionals caring for people in danger of developing, or who already have, AF. These include: Adults with a type of AF called ‘non-valvular’ w

Introduction Atrial fibrillation (AF) affects up to 2% of the population, its prevalence increasing with age; and, with the anticipated rise in the average age of the population, it is likely that the rate of AF will rise considerably. There is a significant risk of stroke, heart failure and mortality associated with AF. Both the National Institute for Health and Care Excellence (NICE) and National Health Service (NHS) Improvement have identified AF and stroke prevention as key areas for maintaining healthcare quality and improvements.1 A key feature is the early identification of patients at risk of thromboembolic events and the prompt init

Stroke risk assessment in AF New insights on stroke risk assessment were provided by Dr Ami Banerjee (University of Birmingham), in a session supported by the Atrial Fibrillation Association. Table 1. CHADS2 score The CHADS2 risk stratification scoring system (table 1) is currently the indicator for the Quality and Outcomes (QoF) framework used to determine whether an atrial fibrillation (AF) patient warrants anticoagulation. It may underestimate risk and those with a score of zero may actually be at substantial stroke risk. He also pointed out that the system has inherent disadvantages. It does not include many of the risk factors for stroke

The study, published in Circulation on June 14 (Circulation 2012; 126:343–8.  http://dx.doi.org/10.1161/CIRCULATIONAHA.111.090464), reported bleeding rates in RE-LY from seven days before until 30 days following invasive procedures in a total of 4,591 patients. Procedures included pacemaker/defibrillator insertion, dental procedures, diagnostic procedures, cataract removal, colonoscopy, and joint replacement. Among patients assigned to dabigatran, the last dose of study drug was given an average of 49 hours prior to the procedure, compared with 114 hours in patients receiving warfarin. Bridging anticoagulation with heparin was given in 28%

The authors, led by Professor Kausik Ray (St George’s University of London) conclude that the modest benefits and the significant increase in risk of bleeding do not justify routine use of aspirin in primary prevention, but that aspirin may be considered in certain higher-risk groups. The recently published meta-analysis (Arch Intern Med 2012;172:209–16), included nine randomised placebo-controlled trials with a total of 100,000 participants. Results (table 1) showed that during a mean follow-up of six years, aspirin treatment reduced total cardiovascular events by 10%, driven primarily by a reduction in non-fatal myocardial infarction (M

Identifying targets in the thrombosis pathway Figure 1. Central role of platelets and interaction with coagulation in the genesis of thrombosis (1) Figure 1 summarises the central role of platelets in the genesis of thrombosis.1 The platelet is initially activated in response to shear stress, events such as percutaneous coronary intervention (PCI) or plaque rupture, and the release of local agonists and exposure of the subendothelial components to flowing blood. Tissue factor ‘lights the fire’ by producing minute quantities of thrombin which then amplify the process. Binding of platelets to collagen and von Willebrand