#CHA2DS2-VASc Scores and Major #Bleeding in Patients With Nonvalvular Atrial Fibrillation Who Are Receiving Rivaroxaban
http://www.annemergmed.com/article/S0196-0644(16)31111-8/fulltext?rss=yes
Higher CHA2DS2-VASc scores are associated with increased incidence of major bleeding in nonvalvular atrial fibrillation patients receiving rivaroxaban.
http://www.annemergmed.com/article/S0196-0644(16)31111-8/fulltext?rss=yes
Higher CHA2DS2-VASc scores are associated with increased incidence of major bleeding in nonvalvular atrial fibrillation patients receiving rivaroxaban.
A Comparison of the Rate of Gastrointestinal #Bleeding in Patients Taking #Non-Vitamin K Antagonist Oral Anticoagulants or Warfarin
http://www.nature.com/ajg/journal/vaop/ncurrent/full/ajg201739a.html
We identified 803 patients on NOACs and 6,263 on warfarin. One hundred and fifty-eight patients on warfarin had GIB (2.5%), compared with only five patients (0.6%) on NOACs (odds ratio=4.13; 95% confidence interval: 1.69–10.09). Blood transfusion for GIB was significantly more common in patients on warfarin than on NOACs (64.6% vs. 20%, P=0.04). Within 90 days of GIB hospitalization, 12 patients (7.6%) in the warfarin group died, whereas there were no deaths in the NOAC group.
Conclusions:
In our patients, the incidence of GIB for those on warfarin was more than four times that for those on NOACs. Blood transfusions for GIB were more common in warfarin patients, and no NOAC patients died of GIB. In contrast to early reports, our findings suggest that the risk of GIB and subsequent complications is considerably lower for patients on NOACs than for patients on warfarin.
http://www.nature.com/ajg/journal/vaop/ncurrent/full/ajg201739a.html
We identified 803 patients on NOACs and 6,263 on warfarin. One hundred and fifty-eight patients on warfarin had GIB (2.5%), compared with only five patients (0.6%) on NOACs (odds ratio=4.13; 95% confidence interval: 1.69–10.09). Blood transfusion for GIB was significantly more common in patients on warfarin than on NOACs (64.6% vs. 20%, P=0.04). Within 90 days of GIB hospitalization, 12 patients (7.6%) in the warfarin group died, whereas there were no deaths in the NOAC group.
Conclusions:
In our patients, the incidence of GIB for those on warfarin was more than four times that for those on NOACs. Blood transfusions for GIB were more common in warfarin patients, and no NOAC patients died of GIB. In contrast to early reports, our findings suggest that the risk of GIB and subsequent complications is considerably lower for patients on NOACs than for patients on warfarin.
Age-specific risks, severity, time course, and outcome of #bleeding on long-term #antiplatelet treatment after vascular events: a population-based cohort study
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30770-5/fulltext?elsca1=tlpr
Lifelong antiplatelet treatment is recommended after ischaemic vascular events, on the basis of trials done mainly in patients younger than 75 years. Upper gastrointestinal bleeding is a serious complication, but had low case fatality in trials of aspirin and is not generally thought to cause long-term disability. Consequently, although co-prescription of proton-pump inhibitors (PPIs) reduces upper gastrointestinal bleeds by 70–90%, uptake is low and guidelines are conflicting. We aimed to assess the risk, time course, and outcomes of bleeding on antiplatelet treatment for secondary prevention in patients of all ages. The estimated NNT for routine PPI use to prevent one disabling or fatal upper gastrointestinal bleed over 5 years fell from 338 for individuals younger than 65 years, to 25 for individuals aged 85 years or older.
Interpretation
In patients receiving aspirin-based antiplatelet treatment without routine PPI use, the long-term risk of major bleeding is higher and more sustained in older patients in practice than in the younger patients in previous trials, with a substantial risk of disabling or fatal upper gastrointestinal bleeding. Given that half of the major bleeds in patients aged 75 years or older were upper gastrointestinal, the estimated NNT for routine PPI use to prevent such bleeds is low, and co-prescription should be encouraged.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30770-5/fulltext?elsca1=tlpr
Lifelong antiplatelet treatment is recommended after ischaemic vascular events, on the basis of trials done mainly in patients younger than 75 years. Upper gastrointestinal bleeding is a serious complication, but had low case fatality in trials of aspirin and is not generally thought to cause long-term disability. Consequently, although co-prescription of proton-pump inhibitors (PPIs) reduces upper gastrointestinal bleeds by 70–90%, uptake is low and guidelines are conflicting. We aimed to assess the risk, time course, and outcomes of bleeding on antiplatelet treatment for secondary prevention in patients of all ages. The estimated NNT for routine PPI use to prevent one disabling or fatal upper gastrointestinal bleed over 5 years fell from 338 for individuals younger than 65 years, to 25 for individuals aged 85 years or older.
Interpretation
In patients receiving aspirin-based antiplatelet treatment without routine PPI use, the long-term risk of major bleeding is higher and more sustained in older patients in practice than in the younger patients in previous trials, with a substantial risk of disabling or fatal upper gastrointestinal bleeding. Given that half of the major bleeds in patients aged 75 years or older were upper gastrointestinal, the estimated NNT for routine PPI use to prevent such bleeds is low, and co-prescription should be encouraged.
Association Between Use of Non–Vitamin K Oral #Anticoagulants With and Without Concurrent Medications and Risk of Major #Bleeding in Nonvalvular Atrial #Fibrillation
http://jamanetwork.com/journals/jama/article-abstract/2656168
Non–vitamin K oral anticoagulants (NOACs) are commonly prescribed with other medications that share metabolic pathways that may increase major bleeding risk
Concurrent use of amiodarone, fluconazole, rifampin, and phenytoin with NOACs had a significant increase in adjusted incidence rates per 1000 person-years of major bleeding than NOACs alone: 38.09 for NOAC use alone vs 52.04 for amiodarone (difference, 13.94 99% CI, 9.76-18.13); 102.77 for NOAC use alone vs 241.92 for fluconazole (difference, 138.46 99% CI, 80.96-195.97); 65.66 for NOAC use alone vs 103.14 for rifampin (difference, 36.90 99% CI, 1.59-72.22); and 56.07 for NOAC use alone vs 108.52 for phenytoin (difference, 52.31 [99% CI, 32.18-72.44; P < .01 for all comparisons). Compared with NOAC use alone, the adjusted incidence rate for major bleeding was significantly lower for concurrent use of atorvastatin, digoxin, and erythromycin or clarithromycin and was not significantly different for concurrent use of verapamil; diltiazem; cyclosporine; ketoconazole, itraconazole, voriconazole, or posaconazole; and dronedarone.
Conclusions and Relevance Among patients taking NOACs for nonvalvular atrial fibrillation, concurrent use of amiodarone, fluconazole, rifampin, and phenytoin compared with the use of NOACs alone, was associated with increased risk of major bleeding. Physicians prescribing NOAC medications should consider the potential risks associated with concomitant use of other drugs
http://jamanetwork.com/journals/jama/article-abstract/2656168
Non–vitamin K oral anticoagulants (NOACs) are commonly prescribed with other medications that share metabolic pathways that may increase major bleeding risk
Concurrent use of amiodarone, fluconazole, rifampin, and phenytoin with NOACs had a significant increase in adjusted incidence rates per 1000 person-years of major bleeding than NOACs alone: 38.09 for NOAC use alone vs 52.04 for amiodarone (difference, 13.94 99% CI, 9.76-18.13); 102.77 for NOAC use alone vs 241.92 for fluconazole (difference, 138.46 99% CI, 80.96-195.97); 65.66 for NOAC use alone vs 103.14 for rifampin (difference, 36.90 99% CI, 1.59-72.22); and 56.07 for NOAC use alone vs 108.52 for phenytoin (difference, 52.31 [99% CI, 32.18-72.44; P < .01 for all comparisons). Compared with NOAC use alone, the adjusted incidence rate for major bleeding was significantly lower for concurrent use of atorvastatin, digoxin, and erythromycin or clarithromycin and was not significantly different for concurrent use of verapamil; diltiazem; cyclosporine; ketoconazole, itraconazole, voriconazole, or posaconazole; and dronedarone.
Conclusions and Relevance Among patients taking NOACs for nonvalvular atrial fibrillation, concurrent use of amiodarone, fluconazole, rifampin, and phenytoin compared with the use of NOACs alone, was associated with increased risk of major bleeding. Physicians prescribing NOAC medications should consider the potential risks associated with concomitant use of other drugs
2017 ACC Expert Consensus Decision Pathway on Management of #Bleeding in Patients on Oral #Anticoagulants
A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways
http://www.onlinejacc.org/content/early/2017/11/10/j.jacc.2017.09.1085
.. Expert Consensus Documents are intended to provide guidance for clinicians in areas in which evidence may be limited or new and evolving, or in which data are insufficient to fully inform clinical decision making.
In an effort to increase the impact of ACC policy on patient care, an ACC Presidential Task Force was formed in 2014 to examine the ACC’s clinical documents. The main recommendation of the Task Force was a new focus on concise decision pathways and/or key points of care, instead of the traditional longer documents. The Task Force also established criteria for identifying high-value clinical topics to be addressed, as well as an innovative approach to collecting stakeholder input through a roundtable or think tank meeting. To complement the new focus on brief decision pathways and key points, Expert Consensus Documents were rebranded “Expert Consensus Decision Pathways” (ECDPs)
A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways
http://www.onlinejacc.org/content/early/2017/11/10/j.jacc.2017.09.1085
.. Expert Consensus Documents are intended to provide guidance for clinicians in areas in which evidence may be limited or new and evolving, or in which data are insufficient to fully inform clinical decision making.
In an effort to increase the impact of ACC policy on patient care, an ACC Presidential Task Force was formed in 2014 to examine the ACC’s clinical documents. The main recommendation of the Task Force was a new focus on concise decision pathways and/or key points of care, instead of the traditional longer documents. The Task Force also established criteria for identifying high-value clinical topics to be addressed, as well as an innovative approach to collecting stakeholder input through a roundtable or think tank meeting. To complement the new focus on brief decision pathways and key points, Expert Consensus Documents were rebranded “Expert Consensus Decision Pathways” (ECDPs)
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Full Study Report of #Andexanet Alfa for #Bleeding Associated with Factor Xa Inhibitors
https://www.nejm.org/doi/full/10.1056/NEJMoa1814051
In patients who had received apixaban, the median anti–factor Xa activity decreased from 149.7 ng per milliliter at baseline to 11.1 ng per milliliter after the andexanet bolus (92% reduction; 95% confidence interval [CI], 91 to 93); in patients who had received rivaroxaban, the median value decreased from 211.8 ng per milliliter to 14.2 ng per milliliter (92% reduction; 95% CI, 88 to 94). Excellent or good hemostasis occurred in 204 of 249 patients (82%) who could be evaluated. Within 30 days, death occurred in 49 patients (14%) and a thrombotic event in 34 (10%). Reduction in anti–factor Xa activity was not predictive of hemostatic efficacy overall but was modestly predictive in patients with intracranial hemorrhage.
CONCLUSIONS
In patients with acute major bleeding associated with the use of a factor Xa inhibitor, treatment with andexanet markedly reduced anti–factor Xa activity, and 82% of patients had excellent or good hemostatic efficacy at 12 hours, as adjudicated according to prespecified criteria.
Full Study Report of #Andexanet Alfa for #Bleeding Associated with Factor Xa Inhibitors
https://www.nejm.org/doi/full/10.1056/NEJMoa1814051
In patients who had received apixaban, the median anti–factor Xa activity decreased from 149.7 ng per milliliter at baseline to 11.1 ng per milliliter after the andexanet bolus (92% reduction; 95% confidence interval [CI], 91 to 93); in patients who had received rivaroxaban, the median value decreased from 211.8 ng per milliliter to 14.2 ng per milliliter (92% reduction; 95% CI, 88 to 94). Excellent or good hemostasis occurred in 204 of 249 patients (82%) who could be evaluated. Within 30 days, death occurred in 49 patients (14%) and a thrombotic event in 34 (10%). Reduction in anti–factor Xa activity was not predictive of hemostatic efficacy overall but was modestly predictive in patients with intracranial hemorrhage.
CONCLUSIONS
In patients with acute major bleeding associated with the use of a factor Xa inhibitor, treatment with andexanet markedly reduced anti–factor Xa activity, and 82% of patients had excellent or good hemostatic efficacy at 12 hours, as adjudicated according to prespecified criteria.
New England Journal of Medicine
Full Study Report of Andexanet Alfa for Bleeding Associated with Factor Xa Inhibitors | NEJM
Original Article from The New England Journal of Medicine — Full Study Report of Andexanet Alfa for Bleeding Associated with Factor Xa Inhibitors
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Gastrointestinal #bleeding prophylaxis for critically #ill patients: a clinical practice guideline
https://bit.ly/39UWX5w
Gastrointestinal #bleeding prophylaxis for critically #ill patients: a clinical practice guideline
https://bit.ly/39UWX5w
The BMJ
Gastrointestinal bleeding prophylaxis for critically ill patients: a clinical practice guideline
Clinical question What is the role of gastrointestinal bleeding prophylaxis (stress ulcer prophylaxis) in critically ill patients? This guideline was prompted by the publication of a new large randomised controlled trial.
Current practice Gastric acid suppression…
Current practice Gastric acid suppression…
Timing of #Endoscopy for Acute Upper Gastrointestinal #Bleeding
https://2medical.news/2020/04/07/timing-of-endoscopy-for-acute-upper-gastrointestinal-bleeding/
To evaluate whether urgent endoscopy improves outcomes in patients predicted to be at high risk for further bleeding or death, we randomly assigned patients with overt signs of acute upper gastrointestinal bleeding and a Glasgow–Blatchford score of 12 or higher (scores range from 0 to 23, with higher scores indicating a higher risk of further bleeding or death) to undergo endoscopy within 6 hours (urgent-endoscopy …
https://2medical.news/2020/04/07/timing-of-endoscopy-for-acute-upper-gastrointestinal-bleeding/
To evaluate whether urgent endoscopy improves outcomes in patients predicted to be at high risk for further bleeding or death, we randomly assigned patients with overt signs of acute upper gastrointestinal bleeding and a Glasgow–Blatchford score of 12 or higher (scores range from 0 to 23, with higher scores indicating a higher risk of further bleeding or death) to undergo endoscopy within 6 hours (urgent-endoscopy …
Efficacy and safety of gastrointestinal #bleeding prophylaxis in critically #ill patients: an updated systematic review and network meta-analysis of randomized trials
https://2medical.news/2020/08/28/efficacy-and-safety-of-gastrointestinal-bleeding-prophylaxis-in-critically-ill-patients-an-updated-systematic-review-and-network-meta-analysis-of-randomized-trials/
Motivated by a new randomized trial (the PEPTIC trial) that raised the issue of an increase in mortality with proton pump inhibitors (PPIs) relative to histamine-2 receptor antagonists (H2RAs), we updated our prior systematic review and network meta-analysis (NMA) addressing the impact of pharmacological gastrointestinal bleeding prophylaxis in critically ill patients. Seventy-four trials enrolling 39 569 patients proved eligible. Both PPIs (risk ratio (RR) 1.03, …
https://2medical.news/2020/08/28/efficacy-and-safety-of-gastrointestinal-bleeding-prophylaxis-in-critically-ill-patients-an-updated-systematic-review-and-network-meta-analysis-of-randomized-trials/
Motivated by a new randomized trial (the PEPTIC trial) that raised the issue of an increase in mortality with proton pump inhibitors (PPIs) relative to histamine-2 receptor antagonists (H2RAs), we updated our prior systematic review and network meta-analysis (NMA) addressing the impact of pharmacological gastrointestinal bleeding prophylaxis in critically ill patients. Seventy-four trials enrolling 39 569 patients proved eligible. Both PPIs (risk ratio (RR) 1.03, …
#Endoscopy-related #bleeding and thromboembolic events in patients on direct oral anticoagulants or vitamin K antagonists
https://2medical.news/2021/01/03/endoscopy-related-bleeding-and-thromboembolic-events-in-patients-on-direct-oral-anticoagulants-or-vitamin-k-antagonists/
Few prospective studies have assessed the safety of direct oral anticoagulants (DOACs) in elective endoscopy. Our primary aim was to compare the risks of endoscopy-related gastrointestinal bleeding and thromboembolic events in patients on DOACs or vitamin K antagonists (VKAs) in this setting. Secondarily, we examined the impact of the timing of anticoagulant resumption on the risk of delayed bleeding in high-risk therapeutic procedures.. The 2 …
https://2medical.news/2021/01/03/endoscopy-related-bleeding-and-thromboembolic-events-in-patients-on-direct-oral-anticoagulants-or-vitamin-k-antagonists/
Few prospective studies have assessed the safety of direct oral anticoagulants (DOACs) in elective endoscopy. Our primary aim was to compare the risks of endoscopy-related gastrointestinal bleeding and thromboembolic events in patients on DOACs or vitamin K antagonists (VKAs) in this setting. Secondarily, we examined the impact of the timing of anticoagulant resumption on the risk of delayed bleeding in high-risk therapeutic procedures.. The 2 …
Major GI #bleeding in older persons using #aspirin: incidence and risk factors in the ASPREE randomised controlled trial
https://2medical.news/2021/03/14/major-gi-bleeding-in-older-persons-using-aspirin-incidence-and-risk-factors-in-the-aspree-randomised-controlled-trial/
There is a lack of robust data on significant gastrointestinal bleeding in older people using aspirin. We calculated the incidence, risk factors and absolute risk using data from a large randomised, controlled trial. Design Data were extracted from an aspirin versus placebo primary prevention trial conducted throughout 2010–2017 (‘ASPirin in Reducing Events in the Elderly (ASPREE)’, n=19 114) in community-dwelling persons aged ≥70 years. Clinical characteristics …
https://2medical.news/2021/03/14/major-gi-bleeding-in-older-persons-using-aspirin-incidence-and-risk-factors-in-the-aspree-randomised-controlled-trial/
There is a lack of robust data on significant gastrointestinal bleeding in older people using aspirin. We calculated the incidence, risk factors and absolute risk using data from a large randomised, controlled trial. Design Data were extracted from an aspirin versus placebo primary prevention trial conducted throughout 2010–2017 (‘ASPirin in Reducing Events in the Elderly (ASPREE)’, n=19 114) in community-dwelling persons aged ≥70 years. Clinical characteristics …
Long-Term Risk for Major #Bleeding During Extended Oral Anticoagulant Therapy for First Unprovoked Venous #Thromboembolism
https://2medical.news/2021/09/18/long-term-risk-for-major-bleeding-during-extended-oral-anticoagulant-therapy-for-first-unprovoked-venous-thromboembolism/
https://2medical.news/2021/09/18/long-term-risk-for-major-bleeding-during-extended-oral-anticoagulant-therapy-for-first-unprovoked-venous-thromboembolism/
2Medical.News
Long-Term Risk for Major #Bleeding During Extended Oral Anticoagulant Therapy for First Unprovoked Venous #Thromboembolism
The long-term risk for major bleeding in patients receiving extended (beyond the initial 3 to 6 months) anticoagulant therapy for a first unprovoked venous thromboembolism (VTE) is uncertain. Purpo…
Low-Dose #Aspirin and the Risk of #Stroke and Intracerebral #Bleeding in Healthy Older People Secondary Analysis of a Randomized Clinical Trial
https://2medical.news/2023/08/03/low-dose-aspirin-and-the-risk-of-stroke-and-intracerebral-bleeding-in-healthy-older-people-secondary-analysis-of-a-randomized-clinical-trial/
https://2medical.news/2023/08/03/low-dose-aspirin-and-the-risk-of-stroke-and-intracerebral-bleeding-in-healthy-older-people-secondary-analysis-of-a-randomized-clinical-trial/
2Medical.News
Low-Dose #Aspirin and the Risk of #Stroke and Intracerebral #Bleeding in Healthy Older People Secondary Analysis of a Randomized…
Low-dose aspirin has been widely used for primary and secondary prevention of stroke. The balance between potential reduction of ischemic stroke events and increased intracranial bleeding has not b…