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- Gorog, Diana A, et al.
(författare)
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Assessment and Mitigation of Bleeding Risk in Atrial Fibrillation and Venous Thromboembolism : Executive Summary of a European and Asia-Pacific Expert Consensus Paper
- 2022
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Ingår i: Thrombosis and Haemostasis. - : Georg Thieme Verlag KG. - 0340-6245 .- 2567-689X. ; 122:10, s. 1625-1652
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Forskningsöversikt (refereegranskat)abstract
- While there is a clear clinical benefit of oral anticoagulation in patients with atrial fibrillation (AF) and venous thromboembolism (VTE) in reducing the risks of thromboembolism, major bleeding events (especially intracranial bleeds) may still occur and be devastating. The decision for initiating and continuing anticoagulation is often based on a careful assessment of both thromboembolism and bleeding risk. The more common and validated bleeding risk factors have been used to formulate bleeding risk stratification scores, but thromboembolism and bleeding risk factors often overlap. Also, many factors that increase bleeding risk are transient and modifiable, such as variable international normalized ratio values, surgical procedures, vascular procedures, or drug-drug and food-drug interactions. Bleeding risk is also not a static "one-off" assessment based on baseline factors but is dynamic, being influenced by aging, incident comorbidities, and drug therapies. In this executive summary of a European and Asia-Pacific Expert Consensus Paper, we comprehensively review the published evidence and propose a consensus on bleeding risk assessments in patients with AF and VTE, with a view to summarizing "best practice" when approaching antithrombotic therapy in these patients. We address the epidemiology and size of the problem of bleeding risk in AF and VTE, and review established bleeding risk factors and summarize definitions of bleeding. Patient values and preferences, balancing the risk of bleeding against thromboembolism, are reviewed, and the prognostic implications of bleeding are discussed. We propose consensus statements that may help to define evidence gaps and assist in everyday clinical practice.
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- Rubboli, A., et al.
(författare)
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Low-molecular-weight heparins in conjunction with thrombolysis for ST-elevation acute myocardial infarction : A critical review of the literature
- 2007
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Ingår i: Cardiology. - : S. Karger AG. - 0008-6312 .- 1421-9751. ; 107:2, s. 132-139
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Forskningsöversikt (refereegranskat)abstract
- Background: Intravenous unfractionated heparin (UFH) is recommended in ST-elevation acute myocardial infarction (STEMI), following thrombolysis with fibrin-specific agents. Subcutaneous low-molecular-weight heparins (LMWH), previously proven effective in non-ST-elevation acute coronary syndromes, have been recently investigated in the setting of STEMI. We aimed at evaluating the current level of evidence supporting the use of LMWH in STEMI. Methods: A Medline search of the English language literature between January 1995 and December 2005 was performed and randomized clinical trials comparing LMWH to either placebo or UFH in conjunction with thrombolysis were selected. Results: About 26,800 patients treated with various thrombolytic regimens were included in 12 randomized clinical trials. Dalteparin was superior to placebo on left ventricular thrombosis/arterial thromboembolism, with no significant effect on the early patency rate of the infarct-related artery (IRA). Compared to UFH, dalteparin had no significant effect on clinical events and on the IRA late patency, although less thrombus was present. Enoxaparin was superior to placebo on the medium-term death/reinfarction/angina rate and late IRA patency, and superior also to UFH on in-hospital and medium-term occurrence of death/reinfarction/angina. The effect of enoxaparin on IRA patency rate was not univocal. Compared to placebo, reviparin significantly reduced early and medium-term mortality and reinfarction rates, without a substantial increase in overall stroke rate. As regards safety, bleedings were more frequent than placebo and comparable to UFH in LMWH groups, with the exception of the pre-hospital ASSENT-3 PLUS trial, where in elderly patients, enoxaparin had an incidence of intracranial hemorrhage twice higher than UFH. Conclusions: In-hospital subcutaneous administration of dalteparin, enoxaparin or reviparin, as an adjunct to various thrombolytics in STEMI, appears feasible and at least as effective and safe as intravenous UFH. Before LMWH might be recommended, however, some yet unresolved issues (i.e. use in elderly patients, in severe renal insufficiency, in association with glycoprotein IIb/IIIa inhibitors and during interventional procedures), need to be addressed. Copyright © 2007 S. Karger AG.
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