1,721,029 research outputs found
The future of anticoagulation clinics: a journey to thrombosis centers?
No full textCoumarins were discovered in the late 1930s as a result
of decades of research spent identifying the cause of a
hemorrhagic disease in cattle. At first they were used as
rat poison, but from the mid 1950s they began to have
some clinical impact.1 Since their efficacy was proved in
several clinical studies,2 the use of coumarins, in particular
warfarin, has increased progressively in many countries.
Concomitantly with their clinical use, there was a
need for more precise laboratory control, since bleeding
can at times be fatal. Over the years the prothrombin
time, as a monitoring test to tailor the dosage of oral anticoagulants
in the single patient, underwent a process of
standardization, which was started in 1962 by Leon
Poller.3 In 1983 Kirkwood4 proposed the international
normalized ratio (INR) system, approved by the World
Health Organisation. Despite a few limitations, the INR,
recently reviewed by Poller,5 is currently the standard
way to express the result of a prothrombin time test, and
has served to validate the efficacy of oral anticoagulants
in a number of clinical studies
Has time come for the use of direct oral anticoagulants in the extended prophylaxis of venous thromboembolism in acutely ill medical patients? No
No full textAcutely ill hospitalized medical patients are at high risk of venous thromboembolism (VTE). Although thromboprophylaxis in these patients is recommended since 2004 by the American College of Chest Physicians, it is widely underused. The doubt as to whether or not to treat patients at high VTE risk after hospital discharge came from the knowledge that this risk may persist after the hospital admission period. Two meta-analyses comparing extended- versus short-duration prophylaxis are published. The results demonstrate an unfavorable balance between VTE prevention and incidence of major bleeding in patients assigned to extended-duration thromboprophylaxis. Only in the APEX study, betrixaban, a direct inhibitor of factor Xa, shows similar efficacy and safety compared to enoxaparin. However, while it is very promising, oral anticoagulant phase III studies and post-marketing registers are lacking. Moreover, betrixaban has a long half-life, an excretion in the gut by means of P-glycoprotein, and the lack of an antidote. These characteristics and the meta-analysis results prompt us to answer no to the extended thromboprophylaxis in hospitalized medical patients, at least now
Direct oral anticoagulants: what can we learn?
No full textDirect oral anticoagulants (DOACs) represent an innovation because they avoid periodic laboratory monitoring, and also reduce cerebral bleeding. An examination of the performance of DOACs versus warfarin in randomized clinical trials dedicated to atrial fibrillation would reveal the poor performance of warfarin because the percentage of major bleeding is always above 3%; however, the percentage of major bleeding is less than half of that when the management is done in anticoagulation clinics (ACs). Several years ago, a common opinion was that ACs would disappear as soon as DOACs enter the market. We proposed then that ACs could be transformed into thrombosis centres (TCs) because we envisaged many new activities in terms of diagnostic tools and therapeutic choices. After the introduction of DOACs, the role of the ACs has been re-evaluated because their role may be crucial in selecting both the most appropriate diagnostic approach and the best therapeutic option (including anti-vitamin K drugs) for the single patient. TCs can organize a regular follow-up to improve patient adherence to DOACs. Marketing might have a role in the decision making of the single doctor. Efforts should be made for limiting the relationships between doctors and pharmaceutical companies. It seems reasonable to better prepare doctors, during their university courses, for them to develop a greater scientific culture that would enable them to critically read clinical studies and acquire an independent opinion. Ideally, an expert in haemostasis and thrombosis should handle new and old anticoagulants
Fondaparinux: Should It Be Studied in Patients with COVID-19 Disease?
Full text linkWe have read with interest the review article by Bikdeli et al recently published in Thrombosis and Haemostasis on the priority in planning studies on the different anticoagulants in coronavirus disease 2019 (COVID-19) infection.[1] The authors describe the characteristics of both the anticoagulants available today and in the future. Antiplatelets drugs have been also considered. Surprisingly, fondaparinux (FPX) has reached a lower priority research mean (4.89) than unfractionated heparin (UFH) and low-molecular weight heparin (LMWH) at intermediate (7.82) or therapeutic (7.53) dosage for hospitalized ward and intensive care unit patients. We believe that properties of these drugs have been overlooked by the scientific panel of the Global COVID-19 Thrombosis Collaborative Group
Pulmonary Thrombosis: A Clinical Pathological Entity Distinct from Pulmonary Embolism?
No full textSince Virchow's autopsy studies in the mid-1800s, it has generally been believed that pulmonary embolism (PE) originated from the embolization of fibrin fragments from a deep venous thrombosis (DVT). However, a DVT is often not found in patients with PE (up to 50% of cases). Could fibrin form in the pulmonary vessels without coming from the periphery? In this review, the authors will try to support the hypothesis that a pulmonary thrombosis (PT) may develop. They will do so through different clinical models related to some pathological conditions such as pneumonia, chronic obstructive pulmonary disease (COPD), and asthma, all of which show a close relationship between local inflammation and activation of blood coagulation, two defensive systems that may lead to fibrin deposition in the lungs, thus recognizing the possibility that PT may be a newly recognized entity. An increased risk for PE has been demonstrated in these conditions. Sickle cell disease and assisted reproductive technologies are other very different conditions in which an increased risk for PE has been found. Gaucher's disease is a rare hereditary condition in which the hemostatic system could have a role in the pathogenesis of pulmonary hypertension, which complicates the course of the disease. In particular, the increased risk for PT, common to all these conditions, deserves attention when a patient presents with sudden dyspnea, an unexpected COPD exacerbation, or severe sudden asthmatic dyspnea. As a consequence, prediction scores for venous thromboembolism could be revised
Empathy and the Educational Approach to Patients With Atrial Fibrillation Treated With Direct Oral Anticoagulants
No full textDirect Oral Anticoagulants (DOACs) have shown to be at least effective and safer than anti-vitamin K (VKA) for the prophylaxis of cardioembolism during AF. These drugs do not need laboratory monitoring such as the VKA anticoagulants, but they are at risk of poor adherence and persistence as all drugs taken by mouth. Against this drawback, empathy may have an important role because it is important as a tool to be used for effective interpersonal communication. Patients like to be heard and understand that those who listen to them are immersed in their world. Empathy is part, and is a founding principle, of Narrative Medicine which today is a real discipline with many advantages because it is intrinsically therapeutic for the patient (in telling and being heard). Empathy prevents the disconnection that can intervene between the doctor and the patients. Have we ever wondered if we are sufficiently empathetic? Is it possible to measure our empathy? Yes, across Jefferson's scale. A high score on Jefferson's scale could certainly further improve the quality of the management of anticoagulated patients
Underuse of anticoagulant therapy in hospitalized older patients: comment on the article of Wojszel et al
No full textVitamin K antagonists (coumarins), drugs used in the prevention and treatment of cardioembolism, deep vein thrombosis, and pulmonary embolism
No full textVitamin K antagonists are anticoagulants discovered in 1940. They are still used today in the primary and secondary prophylaxis of cardioembolism due to atrial fibrillation and deep vein thrombosis and pulmonary embolism. Warfarin, acenocoumarol, and phenprocoumon are available on the market, and they block the enzyme epoxide reductase that normally brings back the vitamin K epoxide to its reduced form, the only one capable of inducing carboxylation of the Gla-protein residues of four vitamin K-dependent coagulative factors (II, VII, IX, and X). A monitoring test such as the prothrombin time INR is required to properly adjust the dose needed to optimize the prevention of both thrombotic and bleeding episodes. In this chapter, several practical points, mainly related to our experience in the field, are considered: diet, patient education, quality of life, point-of-care monitoring, organization, and new competitors (direct oral anticoagulants thrombin and factor Xa inhibitors)
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