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Cardiovascular Drugs and Therapy Jun 2024Direct oral anticoagulants (DOACs) have been approved, for over a decade, by both European and American medicine agencies, for treatment and prevention of several... (Review)
Review
PURPOSE
Direct oral anticoagulants (DOACs) have been approved, for over a decade, by both European and American medicine agencies, for treatment and prevention of several cardiovascular conditions. Since then, an increasing amount of data has been added to the medical literature day by day, resulting in a dichotomy in selection of the appropriate agent, dosage, and duration of treatment for special populations with multiple comorbidities. Considering these issues, we have prepared a comprehensive review for the clinical practitioner, to optimize the DOAC utilization in clinical practice.
METHODS
A thorough literature search and review was conducted, concerning mainly the last decade. Our review focused on the current guidelines and the most recently published studies in PubMed, Science Direct Scopus, and Google Scholar to date.
CONCLUSION
The purpose of this study is to provide guidance for healthcare professionals for making proper decisions when confronted with clinical challenges. Nevertheless, further research is required to establish DOAC superiority in complicated cases, where there is clinical uncertainty.
Topics: Humans; Administration, Oral; Anticoagulants; Hemorrhage; Practice Guidelines as Topic; Factor Xa Inhibitors; Blood Coagulation; Cardiovascular Diseases
PubMed: 37552381
DOI: 10.1007/s10557-023-07499-0 -
The Chinese Journal of Dental Research Sep 2023To investigate the dental caries status and periodontal status of disabled children and adolescents aged 0 to 18 years in China and provide suggestions for future...
OBJECTIVE
To investigate the dental caries status and periodontal status of disabled children and adolescents aged 0 to 18 years in China and provide suggestions for future policies.
METHODS
The cross-sectional survey included disabled children and adolescents aged 0 to 18 years in welfare institutions across 10 provinces in eastern, central and western regions in China, between November 2013 and May 2015. Oral health examination included dental caries status and periodontal status. The mean score for decayed, missing and filled teeth (dmft/ DMFT) due to caries in primary/permanent dentition, gingival bleeding rate and calculus rate were recorded and statistically evaluated. Data analysis was performed using SPSS 24.0 software (IBM, Armonk, NY, USA), and the level of statistical significance was P < 0.05.
RESULTS
The mean dmft/DMFT values of for groups aged 0 to 5, 6 to 12 and 13 to 18 years were 1.48 ± 3.00, 2.19 ± 2.94 and 1.78 ± 2.93, respectively. The mean scores for the groups aged 0 to 5 (P < 0.05) and 13 to 18 years (P < 0.01) showed a significant difference among different disability types. A significant difference between sexes was found only in the group aged 0 to 5 years (P < 0.05). Gingival bleeding rates were 13.70% for the group aged 0 to 5 years, 24.81% for the group aged 6 to 12 years and 42.06% for the group aged 13 to 18 years, and calculus rates were 5.48%, 22.41% and 47.62% for the three age groups, respectively. The gingival bleeding rate for all three age groups showed a significant difference between different disability types (P < 0.01), whereas calculus rates a showed significant difference only in the groups aged 6 to 12 and 13 to 18 years (P < 0.01).
CONCLUSION
The prevalence of dental caries, gingival bleeding and calculus in disabled children and adolescents in China is high. Disability type was strongly associated with oral health status. Specially designed oral health education and training are necessary for clinical professionals and caregivers.
Topics: Child; Humans; Adolescent; Disabled Children; Cross-Sectional Studies; Dental Caries; Oral Health; China; Gingival Hemorrhage
PubMed: 37732683
DOI: 10.3290/j.cjdr.b4330833 -
Hematology. American Society of... Dec 2023Liver cirrhosis and splanchnic vein thrombosis (SVT) are strictly correlated. Portal vein thrombosis, the most common location of SVT, is frequently diagnosed in liver... (Review)
Review
Liver cirrhosis and splanchnic vein thrombosis (SVT) are strictly correlated. Portal vein thrombosis, the most common location of SVT, is frequently diagnosed in liver cirrhosis (pooled incidence 4.6 per 100 patient-years), and liver cirrhosis is a common risk factor for SVT (reported in 24%-28% of SVT patients). In cirrhosis-associated SVT, anticoagulant treatment reduces mortality rates, thrombosis extension, and major bleeding, and increases the rates of recanalization, compared to no treatment. Achieving vessel recanalization improves the prognosis of cirrhotic patients by reducing liver-related complications (such as variceal bleeding, ascites, hepatic encephalopathy). Anticoagulation should be therefore routinely prescribed to cirrhotic patients with acute SVT unless contraindicated by active bleeding associated with hemodynamic impairment or by excessively high bleeding risk. Of note, early treatment is associated with higher probability of achieving vessel recanalization. The standard treatment consists of low-molecular-weight heparin, followed by oral anticoagulants (eg, vitamin K antagonists or direct oral anticoagulants), if not contraindicated by severe liver dysfunction. Cirrhotic patients with SVT should be treated long-term (especially if candidate for liver transplantation) since liver cirrhosis is a persistent risk factor for recurrent thrombosis. In this review, we discuss the management of SVT in patients with liver cirrhosis, with a focus on the anticoagulant treatment in terms of indications, timing, drugs, duration, and particular scenarios, such as gastroesophageal varices and thrombocytopenia.
Topics: Humans; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Venous Thrombosis; Anticoagulants; Liver Cirrhosis; Thrombosis; Splanchnic Circulation
PubMed: 38066910
DOI: 10.1182/hematology.2023000481 -
Perfusion Sep 2023The optimal approach for anticoagulation in patients with bioprosthetic valves and atrial fibrillation (AF) remains a subject of debate. A meta-analysis using updated... (Review)
Review
BACKGROUND
The optimal approach for anticoagulation in patients with bioprosthetic valves and atrial fibrillation (AF) remains a subject of debate. A meta-analysis using updated evidence to evaluate the efficacy and safety of direct oral anticoagulants (DOACs) compared to vitamin K antagonists (VKAs) in patients with AF and bioprosthetic valves to address this controversy.
METHODS
A comprehensive search was conducted in multiple databases, including PubMed, Scopus, Web of Science, ProQuest, and the Cochrane Central Register of Controlled Trials, up until March 2023. The search aimed to identify relevant randomized controlled trials (RCTs) that examined the efficacy and safety outcomes of both direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) in patients with bioprosthetic valves and atrial fibrillation. The primary outcomes of interest were major bleeding and all-cause mortality.
RESULTS
Our study demonstrated that despite the difference was not significant, the hazard of all-cause mortality was 2.5% higher in the DOAC group (HR = 1.03, 95% CI = [0.88, 1.19], p-value = .75). Similarly, the hazard of stroke (HR = 1.03, 95% CI = [0.87, 1.32], p-value = .71) and major bleeding (HR = 1.11, 95% CI = [0.89, 1.38], p-value = .36) were found to be respectively 3.2 and 10.7% higher in the DOAC group, although the difference was not significant. However, the hazard of intracranial hemorrhage was found to be 28.8 lower in the DOAC treatment group (HR = 0.71, 95% CI = [0.39, 1.31], p-value = .27), which again was not statistically significant.
CONCLUSIONS
Our meta-analysis demonstrates that in patients undergoing bioprosthetic valve surgery and presenting with AF afterward, DOAC and VKA are similar regarding life-threatening and all-cause mortality outcomes, including major bleeding, stroke, and intracranial hemorrhage.
PubMed: 37697799
DOI: 10.1177/02676591231202383 -
Dentistry Journal May 2024This review's objective is to examine the findings from various studies on oral signs and symptoms related to vitamin deficiency. In October 2023, two electronic... (Review)
Review
This review's objective is to examine the findings from various studies on oral signs and symptoms related to vitamin deficiency. In October 2023, two electronic databases (Scopus and PubMed) were searched for published scientific articles following PRISMA principles. Articles eligible for inclusion in this review had to be published in English between 2017 and 2023, be original studies, and involve human subjects. Fifteen studies were included in this review: three examining oral symptoms of vitamin B12 deficiency; one assessing vitamin B complex and vitamin E for recurrent oral ulcers; one investigating serum vitamin D levels in recurrent aphthous stomatitis patients; three exploring hypovitaminosis effects on dental caries; two measuring blood serum vitamin D levels; one evaluating vitamin B12 hypovitaminosis; three investigating hypovitaminosis as indicative of gingival disease; one focusing on vitamin deficiencies and enamel developmental abnormalities; one assessing vitamin deficiencies in oral cancer patients; one examining vitamin K as an oral anticoagulant and its role in perioperative hemorrhage; and one evaluating vitamin effects on burning mouth syndrome. Despite some limitations, evidence suggests a correlation between vitamin deficiencies and oral symptoms. This systematic review was registered in the International Platform of Registered Systematic Review and Meta-analysis Protocols (INPLASY) database (202430039).
PubMed: 38920853
DOI: 10.3390/dj12060152 -
American Journal of Hematology Sep 2023Chronic kidney disease (CKD) confers a high risk of thrombosis and bleeding. However, little evidence exists regarding the optimal choice of postoperative...
Chronic kidney disease (CKD) confers a high risk of thrombosis and bleeding. However, little evidence exists regarding the optimal choice of postoperative thromboprophylaxis in these patients. We conducted a population-based, retrospective cohort study among adults ≥66 years old with CKD undergoing hip or knee arthroplasty who had filled an outpatient prophylactic anticoagulant prescription between 2010 and 2020 in Ontario, Canada. The primary outcomes of venous thrombosis (VTE) and hemorrhage were identified by validated algorithms using relevant diagnoses and billing codes. Overlap-weighted cause-specific Cox proportional hazard models were used to examine the association of direct oral anticoagulants (DOAC) on the 90-day risk of VTE and hemorrhage compared with low-molecular-weight heparin (LMWH). A total of 27 645 patients were prescribed DOAC (N = 22 943) or LMWH (N = 4702) after arthroplasty. Rivaroxaban was the predominant DOAC (94.5%), while LMWH mainly included enoxaparin (67%) and dalteparin (31.5%). DOAC users had higher eGFRs, fewer co-morbidities, and surgery in more recent years compared to LMWH users. After weighing, DOAC (compared with LMWH) was associated with a lower risk of VTE (DOAC: 1.5% vs. LMWH: 2.1%, weighted hazard ratio [HR] 0.75, 95% confidence interval [CI] 0.59-0.94) and a higher risk of hemorrhage (DOAC: 1.3% vs. LMWH: 1.0%, weighted HR 1.44, 95% CI 1.04-1.99). Additional analyses including a more stringent VTE defining algorithm, different eGFR cut-offs, and limiting to rivaroxaban and enoxaparin showed consistent findings. Among elderly adults with CKD, DOAC was associated with a lower VTE risk and a higher hemorrhage risk compared to LMWH following hip or knee arthroplasty.
Topics: Adult; Humans; Aged; Anticoagulants; Venous Thromboembolism; Heparin, Low-Molecular-Weight; Enoxaparin; Rivaroxaban; Arthroplasty, Replacement, Knee; Retrospective Studies; Hemorrhage; Renal Insufficiency, Chronic; Ontario
PubMed: 37340812
DOI: 10.1002/ajh.26994 -
The American Journal of Cardiology Oct 2023Left atrial appendage closure (LAAC) proved to be noninferior to oral anticoagulation (OAC) in nonablated patients with atrial fibrillation (AF). This study aimed to...
Left atrial appendage closure (LAAC) proved to be noninferior to oral anticoagulation (OAC) in nonablated patients with atrial fibrillation (AF). This study aimed to compare the efficacy and safety of LAAC with those of OAC therapy in patients after AF ablation. This study included patients who underwent catheter ablation (CA) of AF between January 2016 and December 2020. The cohort was divided into CA + LAAC and CA + OAC, where propensity score matching was used to select controls, and each group contained 682 subjects. The enrolled patients' mean age was 70.34 ± 8.32 years, and 47.3% were female; their CHADS-VASc score was 3.48 ± 1.17. Baseline characteristics were similar between groups. After a 3-year mean follow-up, the incidence of thromboembolic events was 1.25 and 1.10 and that of major bleeding events was 0.65 and 1.72 per 100 patient-years in the CA + LAAC, and CA + OAC groups, respectively. The rate of thromboembolisms and major adverse cardiovascular events was similar between the 2 groups (hazard ratio [HR] 1.162, 95% confidence interval [CI] 0.665 to 2.030, p = 0.598, HR 0.711, 95% CI 0.502 to 1.005, p = 0.053); however, that of major bleeding and all-cause death was significantly reduced with LAAC (HR 0.401, 95% CI 0.216 to 0.746, p = 0.004, HR 0.528, 95% CI 0.281 to 0.989, p = 0.046). There was no significant difference in periprocedural complications (p >0.05) and the rate of AF recurrence (OAC vs LAAC: 39.44% vs 40.62%, p = 0.658). LAAC is a reasonable and safer alternative to OAC therapy in high-risk patients after AF ablation.
Topics: Humans; Female; Middle Aged; Aged; Male; Atrial Fibrillation; Treatment Outcome; Atrial Appendage; Hemorrhage; Thromboembolism; Anticoagulants; Catheter Ablation; Stroke
PubMed: 37567023
DOI: 10.1016/j.amjcard.2023.07.059 -
Clinical Cardiology Nov 2023An unmet need exists to reliably predict the risk of intracranial hemorrhage (ICH) in patients with atrial fibrillation (AF) treated with oral anticoagulants (OACs).
BACKGROUND
An unmet need exists to reliably predict the risk of intracranial hemorrhage (ICH) in patients with atrial fibrillation (AF) treated with oral anticoagulants (OACs).
HYPOTHESIS
An externally validated model improves ICH risk stratification.
METHODS
Independent factors associated with ICH were identified by Cox proportional hazard modeling, using pooled data from the GARFIELD-AF (Global Anticoagulant Registry in the FIELD-Atrial Fibrillation) and ORBIT-AF (Outcomes Registry for Better Informed Treatment of Atrial Fibrillation) registries. A predictive model was developed and validated by bootstrap sampling and by independent data from the Danish National Patient Register.
RESULTS
In the combined training data set, 284 of 53 878 anticoagulated patients had ICH over a 2-year period (0.31 per 100 person-years; 95% confidence interval [CI]: 0.28-0.35). Independent predictors of ICH included: older age, prior stroke or transient ischemic attack, concomitant antiplatelet (AP) use, and moderate-to-severe chronic kidney disease (CKD). Vitamin K antagonists (VKAs) were associated with a significantly higher risk of ICH compared with non-VKA oral anticoagulants (NOACs) (adjusted hazard ratio: 1.61; 95% CI: 1.25-2.08; p = .0002). The ability of the model to discriminate individuals in the training set with and without ICH was fair (optimism-corrected C-statistic: 0.68; 95% CI: 0.65-0.71) and outperformed three previously published methods. Calibration between predicted and observed ICH probabilities was good in both training and validation data sets.
CONCLUSIONS
Age, prior ischemic events, concomitant AP therapy, and CKD were important risk factors for ICH in anticoagulated AF patients. Moreover, ICH was more frequent in patients receiving VKA compared to NOAC. The new validated model is a step toward mitigating this potentially lethal complication.
Topics: Humans; Anticoagulants; Atrial Fibrillation; Administration, Oral; Intracranial Hemorrhages; Stroke; Risk Factors; Registries; Renal Insufficiency, Chronic; Vitamin K
PubMed: 37596725
DOI: 10.1002/clc.24109 -
Hamostaseologie Dec 2023For life-threatening or uncontrollable bleeding in association with the thrombin inhibitor dabigatran, the monoclonal antibody fragment idarucizumab is available, and...
BACKGROUND
For life-threatening or uncontrollable bleeding in association with the thrombin inhibitor dabigatran, the monoclonal antibody fragment idarucizumab is available, and for bleeding in association with the direct factor Xa inhibitors rivaroxaban or apixaban, the modified recombinant FXa protein andexanet is available for reversal. These antidotes represent emergency drugs that are typically used only after performing guideline-compliant multimodal measures.
METHODS
An interdisciplinary group of experienced experts in the fields of angiology, hematology, internal medicine, clinical pharmacology, laboratory medicine, transfusion medicine, anesthesiology, intensive care, and hemostaseology developed recommendations relevant to daily clinical practice based on the current scientific evidence.
RESULTS
Reversal of oral anticoagulants should be considered for severe bleeding in the following situations: (1) life-threatening bleeding or refractory hemorrhagic shock, (2) intracerebral bleeding, or (3) endoscopically unstoppable gastrointestinal bleeding. After successful hemostasis, anticoagulation (e.g., direct oral anticoagulant, vitamin K antagonist, and heparin) should be resumed promptly, taking into account individual bleeding and thromboembolic risk.
DISCUSSION
This article aims to facilitate the management of patients with andexanet by all medical disciplines involved, thereby ensuring optimal care of patients during bleeding episodes.
Topics: Humans; Anticoagulants; Hemorrhage; Rivaroxaban; Heparin; Recombinant Proteins; Factor Xa Inhibitors; Administration, Oral
PubMed: 37813368
DOI: 10.1055/a-2136-2391 -
Pharmacoepidemiology and Drug Safety Dec 2023In addition to identifying new safety signals, pharmacovigilance databases could be used to identify potential risk factors for adverse drug reactions (ADRs).
INTRODUCTION
In addition to identifying new safety signals, pharmacovigilance databases could be used to identify potential risk factors for adverse drug reactions (ADRs).
OBJECTIVE
To evaluate whether data mining in a pharmacovigilance database can be used to identify known and possible novel risk factors for ADRs, for use in pharmacovigilance practice.
METHOD
Exploratory data mining was performed within the Swedish national database of spontaneously reported ADRs. Bleeding associated with direct oral anticoagulants (DOACs)-rivaroxaban, apixaban, edoxaban, and dabigatran-was used as a test model. We compared demographics, drug treatment, and clinical features between cases with bleeding (N = 965) and controls who had experienced other serious ADRs to DOACs (N = 511). Statistical analysis was performed by unadjusted and age adjusted logistic regression models, and the random forest based machine-learning method Boruta.
RESULTS
In the logistic regression, 13 factors were significantly more common among cases of bleeding compared with controls. Eleven were labelled or previously proposed risk factors. Cardiac arrhythmia (e.g., atrial fibrillation), hypertension, mental impairment disorders (e.g., dementia), renal and urinary tract procedures, gastrointestinal ulceration and perforation, and interacting drugs remained significant after adjustment for age. In the Boruta analysis, high age, arrhythmia, hypertension, cardiac failure, thromboembolism, and pharmacodynamically interacting drugs had a larger than random association with the outcome. High age, cardiac arrhythmia, hypertension, cardiac failure, and pharmacodynamically interacting drugs had odds ratios for bleeding above one, while thromboembolism had an odds ratio below one.
CONCLUSIONS
We demonstrated that data mining within a pharmacovigilance database identifies known risk factors for DOAC bleeding, and potential risk factors such as dementia and atrial fibrillation. We propose that the method could be used in pharmacovigilance for identification of potential ADR risk factors that merit further evaluation.
Topics: Humans; Anticoagulants; Stroke; Atrial Fibrillation; Pharmacovigilance; Hemorrhage; Thromboembolism; Risk Factors; Heart Failure; Hypertension; Dementia
PubMed: 37580910
DOI: 10.1002/pds.5679