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Revista Medica de Chile May 2021Vitamin K antagonists such as acenocoumarol and warfarin are usually indicated for the treatment of Atrial Fibrillation (AF). The Therapeutic Range Time (TRT) is a...
BACKGROUND
Vitamin K antagonists such as acenocoumarol and warfarin are usually indicated for the treatment of Atrial Fibrillation (AF). The Therapeutic Range Time (TRT) is a quality of treatment indicator. Values greater than 65% are associated with significantly lower stroke and bleeding rates. Proper pharmaceutical care improves TRT.
AIM
To evaluate the impact of pharmaceutical care in patients with AF treated with acenocoumarol.
MATERIAL AND METHODS
We studied 41 patients using acenocoumarol for AF aged 71 ± 11 years (43% women). They received pharmaceutical counseling during 12 weeks. TRT was calculated retrospectively for the year before counseling and prospectively during the intervention period.
RESULTS
After receiving pharmaceutical counseling TRT improved from 29% at baseline to 46% at the end of the intervention (p < 0.01). After pharmaceutical care, the adherence of patients to drug treatment improved from 27% at baseline to 85% at the end of the study. The user satisfaction survey of the pharmaceutical care received showed a high degree of patient satisfaction.
CONCLUSIONS
Pharmaceutical care in patients with oral anticoagulant treatment improves TRT of anticoagulation. It is accepted and positively evaluated by patients.
Topics: Administration, Oral; Anticoagulants; Atrial Fibrillation; Counseling; Female; Humans; Male; Pharmaceutical Preparations; Retrospective Studies; Stroke
PubMed: 34751325
DOI: 10.4067/s0034-98872021000500724 -
The Neurologist Nov 2021Protein S deficiency and coronavirus disease 2019 (COVID-19) are rare etiologies of ischemic stroke. We describe a case of an ischemic stroke revealing severe acute...
INTRODUCTION
Protein S deficiency and coronavirus disease 2019 (COVID-19) are rare etiologies of ischemic stroke. We describe a case of an ischemic stroke revealing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in a patient with a history of protein S deficiency and cerebral imaging suggestive of vasculitis.
CASE REPORT
A 52-year-old woman, with history of protein S deficiency, was admitted for right hemiparesis and aphasia that happened 6 hours before her consultation. Her National Institutes of Health Stroke Scale (NIHSS) was 11. She had hypoxia (SpO2 93%). COVID-19 polymerase chain reaction was positive. Cerebral computed tomography scan showed an ischemic stroke in the territory of the superficial left middle cerebral artery. The recommended time period for thrombolysis was exceeded and we did not dispose of sufficient resources to deliver thrombectomy. She was treated with aspirin, statins, antibiotic therapy, and oxygen. Considering the high risk of thromboembolic complications and the history of protein S deficiency, anticoagulation treatment with heparin followed by acenocoumarol was started. Evolution was marked by the appearance of 24 hours regressive, acute symptoms of confusion. Brain magnetic resonance imaging showed new ischemic strokes in both anterior cerebral arteries and on magnetic resonance angiography narrowing of the left internal carotid artery and both anterior cerebral arteries suggestive of vasculitis was seen. We maintained anticoagulation and prescribed methylprednisolone 500 mg daily for 3 days. Evolution was marked by improvement of clinical deficit and respiratory status.
CONCLUSIONS
SARS-CoV-2 infection potentializes the prothrombotic effect and vascular inflammation by accentuating protein S deficit. The place of steroids seems justifiable in the presence of symptoms of vasculitis in brain imaging.
Topics: Brain Ischemia; COVID-19; Female; Humans; Middle Aged; Protein S Deficiency; SARS-CoV-2; Stroke
PubMed: 34734908
DOI: 10.1097/NRL.0000000000000367 -
Biomedica : Revista Del Instituto... Sep 2021We present the clinical case of a 10-year-old patient diagnosed with dilated cardiomyopathy who registered INR values above 10 upon receiving standard doses of...
We present the clinical case of a 10-year-old patient diagnosed with dilated cardiomyopathy who registered INR values above 10 upon receiving standard doses of acenocoumarol, as well as other values reported as uncoagulable, forcing the discontinuation and restart of treatment more than once. Expected and stable INR levels were achieved after more than 30 days of treatment, surprisingly with half the recommended dose for a patient of her age and weight. We decided to conduct a retrospective pharmacogenomic analysis including nucleotide genetic polymorphisms (SNPs) with different degrees of association with the dose/response to antivitamin K (AVK) drugs: rs2108622 (gene CYP4F2), rs9923231, rs7294 (gene VKORC1), rs1799853, and rs1057910 (CYP2C9 gene) using TaqMan® RT-PCR. The patient was homozygous for rs9923231 (VKORC1) and heterozygous for rs2108622 (CYP4F2),a genetic profile strongly associated with a requirement of lower AVK doses as shown by national and international evidence. In conclusion, the pharmacogenetic analysis confirmed that this patient’s genetic conditions, involving low expression of the VKA therapeutic target, required a lower dose than that established in clinical protocols as recommended by the Food and Drug Administration (FDA) and the PharmGKB® for coumarin drugs. A previous genotypic analysis of the patient would have allowed reaching the therapeutic range sooner, thus avoiding potential bleeding risks. This shows the importance of pharmacogenetic analyses for highly variable treatments with a narrow therapeutic range.
Topics: Anticoagulants; Child; Female; Genotype; Humans; Pharmacogenomic Testing; Polymorphism, Single Nucleotide; Retrospective Studies; Vitamin K Epoxide Reductases
PubMed: 34559488
DOI: 10.7705/biomedica.5840 -
Annals of the Rheumatic Diseases May 2021Vitamin K is hypothesised to play a role in osteoarthritis (OA) pathogenesis through effects on vitamin K-dependent bone and cartilage proteins, and therefore may...
OBJECTIVES
Vitamin K is hypothesised to play a role in osteoarthritis (OA) pathogenesis through effects on vitamin K-dependent bone and cartilage proteins, and therefore may represent a modifiable risk factor. A genetic variant in a vitamin K-dependent protein that is an essential inhibitor for cartilage calcification, matrix Gla protein (MGP), was associated with an increased risk for OA. Vitamin K antagonist anticoagulants (VKAs), such as warfarin and acenocoumarol, act as anticoagulants through inhibition of vitamin K-dependent blood coagulation proteins. VKAs likely also affect the functioning of other vitamin K-dependent proteins such as MGP.
METHODS
We investigated the effect of acenocoumarol usage on progression and incidence of radiographic OA in 3494 participants of the Rotterdam Study cohort. We also examined the effect of and single nucleotide variants on this association.
RESULTS
Acenocoumarol usage was associated with an increased risk of OA incidence and progression (OR=2.50, 95% CI=1.94-3.20), both for knee (OR=2.34, 95% CI=1.67-3.22) and hip OA (OR=2.74, 95% CI=1.82-4.11). Among acenocoumarol users, carriers of the high ) expression haplotype together with the OA risk allele (rs1800801-T) had an increased risk of OA incidence and progression (OR=4.18, 95% CI=2.69-6.50), while this relationship was not present in non-users of that group (OR=1.01, 95% CI=0.78-1.33).
CONCLUSIONS
These findings support the importance of vitamin K and vitamin K-dependent proteins, as MGP, in the pathogenesis of OA. Additionally, these results may have direct implications for the clinical prevention of OA, supporting the consideration of direct oral anticoagulants in favour of VKAs.
Topics: 4-Hydroxycoumarins; Acenocoumarol; Aged; Alleles; Anticoagulants; Calcium-Binding Proteins; Disease Progression; Extracellular Matrix Proteins; Female; Humans; Incidence; Indenes; Male; Middle Aged; Osteoarthritis; Polymorphism, Single Nucleotide; Prospective Studies; Vitamin K; Vitamin K Epoxide Reductases; Matrix Gla Protein
PubMed: 34412027
DOI: 10.1136/annrheumdis-2020-219483 -
Revista de Neurologia Sep 2021Spontaneous intracerebral haemorrhage associated with oral anticoagulants (ICH-OAC) has a high mortality rate. The emergence of new anticoagulant drugs and reversal... (Observational Study)
Observational Study
INTRODUCTION
Spontaneous intracerebral haemorrhage associated with oral anticoagulants (ICH-OAC) has a high mortality rate. The emergence of new anticoagulant drugs and reversal protocols increases interest in this entity.
OBJECTIVES
The main objective is to determine the mortality rate in patients with ICH-OAC (early, in-hospital, global) in our health area and to analyse the main variables related to it. The secondary objective is to determine the efficacy of anticoagulation reversal therapies (ART) as reflected by radiological expansion of the haematoma and the functional prognosis.
PATIENTS AND METHODS
A prospective observational study that introduced a protocol aimed at the management of patients with ICH-OAC. It included general measures and neuromonitoring, individualised administration of ART, cranial tomography and a six-month follow-up. Data on the drugs prescribed in the area during this period, mortality and functional prognosis were collected. A bivariate and logistic regression study was designed to investigate mortality-related variables.
RESULTS
Forty-nine patients were included over three years; of these, 71.4% received ART. Mortality was 16.3% (first 24 hours), 53.1% (admission) and 61.2% (180 days). Lower survival was observed among patients with higher baseline scores on the National Institutes of Health Stroke Scale (NIHSS) (p < 0.0001), creatinine value (p = 0.02), International Normalised Index (p = 0.048), bleeding volume (p = 0.008), hydrocephalus (p = 0.015) and acenocoumarol intake (p = 0.030). Patients who did not receive ART had a greater rate of early mortality (p = 0.003). The only variable independently related to overall mortality was the baseline NIHSS score (odds ratio = 1.282; 95% confidence interval: 1.023-1.608; p = 0.031).
CONCLUSIONS
ICH-OAC has a high mortality rate, related to the use of acenocoumarol and regardless of the initial clinical situation. A lower rate of early mortality was found among patients who received ART.
Topics: Aged; Aged, 80 and over; Anticoagulants; Anticoagulation Reversal; Antidotes; Cerebral Hemorrhage; Clinical Protocols; Factor Xa Inhibitors; Female; Follow-Up Studies; Hospital Mortality; Humans; Incidence; Kaplan-Meier Estimate; Male; Middle Aged; Neuroimaging; Prospective Studies; Severity of Illness Index; Tertiary Care Centers; Thromboembolism; Tomography, X-Ray Computed; Treatment Outcome; Vitamin K
PubMed: 34328205
DOI: 10.33588/rn.7305.2020565 -
European Review For Medical and... Jul 2021The embolization of thrombi formed within the atria can occur in any form of atrial fibrillation (AF), i.e., paroxysmal, persistent, or permanent. Although ischemic... (Comparative Study)
Comparative Study
OBJECTIVE
The embolization of thrombi formed within the atria can occur in any form of atrial fibrillation (AF), i.e., paroxysmal, persistent, or permanent. Although ischemic stroke is the most frequent embolic event associated with AF, embolization to other sites in the pulmonary and systemic circulations may occasionally occur. To avert the risk of embolization, long-term oral anticoagulation therapy is recommended for all AF patients if the CHA2DS2-VASC score is at least 1 for men and at least 2 for women. Since anticoagulant therapy is associated with an increased risk of bleeding, the choice of oral anticoagulant agent should be made by careful consideration of the benefit-to-risk ratio. The use of a newer class of direct oral anticoagulants (DOACs) as an alternative to the anti-vitamin K (AVK) anticoagulants (warfarin, acenocumarol, etc.) can help mitigate the need for periodic monitoring of International Normalized Ratio (INR) and adverse bleeding events that are commonly associated with the use of AVK anticoagulants. Though the use of DOACs (dabigatran, rivaroxaban, edoxaban, apixaban, etc.) is gaining ground due to their relative safety profile and the low overall cost, quite a few clinicians remain skeptical about their use.
PATIENTS AND METHODS
Our objective was to evaluate the risk of thromboembolism, stroke, neuropsychiatric illness, depression, and dementia, in patients with non-valvular atrial fibrillation who have been treated with either acenocumarol or apixaban, as well as to see the inflammatory status (ESR) and levels of fibrinogen. Our team at Municipal Emergency University Hospital, Timisoara, Romania, conducted a retrospective study using the medical records of AF patients who were treated with either apixaban or acenocumarol between 2016-2019. We divided the patients into two groups and compared the groups for the aforementioned outcomes.
RESULTS
AF patients who were prescribed apixaban had a lower rate of stroke and psychiatric illness compared to those on acenocumarol. No significant correlation was found in terms of risk of developing depression or dementia between the groups.
CONCLUSIONS
Non-valvular AF patients on apixaban had lower rates of thromboembolic events than the patients on acenocumarol. This article will serve as a reminder of the positive health and financial outcomes of apixaban use, especially to those healthcare systems that are still oblivious to the decrease in economic burden and gain in quality-adjusted life years (QALY) by the long-term use of NOACS/ DOACS instead of the AVK anticoagulants.
Topics: Acenocoumarol; Administration, Oral; Aged; Anticoagulants; Atrial Fibrillation; Clinical Decision-Making; Female; Hemorrhage; Humans; Incidence; International Normalized Ratio; Male; Middle Aged; Pyrazoles; Pyridones; Quality-Adjusted Life Years; Retrospective Studies; Risk Assessment; Romania; Stroke
PubMed: 34286492
DOI: 10.26355/eurrev_202107_26241 -
The Pan African Medical Journal 2021Vitamin K antagonists (VKA) based oral anticoagulation, is widely used for the prevention and treatment of thromboembolic disease. The major complication of this therapy...
Vitamin K antagonists (VKA) based oral anticoagulation, is widely used for the prevention and treatment of thromboembolic disease. The major complication of this therapy is bleeding, and sometimes it can occur in unsuspected areas. Spontaneous pectoral hematoma is one of the rare complications due to over anticoagulation by VKA therapy, with only a few cases reported in the literature. Concomitant use of this therapy with commonly used antibiotic, especially in the elderly with multiple comorbidities, can increase the risk of bleeding. Herein, we report a case of a 72-year-old woman under VKA for the treatment of atrial fibrillation, who presented with a spontaneous massive pectoral hematoma, while using antibiotic to treat a respiratory tract infection, who was successfully managed.
Topics: Acenocoumarol; Aged; Anticoagulants; Atrial Fibrillation; Female; Hematoma; Hemorrhage; Humans; Thromboembolism; Vitamin K
PubMed: 34285747
DOI: 10.11604/pamj.2021.38.324.28454 -
BMC Public Health Jul 2021Assessment health literacy in people with cardiovascular health problems would facilitate the development of appropriate health strategies for the care and reduction of...
BACKGROUND
Assessment health literacy in people with cardiovascular health problems would facilitate the development of appropriate health strategies for the care and reduction of complications associated with oral anticoagulation therapy.
AIM
To evaluate the relationship between health literacy and health and treatment outcomes (concordance with oral anticoagulants, Normalized Ratio control and occurrence of complications) in patients with cardiovascular pathology.
METHODS
Observational, analytic and cross-sectional study carried out on 252 patients with cardiovascular pathology (atrial fibrillation, flutter or valve prosthesis), aged 50-85 years, accessing primary care services in Valencia (Spain) in 2018-2019. Variables referring to anticoagulant treatment with vitamin K antagonists (years of treatment, adequate control, polypharmacy and occurrence of complications, among others) and health literacy (Health Literacy Questionnaire) were analysed.
RESULTS
All dimensions of health literacy were significantly related to the level of education (p < 0.02), social class (p < 0.02), an adequate control of acenocoumarol (p < 0.001), frequentation of health services (p < 0.001), information by patients to health professionals about anticoagulant treatment (p < 0.03), emergency care visits (p < 0.001) and unscheduled hospital admissions (p < 0.001).
CONCLUSION
Health literacy has a relevant influence on the adequate self-management of anticoagulation treatment and the frequency of complications. The different dimensions that comprise health literacy play an important role, but the "social health support" dimension seems to be essential for such optimal self-management.
TRIAL REGISTRATION
ACC-ACE-2016-01. Registration date: December 2015.
Topics: Administration, Oral; Anticoagulants; Atrial Fibrillation; Cross-Sectional Studies; Health Literacy; Humans; Social Determinants of Health; Spain; Treatment Outcome
PubMed: 34243749
DOI: 10.1186/s12889-021-11259-w -
Journal of Clinical Medicine Jun 2021Patients with venous thromboembolism (VTE) require immediate treatment with anticoagulants such as acenocoumarol. This multicentre randomised clinical trial evaluated...
Patients with venous thromboembolism (VTE) require immediate treatment with anticoagulants such as acenocoumarol. This multicentre randomised clinical trial evaluated the effectiveness of a dosing pharmacogenetic algorithm versus a standard-of-care dose adjustment at the beginning of acenocoumarol treatment. We included 144 patients with VTE. On the day of recruitment, a blood sample was obtained for genotyping (, , , , ). Dose adjustment was performed on day 3 or 4 after the start of treatment according to the assigned group and the follow-up was at 12 weeks. The principal variable was the percentage of patients with an international normalised ratio (INR) within the therapeutic range on day 7. Thirty-four (47.2%) patients had an INR within the therapeutic range at day 7 after the start of treatment in the genotype-guided group compared with 14 (21.9%) in the control group ( = 0.0023). There were no significant differences in the time to achieve a stable INR, the number of INRs within the range in the first 6 weeks and at the end of study. Our results suggest the use of a pharmacogenetic algorithm for patients with VTE could be useful in achieving target INR control in the first days of treatment.
PubMed: 34209131
DOI: 10.3390/jcm10132949 -
PloS One 2021The study examined the Drug-Related Problems (DRPs) of patients with polypharmacy in 78 Hungarian community pharmacies, especially the interaction risks in terms of...
Analysis of interaction risks of patients with polypharmacy and the pharmacist interventions performed to solve them-A multicenter descriptive study according to medication reviews in Hungarian community pharmacies.
OBJECTIVE
The study examined the Drug-Related Problems (DRPs) of patients with polypharmacy in 78 Hungarian community pharmacies, especially the interaction risks in terms of their clinical severity. Also, the objective was to analyze pharmacists' interventions to solve the identified interaction risks.
METHODOLOGY
The research was carried out in the framework of the training of specialist pharmacists at Semmelweis University, with the participation of 78 graduated pharmacists with the collaboration of 98 GPs. A total of 755 patients participated in pharmaceutical counseling which meant a medication review process. DRPs were uniformly categorized and the interventions were recorded by pharmacists, while a detailed analysis of interaction risks was performed by authors.
RESULTS
A total of 984 DRPs were registered. The most common category of DRPs was the "non-quantitative safety problems" (62.6%). Interaction risk was the most common cause of DRPs (54.0%). The highest proportion of interaction risks were between two prescription drugs (66.7%). In 30.7% of interaction risks' cases, there was not known negative outcome. In contrast, it was recommended to modify the therapy in 14.9% of interaction risks. Acetylsalicylic acid (22.8%), acenocoumarol (17.7%), and diclofenac (13.9%) were the most common active substances which caused serious interaction risks. A total of 599 pharmacist interventions were used to solve the 531 interaction risks. Pharmacists notified the GPs about the problem in 28.4% of cases and they intervened without the GP in 63.1% of cases, most often with patient education (27.4%).
CONCLUSION
Medication review by community pharmacists is required for the safe medicine using of patients with polypharmacy, as a significant number of DRPs have been recorded. The incidence of interaction risks stood out. It is essential to develop a pharmaceutical guideline to properly classify the clinical relevance of interaction risks (e.g. according to high-risk active substances) and to increase the collaboration with GPs.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Community Pharmacy Services; Female; Humans; Hungary; Male; Middle Aged; Pharmacists; Polypharmacy; Practice Patterns, Pharmacists'; Risk Factors; Young Adult
PubMed: 34157039
DOI: 10.1371/journal.pone.0253645