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Journal of the American Heart... Dec 2023Intravenous thrombolysis (IVT) is an effective stroke therapy that remains underused. Currently, the use of IVT in patients with recent direct oral anticoagulant (DOAC)... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Intravenous thrombolysis (IVT) is an effective stroke therapy that remains underused. Currently, the use of IVT in patients with recent direct oral anticoagulant (DOAC) intake is not recommended. In this study we aim to investigate the safety and efficacy of IVT in patients with acute ischemic stroke and recent DOAC use.
METHODS AND RESULTS
A systematic review and meta-analysis of proportions evaluating IVT with recent DOAC use was conducted. Outcomes included symptomatic intracranial hemorrhage, any intracranial hemorrhage, serious systemic bleeding, and 90-day functional independence (modified Rankin scale score 0-2). Additionally, rates were compared between patients receiving IVT using DOAC and non-DOAC by a random effect meta-analysis to calculate pooled odds ratios (OR) for each outcome. Finally, sensitivity analysis for idarucizumab, National Institutes of Health Stroke Scale, and timing of DOAC administration was completed. Fourteen studies with 247 079 patients were included (3610 in DOAC and 243 469 in non-DOAC). The rates of IVT complications in the DOAC group were 3% (95% CI, 3-4) symptomatic intracranial hemorrhage, 12% (95% CI, 7-19) any ICH, and 0.7% (95%CI, 0-1) serious systemic bleeding, and 90-day functional independence was achieved in 57% (95% CI, 43-70). The rates of symptomatic intracranial hemorrhage (3.4 versus 3.5%; OR, 0.95 [95% CI, 0.67-1.36]), any intracranial hemorrhage (17.7 versus 17.3%; OR, 1.23 [95% CI, 0.61-2.48]), serious systemic bleeding (0.7 versus 0.6%; OR, 1.27 [95% CI, 0.79-2.02]), and 90-day modified Rankin scale score 0-2 (46.4 versus 56.8%; OR, 1.21 [95% CI, 0.400-3.67]) did not differ between DOAC and non-DOAC groups. There was no difference in symptomatic intracranial hemorrhage rate based on idarucizumab administration.
CONCLUSIONS
Patients with acute ischemic stroke treated with IVT in recent DOAC versus non-DOAC use have similar rates of hemorrhagic complications and functional independence. Further prospective randomized trials are warranted.
Topics: Humans; Stroke; Fibrinolytic Agents; Ischemic Stroke; Thrombolytic Therapy; Brain Ischemia; Hemorrhage; Intracranial Hemorrhages; Treatment Outcome; Anticoagulants
PubMed: 38108256
DOI: 10.1161/JAHA.123.031669 -
Journal of Thrombosis and Haemostasis :... Mar 2024Patients with cancer commonly require a central venous catheter, which is associated with an increased risk of venous thromboembolism (VTE). Despite the frequent... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Patients with cancer commonly require a central venous catheter, which is associated with an increased risk of venous thromboembolism (VTE). Despite the frequent occurrence, the optimal anticoagulation management and outcomes for patients with cancer and catheter-related upper extremity deep vein thrombosis (DVT) are unclear.
OBJECTIVE
We performed a systematic review and meta-analysis to evaluate the rates of recurrent VTE and bleeding in patients with cancer and catheter-related upper extremity DVT.
METHODS
We searched MEDLINE, Embase, Scopus, and CENTRAL from inception to June 2, 2023. The primary efficacy outcome was recurrent VTE, and the primary safety outcome was major bleeding. The incidence rates (with 95% CI) of outcomes were pooled using random effects model.
RESULTS
We included 29 studies (N = 2,836), among which 5 were prospective. The duration of follow-up and anticoagulation varied considerably. The main long-term anticoagulant used was low molecular weight heparin, followed by direct oral anticoagulants. The pooled 3-month recurrent VTE rate from 14 studies (N = 1,128) was 0.56% (95% CI, 0.10%-3.01%; I = 0%). The pooled 3-month major bleeding rate from 10 studies (N = 834) was 2.34% (95% CI, 1.14%-4.76%; I = 0%). We were unable to pool event rates beyond 3 months, given high heterogeneity. All studies had serious risk of bias.
CONCLUSIONS
Our study demonstrated a relatively low rate of recurrent VTE and moderate rate of major bleeding events within the first 3 months in patients with cancer and catheter-related upper extremity DVT. However, there was significant heterogeneity in the management and reporting after 3 months.
Topics: Humans; Upper Extremity Deep Vein Thrombosis; Venous Thromboembolism; Prospective Studies; Anticoagulants; Hemorrhage; Central Venous Catheters; Neoplasms
PubMed: 38065528
DOI: 10.1016/j.jtha.2023.11.017 -
Thrombosis Research Jan 2024Left atrial appendage occlusion (LAAO) provides an alternative for poor candidates of long-term oral anticoagulant (OAC) therapy; however, anticoagulant therapy after... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Left atrial appendage occlusion (LAAO) provides an alternative for poor candidates of long-term oral anticoagulant (OAC) therapy; however, anticoagulant therapy after surgical procedures has limited use due to associated uncertainties. We aimed to evaluate the effectiveness and safety of the short-term use of direct oral anticoagulant (DOAC) and warfarin after LAAO.
METHOD
Electronic databases such as PubMed, Embase, Medline, and Cochrane Library databases were searched up to November 11, 2022. Our study compared DOAC therapy and warfarin in patients after LAAO. A meta-analysis was conducted with the Review Manager software (version 5.4).
RESULTS
The meta-analysis included 13 cohort studies with a total of 32,607 patients. Our findings indicated that the incidence of stroke/TIA/SE, peri-device leaks>5 mm, device-related thrombosis, and all-cause mortality were not significantly different between the two groups after LAAO (P > 0.05). The DOAC group had a significantly lower incidence of major bleeding (OR = 0.83, 95 % CI: 0.74-0.94, P = 0.003), any bleeding (OR = 0.34, 95 % CI: 0.23-0.51, P < 0.001), stroke/TIA/SE and major bleeding (OR = 0.57, 95 % CI: 0.34-0.95, P = 0.03), and any major adverse event (OR = 0.89, 95 % CI:0.82-0.97, P = 0.010) than the warfarin group. The subgroup analysis revealed that the rate of stroke/TIA/SE was similar in the two groups in terms of the different regions, follow-up time, study type, anticoagulant strategy, and bleeding risk. The incidence of major bleeding in the DOAC group was significantly lower than that in the warfarin group in North America, as well as at follow-up period ≤6 months, retrospective cohort, HAS-BLED average score ≥ 3. In addition, the risk of major bleeding was higher with the combination of OAC and single antiplatelet therapy (SAPT) than with OAC alone. Finally, in the North American region, retrospective cohort, and HAS-BLED average score ≥ 3, the incidence of any serious adverse event in the DOAC group was still significantly lower than that in the warfarin group.
CONCLUSION
Compared to warfarin, DOAC reduced the risk of major bleeding and any serious adverse event in patients after LAAO. This advantage was particularly notable in North America and high-risk populations for bleeding. In addition, the incidence of device-related thrombosis, peri-device leaks, stroke/TIA/SE and all-cause mortality were similar in both groups. The risk of major bleeding was lower in patients taking OAC alone compared with those taking OAC plus SAPT, without increasing the risk of thrombosis.
Topics: Humans; Anticoagulants; Warfarin; Ischemic Attack, Transient; Atrial Appendage; Retrospective Studies; Atrial Fibrillation; Treatment Outcome; Stroke; Hemorrhage; Thrombosis
PubMed: 38035647
DOI: 10.1016/j.thromres.2023.10.021 -
International Journal of Dermatology Apr 2024Many patients undergoing cutaneous surgery are prescribed at least one anticoagulant or antiplatelet agent. With the recent emergence of direct oral anticoagulants... (Review)
Review
INTRODUCTION
Many patients undergoing cutaneous surgery are prescribed at least one anticoagulant or antiplatelet agent. With the recent emergence of direct oral anticoagulants (DOACs), there is a deficit of knowledge regarding optimal perioperative management. This review aims to evaluate the evidence and risk surrounding management of DOACs in patients undergoing skin surgeries.
METHODS
Systematic review of EMBASE, Scopus, and PubMed, with inclusion of studies that detailed perioperative management of DOACs in those undergoing skin surgery. Primary outcome measures were perioperative hemorrhagic and thromboembolic complications.
RESULTS
Seven thousand seven hundred and forty-one abstracts were identified, with 13 articles meeting inclusion criteria. Two studies investigated complication risk associated with DOAC continuation in skin surgery and found an average rate of hemorrhagic complications of 1.74%. Two studies evaluated complications associated with DOAC cessation prior to skin surgery, with a pooled thromboembolic complication rate of 0.15%. Articles comparing continuation and cessation discovered no decreased risk of bleeding with DOAC cessation prior to surgery (P = 0.93). Seven of the 13 articles compared complications in a control vs a DOAC group undergoing cutaneous procedures. Evidence was conflicting but may have suggested a small increase in bleeding risk in those on DOAC therapy.
CONCLUSION
Optimal management of anticoagulants perioperatively is difficult because of conflicting information, complicated by advent of novel agents. Risk of hemorrhagic complications with both continuation and interruption of DOAC therapy was low. Perioperative DOAC management can be guided by procedural bleeding and patient clotting risk and can often be continued in minor dermatologic procedures.
Topics: Humans; Anticoagulants; Hemorrhage; Platelet Aggregation Inhibitors; Dermatologic Surgical Procedures; Administration, Oral
PubMed: 38009338
DOI: 10.1111/ijd.16916 -
Journal of the Formosan Medical... May 2024The introduction of non-vitamin K antagonist oral anticoagulants (NOACs), with a non-inferior or superior clinical efficacy profile compared to vitamin K antagonists... (Meta-Analysis)
Meta-Analysis Comparative Study
BACKGROUND
The introduction of non-vitamin K antagonist oral anticoagulants (NOACs), with a non-inferior or superior clinical efficacy profile compared to vitamin K antagonists (VKAs), has significantly improved the safety profile and treatment adherence of patients with non-valvular atrial fibrillation (AF). However, few studies have compared the effectiveness and safety of NOACs. Therefore, we conducted this systematic review and network meta-analysis to compare the safety and clinical effectiveness of NOACs and VKAs in patients with non-valvular AF.
METHODS
An online bibliographic search was conducted to retrieve real-world evidence studies published between January 2019 and June 2022.
RESULTS
Dabigatran was associated with lower risks of major bleeding, ischemic stroke, and intracranial hemorrhage than warfarin. Among the NOACs, only dabigatran had a lower risk of all-cause mortality than warfarin. Dabigatran was also associated with lower risks of major bleeding and intracranial hemorrhage than rivaroxaban.
CONCLUSION
Our meta-analysis confirms that dabigatran's real-world safety and clinical effectiveness align with the results of pivotal clinical trials.
Topics: Humans; Atrial Fibrillation; Warfarin; Anticoagulants; Network Meta-Analysis; Dabigatran; Administration, Oral; Hemorrhage; Stroke; Rivaroxaban; Vitamin K
PubMed: 37996330
DOI: 10.1016/j.jfma.2023.10.014 -
American Journal of Cardiovascular... Jan 2024Cangrelor is a potent intravenous non-thienopyridine P2Y12 inhibitor. We conducted a network meta-analysis to study the efficacy and safety of cangrelor as compared with... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Cangrelor is a potent intravenous non-thienopyridine P2Y12 inhibitor. We conducted a network meta-analysis to study the efficacy and safety of cangrelor as compared with the oral P2Y12 inhibition, clopidogrel, or placebo in acute coronary syndromes.
METHODS
This meta-analysis followed the Cochrane collaboration guidelines and the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) protocols. Outcomes of interest included all-cause mortality, myocardial infarction, stent thrombosis, target vessel revascularization, major bleeding, minor bleeding, and the need for blood transfusion.
RESULTS
The analysis was comprised of 6 studies including 26,444 patients treated with cangrelor, clopidogrel, or placebo. There were no statistically significant differences in the incidence of all-cause mortality, myocardial infarction, stent thrombosis, target vessel revascularization, or major bleeding. Cangrelor was associated with a higher risk of minor bleeding than clopidogrel or placebo, with no difference in requiring blood transfusion.
CONCLUSION
Cangrelor has comparable outcomes to clopidogrel in patients with acute coronary syndromes and can be used as a reliable alternative in this population.
Topics: Humans; Clopidogrel; Acute Coronary Syndrome; Platelet Aggregation Inhibitors; Network Meta-Analysis; Purinergic P2Y Receptor Antagonists; Adenosine Monophosphate; Myocardial Infarction; Hemorrhage; Percutaneous Coronary Intervention; Treatment Outcome; Thrombosis
PubMed: 37995040
DOI: 10.1007/s40256-023-00616-2 -
European Journal of Obstetrics,... Jan 2024A large number of randomized controlled trials (RCTs) have been published on the effects of oral/vaginal misoprostol and oxytocin on delivery outcomes; however, data... (Meta-Analysis)
Meta-Analysis Review
Effect of misoprostol versus oxytocin on delivery outcomes after labour induction in pregnant women: A systematic review and meta-analysis of randomized controlled trials.
A large number of randomized controlled trials (RCTs) have been published on the effects of oral/vaginal misoprostol and oxytocin on delivery outcomes; however, data from these RCTs are conflicting. Although some meta-analyses summarized available findings in this regard, several eligible RCTs have been published since the release of those meta-analyses. Therefore, the current updated systematic review and meta-analysis of RCTs was conducted to compare the effects of oral/vaginal misoprostol and oxytocin on delivery and neonatal outcomes. A systematic search, using relevant keywords, was done in the online databases of PubMed/Medline, Scopus, and ISI Web of Science, up to April 2023, to identify eligible articles investigating the effect of oral/vaginal misoprostol and oxytocin on delivery outcomes including maternal [cesarean/vaginal delivery within 24 h after labour induction, Tachysystole, hypertonicity, hyper-stimulation, postpartum hemorrhage (PPH)] and neonatal outcomes [mean Apgar score, admission to neonatal intensive care unit (NICU), and death]. In total, 45 RCTs with a total sample size of 8406 participants were included. Meta-analysis revealed that vaginal misoprostol administration, compared with oxytocin, resulted in a significant reduction in the rate of cesarean and a significant increase in the rate of vaginal delivery and Tachysystole risk. Also, oral misoprostol was associated with a significant reduction in the rate of cesarean and a significant increase in the risk of hypertonicity compared with oxytocin. However, oral misoprostol had no significant effect on vaginal delivery compared with oxytocin. For other outcomes including hyper-stimulation, perinatal death, NICU admission, and mean Apgar score among newborns, we found no significant difference between oral/vaginal misoprostol and oxytocin. In total, vaginal/oral misoprostol might be a better method for labour induction compared with oxytocin. PROSPERO registration: CRD42023412325.
Topics: Pregnancy; Female; Infant, Newborn; Humans; Misoprostol; Oxytocin; Oxytocics; Pregnant Women; Randomized Controlled Trials as Topic; Labor, Induced; Administration, Intravaginal
PubMed: 37976769
DOI: 10.1016/j.ejogrb.2023.11.006 -
Circulation Mar 2024Device-detected atrial fibrillation (also known as subclinical atrial fibrillation or atrial high-rate episodes) is a common finding in patients with an implanted... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Device-detected atrial fibrillation (also known as subclinical atrial fibrillation or atrial high-rate episodes) is a common finding in patients with an implanted cardiac rhythm device and is associated with an increased risk of ischemic stroke. Whether oral anticoagulation is effective and safe in this patient population is unclear.
METHODS
We performed a systematic review of MEDLINE and Embase for randomized trials comparing oral anticoagulation with antiplatelet or no antithrombotic therapy in adults with device-detected atrial fibrillation recorded by a pacemaker, implantable cardioverter defibrillator, cardiac resynchronization therapy device, or implanted cardiac monitor. We used random-effects models for meta-analysis and rated the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework (GRADE). The review was preregistered (PROSPERO CRD42023463212).
RESULTS
From 785 citations, we identified 2 randomized trials with relevant clinical outcome data: NOAH-AFNET 6 (Non-Vitamin K Antagonist Oral Anticoagulants in Patients With Atrial High Rate Episodes; 2536 participants) evaluated edoxaban, and ARTESiA (Apixaban for the Reduction of Thrombo-Embolism in Patients With Device-Detected Sub-Clinical Atrial Fibrillation; 4012 participants) evaluated apixaban. Meta-analysis demonstrated that oral anticoagulation with these agents reduced ischemic stroke (relative risk [RR], 0.68 [95% CI, 0.50-0.92]; high-quality evidence). The results from the 2 trials were consistent (I statistic for heterogeneity=0%). Oral anticoagulation also reduced a composite of cardiovascular death, all-cause stroke, peripheral arterial embolism, myocardial infarction, or pulmonary embolism (RR, 0.85 [95% CI, 0.73-0.99]; I=0%; moderate-quality evidence). There was no reduction in cardiovascular death (RR, 0.95 [95% CI, 0.76-1.17]; I=0%; moderate-quality evidence) or all-cause mortality (RR, 1.08 [95% CI, 0.96-1.21]; I=0%; moderate-quality evidence). Oral anticoagulation increased major bleeding (RR, 1.62 [95% CI, 1.05-2.50]; I²=61%; high-quality evidence).
CONCLUSIONS
The results of the NOAH-AFNET 6 and ARTESiA trials are consistent with each other. Meta-analysis of these 2 large randomized trials provides high-quality evidence that oral anticoagulation with edoxaban or apixaban reduces the risk of stroke in patients with device-detected atrial fibrillation and increases the risk of major bleeding.
Topics: Humans; Administration, Oral; Anticoagulants; Atrial Fibrillation; Embolism; Hemorrhage; Ischemic Stroke; Pyridines; Stroke; Thiazoles; Treatment Outcome; Randomized Controlled Trials as Topic
PubMed: 37952187
DOI: 10.1161/CIRCULATIONAHA.123.067512 -
Journal of Thrombosis and Haemostasis :... Feb 2024Limited evidence is available on management of splanchnic vein thrombosis (SVT). (Meta-Analysis)
Meta-Analysis
BACKGROUND
Limited evidence is available on management of splanchnic vein thrombosis (SVT).
OBJECTIVES
This study aimed to evaluate safety and efficacy of direct oral anticoagulants (DOACs) for SVT treatment.
METHODS
Studies were systematically searched in the PubMed, Web of Science, and Scopus databases according to PRISMA guidelines. We assessed any recanalization, full recanalization, recurrence, mortality, and major bleeding as outcomes of interest. Results were reported as weighted mean prevalence (WMP) with 95% CI. Subgroup analyses and meta-regressions have been performed to address heterogeneity and adjust for potential confounders.
RESULTS
We included a total of 16 studies (17 datasets) on 648 patients with SVT treated with DOACs. We found any recanalization in 60.3% (95% CI: 41.8%-76.3%; I = 84.9%; P < .001) and full recanalization in 51.7% (95% CI: 36.0%-67.0%; I = 87.4%; P < .001). Recurrent venous thromboembolism occurred in 2.8% (95% CI: 1.4%-5.9%; I = 0%; P = .787) and death in 3.4% (95% CI: 1.6%-7.3%; I = 13.2%; P = .318) of patients. Major bleeding was reported by 5.8% (95% CI: 3.7%-8.9%; I = 29.2%; P = .125) of patients. Results were consistent when separately analyzing prospective studies, retrospective studies, studies on cirrhotic patients, and studies enrolling patients with portal vein thrombosis. Meta-regression analyses showed that an increasing age and cancer impacted the rate of recanalization. Cirrhosis was associated with a higher rate of major bleeding and mortality.
CONCLUSION
The results of the present study, mostly based on observational studies, suggest good safety and efficacy profiles of DOACs in patients with SVT. Randomized studies are needed to corroborate our findings.
Topics: Humans; Anticoagulants; Prospective Studies; Retrospective Studies; Venous Thrombosis; Hemorrhage; Venous Thromboembolism; Splanchnic Circulation
PubMed: 37926192
DOI: 10.1016/j.jtha.2023.10.023 -
Medicina (Kaunas, Lithuania) Oct 2023: Venous thromboembolism (VTE) is common in cancer patients. Anticoagulant therapy with low-molecular-weight heparins (LMWHs) and direct oral anticoagulants (DOACs),... (Meta-Analysis)
Meta-Analysis Review
: Venous thromboembolism (VTE) is common in cancer patients. Anticoagulant therapy with low-molecular-weight heparins (LMWHs) and direct oral anticoagulants (DOACs), such as dalteparin and apixaban, have demonstrated efficacy and safety. However, more comparative research of these drugs is still needed. This study aimed to synthesize evidence on the efficacy of apixaban compared to dalteparin in reducing recurrent VTE, major bleeding, and clinically relevant non-major bleeding associated with cancer. : We systematically searched the PubMed, Scopus, Web of Science, Embase, Cochrane Library, and ClinicalTrials databases up to 5 January 2023, for randomized controlled trials comparing apixaban versus dalteparin as treatment for cancer-associated VTE. Five studies were included. Effects according to meta-analyses were reported as relative risks (RRs) and their 95% confidence intervals (CIs). : It was found that 33 of 734 (4.5%) patients treated with apixaban and 56 of 767 (7.3%) with dalteparin had recurrent VTE as the efficacy outcome (RR 0.49, 95% CI 0.15-1.58, I 38%). Major bleeding occurred in 25 of 734 patients treated with apixaban (3.4%) and 27 of 767 with dalteparin (3.5%) (RR 1.29, 95% CI 0.31-5.27, I 59%). Likewise, clinically relevant non-major bleeding occurred in 64 of 734 patients treated with apixaban (8.7%) and 46 of 767 (5.9%) with dalteparin (RR 1.52, 95% CI 1.05-2.19, I 0%). : Apixaban showed a lower risk of recurrent VTE than dalteparin in patients with cancer-associated VTE, albeit with no statistical difference. Statistical significance was observed for no major clinically relevant bleeding but not for major bleeding.
Topics: Humans; Dalteparin; Venous Thromboembolism; Anticoagulants; Hemorrhage; Neoplasms
PubMed: 37893585
DOI: 10.3390/medicina59101867