RESUMEN
After a first episode of unprovoked vein thrombosis, the risk of recurrence persists for many years. Long term of anticoagulant therapy prevents the recurrence of vein thrombosis but is associated with a major risk of bleeding. As platelets play a role in the initiation and propagation of venous thromboembolism as well, antiplatelet agents, may play a role in the treatment and prevention of this disease. This review summarizes available evidence on effect of aspirin in the prevention of recurrent deep vein thrombosis.
Asunto(s)
Aspirina , Inhibidores de Agregación Plaquetaria , Prevención Secundaria , Tromboembolia Venosa , Humanos , Aspirina/uso terapéutico , Tromboembolia Venosa/prevención & control , Inhibidores de Agregación Plaquetaria/uso terapéutico , RecurrenciaRESUMEN
GOALS: Transcatheter aortic valve or leaflets thrombosis are mainly misapprehended. It negatively impacts the long-term efficiency of such prosthesis. Moreover, its incidence is presumably higher than previously described. EPIDEMIOLOGY: Recently reported subclinical leaflet thrombosis, occurring between first to third months after implantation, is about 10to 15%. All prosthesis are concerned by potential thrombosis. DIAGNOSIS: Transcatheter aortic valve thrombosis is usually detected on the basis of increased transvalvular pressure gradients or symptoms at routine follow-up. Main causes of post-TAVI thrombosis are: elderly patients, incomplete TAVI expansion, incomplete TAVI apposition to the aortic wall, areas of diminished blood flow and stagnation around the prosthesis. Main risk-factors of thrombosis are: large valves, patients with ejection fraction lower than 35%, valve-in-valve implantation, males, patients with large sinus of Valsalva, patients without anticoagulants. TREATMENT: Post-TAVI anti thrombotic regimen remains empirical. It is based on aspirin alone or dual antiplatelet therapy for 1-6months, followed by aspirin for life. Symptomatic patients with thrombus-based valve dysfunction are to be treated by oral anticoagulation (i.e., VKA or new oral anticoagulants NOAC). This treatment allows the restoration of normal leaflet motion in patients with a median time of 14 days.
Asunto(s)
Anticoagulantes/uso terapéutico , Prótesis Valvulares Cardíacas/efectos adversos , Trombosis/tratamiento farmacológico , Trombosis/etiología , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Válvula Aórtica/cirugía , Francia/epidemiología , Humanos , Incidencia , Inhibidores de Agregación Plaquetaria/uso terapéutico , Factores de Riesgo , Trombosis/diagnóstico , Trombosis/epidemiología , Resultado del TratamientoRESUMEN
OBJECTIVES: No recommendations are currently available to help the clinician with the pharmacological management of intensive care unit (ICU) patients with elevated cardiac troponin (cTn) not linked to type 1 AMI. The aim of this study was to evaluate the pattern of cardiologic medications for patients with elevated cTnI in ICU not link to type 1 AMI and their effects on in-hospital mortality. MATERIAL AND METHODS: A prospective observational cohort study conducted in two ICU units. Patients with increased plasma concentration of cTnI at admission not linked to type 1 AMI were consecutively included. RESULTS: One hundred and ninety of the 835 patients admitted (23%) had an increased plasma concentration of cTnI not related to type 1 AMI. Antiplatelet therapy (AT) and statin were prescribed in 56 (29.5%) and 50 (26.3%) of patients, respectively. Others cardiologic medications were prescribed in less than 5% of all cases and were considered as contraindicated in more than 50% of cases. Antiplatelet therapy was the only cardiologic treatment associated with reduction of in-hospital mortality following uni- and multivariate analysis. The death rate was 23% and 40% in these patients treated with and without AT, respectively (aOR=0.39 [95% CI: 0.15-0.97]). CONCLUSIONS: Statin and AT were frequently prescribed to patients with a cTnI elevation not linked to type 1 AMI. This study suggests that AT in patients with an increased plasma concentration of cTnI, not related to type 1 AMI in ICU, could reduce in-hospital mortality.
Asunto(s)
Enfermedad Crítica/mortalidad , Mortalidad Hospitalaria , Unidades de Cuidados Intensivos , Troponina I/sangre , Biomarcadores/sangre , Humanos , Infarto del Miocardio/sangre , Estudios ProspectivosRESUMEN
BACKGROUND: When pleural procedures (thoracocentesis, blind pleural biopsies and chest tube insertion) are required in patients taking long-term platelet aggregation inhibitors, the risk of bleeding must be balanced against the risk of arterial thrombosis. Currently, the bleeding risk of pleural procedures is poorly understood. OBJECTIVE: The objective of the survey was to gather the opinion of respiratory physicians regarding the bleeding risk of pleural procedures in patients taking platelet aggregation inhibitors. METHODS: We emailed a standardized questionnaire designed by the French National Authority for Health to 2697 French respiratory physicians. RESULTS: One hundred and eighty-eight of the 2697 questionnaires were returned (response rate: 7 %). The respiratory physicians declared that they performed an average of 8 pleural procedures per month. One hundred and seventy-five responders (95 %) practised pleural procedures in patients receiving platelet aggregation inhibitors; 68 of them (39 %) reported experiencing haemorrhagic complications. The bleeding risk associated with thoracentesis and chest tube insertion was considered minor by 97.8 and 65 % of responders respectively, whereas it was considered major for blind pleural biopsies by 73.4 %. Respiratory physicians were more reticent about performing pleural procedures in patients treated with clopidogrel than in those taking aspirin. CONCLUSION: This study provides an overview of how respiratory physicians perceive the bleeding risk associated with pleural procedures in patients taking platelet aggregation inhibitors.
Asunto(s)
Inhibidores de Agregación Plaquetaria/uso terapéutico , Pleura/cirugía , Procedimientos Quirúrgicos Torácicos , Humanos , Hemorragia Posoperatoria/inducido químicamente , Hemorragia Posoperatoria/epidemiología , Factores de Riesgo , Encuestas y CuestionariosRESUMEN
INTRODUCTION: Tooth extraction for patients treated by AVK and/or platelet aggregation inhibitor is performed according to local habits rather than to a consensus. We had for objective to assess hemorrhagic and thromboembolic risks for patients for whom treatment with AVK and/or platelet aggregation inhibitor was modified before tooth extraction. MATERIALS AND METHODS: Ninety-three patient files were examined retrospectively. The following data was collected: epidemiological data, ASA score, nature and changes of antithrombotic therapy, preoperative INR, number teeth extracted, postoperative complications (bleeding and thromboembolic events). RESULTS: Thirty-seven patients were treated with oral anticoagulants, 41 by a platelet aggregation inhibitor, 10 by double platelet aggregation inhibitor therapy, and 5 by an AVK-platelet aggregation inhibitor combination. At D0, the mean INR was decreased to 1.4, 4 patients with high thromboembolic risk had received heparin relay treatment; the treatment was stopped for 9 of the 56 patients on monotherapy with antiplatelet therapy, 4 were switched from clopidogrel to lysine acetylate; clopidogrel was stopped for 7 patients under combination therapy. Seven hundred and twenty-six avulsions (mean 8.1 per patient) were performed, 41 patients presented with mild/moderate bleeding, easily resolved. A patient presented with delayed hemorrhage at D6 (AVK overdose). No thromboembolic complication was reported. DISCUSSION: The modification of antithrombotic treatment, as for surgery at high risk of bleeding, seems to limit the risk of bleeding without increasing thromboembolic risk.
Asunto(s)
Fibrinolíticos/uso terapéutico , Complicaciones Posoperatorias , Hemorragia Posoperatoria , Tromboembolia , Extracción Dental/efectos adversos , 4-Hidroxicumarinas/uso terapéutico , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Indenos/uso terapéutico , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , Hemorragia Posoperatoria/epidemiología , Hemorragia Posoperatoria/prevención & control , Estudios Retrospectivos , Factores de Riesgo , Tromboembolia/epidemiología , Tromboembolia/prevención & control , Extracción Dental/estadística & datos numéricos , Vitamina K/antagonistas & inhibidores , Vitamina K/uso terapéuticoRESUMEN
CONTEXT: Lumbar puncture (LP) is a common medical procedure for which no valid consensus exists in situations of hemorrhagic or thrombotic risk. The aim of this study was to identify the opinion-guided practices of LP at a national level. METHODS: A national opinion survey on Internet. An anonymous questionnaire of 19 questions collecting information about the LP practice for patients with hemorrhagic or thrombotic risks. RESULTS: We sent 632 e-mails with the link of the survey and obtained 211 responses in six weeks. None of the responses was unanimous for any of the 13 different clinical situations proposed. Six practices were reported as adopted by the majority of participants, six by more than one-third. Reports of practices were highly variable, particularly for the minimum platelets count accepted, for the management of patients taking two antiplatelet agents or newer anticoagulant agents. DISCUSSION AND CONCLUSION: These results underline the heterogeneity of practices and the lack of recommendations. The establishment of a clear consensus in this area seems essential to guide practices in the future. In order to increase the representativeness of our responses, the survey is still going on online and will be open for all practitioners who wish to participate (http://www.surveymonkey.com/s/hemopl).
Asunto(s)
Hemorragia/epidemiología , Isquemia/epidemiología , Punción Espinal/estadística & datos numéricos , Adulto , Anticoagulantes/efectos adversos , Femenino , Francia , Encuestas de Atención de la Salud , Humanos , Internet , Masculino , Inhibidores de Agregación Plaquetaria/efectos adversos , Recuento de Plaquetas , Riesgo , Punción Espinal/efectos adversos , Punción Espinal/métodos , Encuestas y Cuestionarios , Trombosis/epidemiologíaRESUMEN
The most common risks related to platelet inhibitor therapy are bleeding, drug-drug interactions and therapeutic failure. The new substances prasugrel and ticagrelor are more potent platelet inhibitiors than clopidogrel. This reduces the incidence of ischemic events, but also potentially increases the bleeding risk. Clopidogrel therapy has up to 20% non-response rates, which can partially be explained by genetic polymorphisms and drug-drug interactions. Currently no evidence exists that ticagrelor or prasugrel efficacy is affected by genetic polymorphisms. The therapy in patients at risk still has to be carefully adapted to minimize adverse events. Patients older than 75 years and/or weighing less than 60 kg should receive a reduced dose of prasugrel. The combination of ticagrelor with strong cytochrome-P450-3A4 inhibitors is contraindicated.
Les événements hémorragiques, les interactions médicamenteuses et l'échec de thérapie constituent les risques majeurs des traitements à base d'antiagrégants plaquettaires. Les substances nouvelles, prasugrel et ticagrelor, présentent un effet anitagrégant plus important et diminuent les épisodes ischémiques d'une manière plus efficacement que le clopidogrel. Cependent la possibilité existe d'une augmentation d'épisodes de saignement. Le risque de résistance à la thérapie atteint jusqu'à 20% pour les patients traités à base de clopidogrel, entre autre en raison de polymorphismes génétiques. Il n'existe pas d'evidence pour un mécanisme pareil pour le prasugrel et le ticagrelor. Dans certaines situations de risque par contre, une adaption du dosage est conseillée pour minimiser les effets secondaires négatifs: Chez les patients de plus de 75 ans, et/ou d'un poids corporel de moins de 60 kg, une réduction du dosage de prasugrel est conseillée en raison d'un risque élevé d'hémorragie. Il est contrindiqué d'utiliser ticagrelor en combinaison avec des inhibiteurs puissants du cytochrome-P4503A4.