Items filtered by date: October 2018

Extended treatment of venous thromboembolism: a systematic review and network meta-analysis

Heart

Review of 16 studies (n=22,000) found that, for extended treatment, vitamin K antagonists (VKAs) and direct oral anticoagulants reduced the risk of recurrent venous thromboembolisms vs aspirin. The risk of bleeding was higher with high and standard intensity VKAs however.

 

NIHR Signal: The blood-thinner apixaban is less likely to cause major bleeding than warfarin

National Institute for Health Research Signal

Expert commentary is provided for a cohort study which found a lower rate of major bleeding with apixaban vs warfarin (HR 0.66, 95%CI 0.54- 0.79). Residual confounding is likely however, and these data should only be considered supportive of randomised trials, not replacing them.

 

Venous Thromboembolism: Advances in Diagnosis and Treatment

Journal of the American Medical Association

Amongst other points, this review of 32 studies from the US perspective notes that the introduction of direct oral anticoagulants has allowed for a simplified treatment and has made extended secondary prevention more acceptable.

 

European position paper on the management of patients with patent foramen ovale. General approach and left circulation thromboembolism

European Heart Journal

A patent foramen ovale is implicated in pathogenesis of a number of medical conditions; however, the subject remains controversial and no official statements have been published. This paper reviews available trial evidence and defines principles needed to guide decision making.

 

Association of Genetic Variants With Warfarin-Associated Bleeding Among Patients of African Descent

Journal of the American Medical Association

This case-control study (n=215) in patients of African descent found that 4 single nucleotide polymorphisms on chromosome 6 were associated with an increased risk of major bleeding at INR<4. Authors highlight that validations in an independent prospective cohort is required.

 

Spontaneous splenic rupture due to rivaroxaban

Drug and Therapeutics Bulletin

This summary describes the fifth case report of of spontaneous splenic rupture of a patient treated with rivaroxaban and highlights that this has also been reported with apixaban and dabigatran. It suggests key learning points, including checking for drug interactions.

 

 

The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:

http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services

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Individually shortened duration versus standard duration of elastic compression therapy for prevention of post-thrombotic syndrome: a cost-effectiveness analysis

The Lancet Haematology

Dutch RCT (n=865) found that, using the UK tariff for EQ-5D for ascertaining Quality Adjusted Life Years, an individualised strategy was more effective in clinical outcomes and less costly than standard 2 years of elastic stocking compression therapy.

 

P2Y12-ADP Receptor Blockade in Chronic Kidney Disease Patients With Acute Coronary Syndromes: Review of the Current Evidence

Circulation

This review summarises the mechanisms involved in the high ischaemic and bleeding risk of patients with chronic kidney disease CKD and the risk–benefit ratio of potent antiplatelet drugs during acute coronary syndrome.

 

Rivaroxaban (Xarelto▼) after transcatheter aortic valve replacement:increase in all-cause mortality, thromboembolic and bleeding events in a clinical trial

Medicines and Healthcare products Regulatory Agency

MHRA advises that rivaroxaban treatment in patients who undergo transcatheter aortic valve replacement should be stopped and switched to standard of care. It notes rivaroxaban is not licensed for thromboprophylaxis in patients with prosthetic heart valves, and should not be used.

 

Atrial fibrillation, antithrombotic treatment, and cognitive aging: A population-based study

Neurology

Swedish cohort study (n=2685) found AF linked to faster global cognitive decline and an increased risk of all cause dementia in older people (HR 1.40, 95% CI, 1.11–1.77). Use of anticoagulant drugs (but not antiplatelets) may reduce dementia risk in this group (0.40; 0.18–0.92).

 

Surgery versus thrombolysis for initial management of acute limb ischaemia

Cochrane Database of Systematic Reviews

This updated review (5 RCTs; nil new) concludes there is currently no evidence in favour of either initial thrombolysis or initial surgery as the preferred option in terms of limb salvage, amputation, or death; thrombolysis may be associated with higher risk of complications.

 

 

The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:

http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services

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Prevalence, Safety, and Effectiveness of Oral Anticoagulant Use in People with and without Dementia or Cognitive Impairment: A Systematic Review and Meta-Analysis

Journal of Alzheimer's Disease

Review of 27 trials found fewer people with dementia (DM) received oral anticoagulation (AC) vs. people without DM (32 v. 48%) but there was no difference in composite of embolic events/MI/all-cause death. People with DM had higher bleeding risk and poorer AC control on warfarin.

 

Antiplatelet and anticoagulant agents for primary prevention of thrombosis in individuals with antiphospholipid antibodies

Cochrane Database of Systematic Reviews

Review of 9 studies (n=1,044) found insufficient evidence to demonstrate benefit or harm of using anticoagulants with or without aspirin versus aspirin alone in people with antiphospholipid antibodies and a history of recurrent pregnancy loss and with no such history.

 

NIHR Signal: Two antiplatelet drugs may prevent further strokes but increase major bleeds

National Institute for Health Research Signal

Expert commentary is provided for an RCT which found that clopidogrel plus aspirin resulted in fewer ischaemic events, but more major bleeds vs aspirin. There may be a place for dual anti-platelets, but UK practice is clopidogrel monotherapy, and the comparator here was aspirin.

 

Six months versus 12 months dual antiplatelet therapy after drug-eluting stent implantation in ST-elevation myocardial infarction (DAPT-STEMI): randomised, multicentre, non-inferiority trial

British Medical Journal

RCT (n=870) found dual antiplatelet therapy (DAPT) to 6 months was non-inferior to DAPT for 12 months in patients with event-free STEMI at 6 months after primary PCI with second generation drug-eluting stents (HR 0.73, 95% CI, 0.41-1.27, p=0.26, and p=0.004 for non-inferiority).

 

Periprocedural Outcomes of Direct Oral Anticoagulants Versus Warfarin in Nonvalvular Atrial Fibrillation: Meta-Analysis of Phase III Trials

Circulation

Analysis of 4 substudies found no difference in stroke/systemic embolism, major bleeding, or death linked to procedures requiring temporary interruption of DOACs /warfarin (WF). For procedures using uninterrupted anticoagulation, DOACs had 38% lower risk of major bleeding vs. WF.

 

Anticoagulation for perioperative thromboprophylaxis in people with cancer

Cochrane Database of Systematic Reviews

Review (20 RCTs; n=9771) found no difference between perioperative thromboprophylaxis with low molecular weight heparin (LMWH) vs unfractionated heaparin and LMWH vs fondaparinux in their effects on mortality, thromboembolic outcomes, major bleeding, or minor bleeding.

 

Rivaroxaban or aspirin for patent foramen ovale and embolic stroke of undetermined source: a prespecified subgroup analysis from the NAVIGATE ESUS trial

The Lancet Haematology

Sub group analysis (n=534) found that rivaroxaban was associated with fewer recurrent stroke events than aspirin (4.8 versus 2.6 events/100 person-years) but this effect was not statistically significant.

 

Rivaroxaban vs warfarin in high-risk patients with antiphospholipid syndrome

Blood

This study comparing rivaroxaban and warfarin (target INR 2.5) in high-risk patients with thrombotic antiphospholipid syndrome was terminated prematurely (120 patients enrolled) due to an excess of events in the rivaroxaban group (19% v 3% with warfarin).

 

US FDA approves emicizumab (Hemlibra) to prevent or reduce frequency of bleeding episodes in patients with haemophilia A without factor VIII inhibitors

Biospace Inc.

Approval was based on data from the Phase III HAVEN 3 and HAVEN 4 trials, which showed it was associated with clinically meaningful reductions in treated bleeds compared to no prophylaxis. In the EU it is currently approved only for use in patients with factor VIII inhibitors.

 

 

The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:

http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services

 

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