This article affects the problems of using NOAC in the most defenseless groups of patients with atrial fibrillation: those who have high bleeding and high thromboembolic risk and elderly. The focus is on comparison of effectiveness and safety of NOACs based on randomized clinical trials (RCT) and real-world data (RWD). The possible reasons for the different interpretation of the data of the RCT and the RWD are shown. Use of NOAC in reduced doses prescribing according to RCT and RWD are shown. Our own 13-month observation of patients 75 years and older with very high thromboembolic risk (CHA 2 DS 2-VASc-4,5 points) on rivaroxaban therapy are presented. Good efficacy and safety of full and reduced doses of rivaroxaban were demonstrated: only 2 episodes of small bleedings and no large bleedings (ISTH criteria) were detected as well as no thromboembolic events. Thus, even difficult patients with AF and comorbidity may be safely and effectively treated with NOACs taking into consideration integrated approach and correction of modifiable risk factors.
Aim. To study the frequency and characteristics of the development of thromboembolic and hemorrhagic complications in patients with atrial fibrillation (AF) during planned surgical interventions.Material and methods. Preoperative examination and postoperative observation of 214 patients with AF (139 men and 75 women) who received anticoagulant therapy (ACT) and underwent planned surgery was carried out. The consistency of the used perioperative ACT regimens when performing interventions with current international recommendations was analyzed.Results. Complications developed in 33 patients (15.4%) from the total sample of 214 patients: in 14 (6.5%) thromboembolism, in 19 (8.9%) hemorrhagic complications. Analysis of the complication frequency in various types of surgical interventions showed that the frequency of thromboembolism during heart and vascular operations was 9.8% (4 cases), with interventions for malignant tumors – 7 (6.2%), while performing general surgical abdominal tumors operations – 3 (5.0%). The frequency of bleeding was maximum during operations for cancer 18.6%, this value was significantly higher compared with the frequency of these complications when performing general surgical abdominal operations – 3 cases (5.0%), and during interventions on the heart and vascular vessels bleedings were not observed. The total frequency of complications was also maximal when performing interventions for malignant tumors – 24.8%. This value was significantly higher than in the groups of patients who underwent general surgical abdominal operations – 10.0%, and interventions on the heart and vessels – 9.8%. Analysis of the frequency of compliance with the recommendations of the European Society of Cardiology in terms of ACT usage in patients with AF in the perioperative period and the structure of errors in choosing the ACT regimen showed that among the examined patients the recommendations were followed only in 102 (47.7%), while the frequency of non-recommended regimens use reached 52.3% (112 patients). The most frequently incorrectly used scheme was “bridge therapy” with the possibility of canceling oral anticoagulants in 107 (50.0%) patients.Conclusion. A significantly higher frequency of complications was found in patients, whose management did not follow the recommendations for perioperative ACT.
A literature review provided, on the usage of various schemes of perioperational anticoagulation therapy (ACT) in atrial fibrillation patients undergoing scheduled surgery. It is noted that clinicians quite often pass through a situation when patients taking ACT require invasive investigations and surgery. Perioperational management of such category of patients is complicated as, on the one hand, the surgery under ACT is associated with intraoperational hemorrhagic complications, and, on the other hand, ACT cessation might increase the risk of thrombotic complications. The variants assessed, of different periprocedural ACT in patients taking vitamin K antagonists. It was found that as an alternative to continuous ACT recently, bridge therapy with low molecular weight heparins applied, aiming the decrease of the risk of bleeding in adequate thromboprophylaxis. The results of clinical trials provided on the assessment of bridge therapy in surgery. Risk stratification approaches presents for thromboembolic and hemorrhagic complications in surgery.
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