Achieved Anticoagulation vs Prosthesis Selection for Mitral Mechanical Valve Replacement

Tourneau, Thierry Le; Lim, Vivien K. G.; Inamo, Jocelyn; Miller, Fletcher A.; Mahoney, Douglas W.; Schaff, Hartzell V.; Enríquez-Sarano, Maurice

doi:10.1378/chest.08-1233

Cited by 24 publications

(11 citation statements)

References 42 publications

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“… 7 , 15 , 33–35 The acute risk for valve thrombosis or thromboembolism even in timely anticoagulated patients amounts up to 1% per day for valve thrombosis and 0.2% per day for systemic thromboembolisms including ischaemic stroke and is greatest immediately after surgical implantation. 36 , 37 In line with these data, we here noticed a thromboembolism rate of 0.2% per day in anticoagulated patients, and in patients without anticoagulation there was a rather modestly increased rate of 0.6% per day. Now, comparing incidence rates of haemorrhagic complications we documented a 10 times higher hazard with early anticoagulation.…”

Section: Discussionsupporting

confidence: 89%

Management of therapeutic anticoagulation in patients with intracerebral haemorrhage and mechanical heart valves

Kuramatsu

Sembill

Gerner

et al. 2018

European Heart Journal

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AimsEvidence is lacking regarding acute anticoagulation management in patients after intracerebral haemorrhage (ICH) with implanted mechanical heart valves (MHVs). Our objective was to investigate anticoagulation reversal and resumption strategies by evaluating incidences of haemorrhagic and thromboembolic complications, thereby defining an optimal time-window when to restart therapeutic anticoagulation (TA) in patients with MHV and ICH.Methods and resultsWe pooled individual patient-data (n = 2504) from a nationwide multicentre cohort-study (RETRACE, conducted at 22 German centres) and eventually identified MHV-patients (n = 137) with anticoagulation-associated ICH for outcome analyses. The primary outcome consisted of major haemorrhagic complications analysed during hospital stay according to treatment exposure (restarted TA vs. no-TA). Secondary outcomes comprised thromboembolic complications, the composite outcome (haemorrhagic and thromboembolic complications), timing of TA, and mortality. Adjusted analyses involved propensity-score matching and multivariable cox-regressions to identify optimal timing of TA. In 66/137 (48%) of patients TA was restarted, being associated with increased haemorrhagic (TA = 17/66 (26%) vs. no-TA = 4/71 (6%); P < 0.01) and a trend to decreased thromboembolic complications (TA = 1/66 (2%) vs. no-TA = 7/71 (10%); P = 0.06). Controlling treatment crossovers provided an incidence rate-ratio [hazard ratio (HR) 10.31, 95% confidence interval (CI) 3.67–35.70; P < 0.01] in disadvantage of TA for haemorrhagic complications. Analyses of TA-timing displayed significant harm until Day 13 after ICH (HR 7.06, 95% CI 2.33–21.37; P < 0.01). The hazard for the composite—balancing both complications, was increased for restarted TA until Day 6 (HR 2.51, 95% CI 1.10–5.70; P = 0.03).ConclusionRestarting TA within less than 2 weeks after ICH in patients with MHV was associated with increased haemorrhagic complications. Optimal weighing—between least risks for thromboembolic and haemorrhagic complications—provided an earliest starting point of TA at Day 6, reserved only for patients at high thromboembolic risk.

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Section: Discussionsupporting

confidence: 89%

Management of therapeutic anticoagulation in patients with intracerebral haemorrhage and mechanical heart valves

Kuramatsu

Sembill

Gerner

et al. 2018

European Heart Journal

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“…The risk of thromboembolism is highest in the first 3 months after prosthetic heart valve replacement or repair, with a risk of 3.6% to 10%, declining to \4% after 90 days. 10,11 Whenever possible, elective procedures should be delayed for at least 3 months after valve surgery. 12 Based on the 2006 American College of Cardiology / American Heart Association valvular disease guidelines, the 2012 European Society of Cardiology valvular guidelines, and the 2012 American College of Chest Physicians guidelines, the presence of any one of the following features, in the setting of a prosthetic heart valve, places patients at high risk for thromboembolism: atrial fibrillation, prior thromboembolism, left ventricular ejection fraction \35%, mitral or tricuspid valve placement, 2 prosthetic valves, or older aortic ball or tilting disc valves.…”

Section: Assessment Of Thromboembolic Riskmentioning

confidence: 99%

Perioperative Management of Antithrombotic Therapy in Common Otolaryngologic Surgical Procedures

Hsueh

Hwang

Abuzeid

2015

Otolaryngol.--head neck surg.

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“…Ten studies (n = 93,448) reported 13 evaluations on the relationship between malignancy and major or any bleeding (15,21,23,26,(29)(30)(31)(36)(37)(38). No study reported such a relationship with minor bleeding.…”

Section: Malignancymentioning

confidence: 99%

Are the risk factors listed in warfarin prescribing information associated with anticoagulation-related bleeding? A systematic literature review

Chen

White

Kluger

et al. 2011

International Journal of Clinical Practice

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Warfarin significantly reduces thromboembolic risk, but perceptions of associated bleeding risk limit its use. The evidence supporting the association between bleeding and individual patient risks factors is unclear. This systematic review aims to determine the strength of evidence supporting an accentuated bleeding risk when patients with risk factors listed in the warfarin prescribing information are prescribed the drug. A systematic literature search of MEDLINE and Cochrane CENTRAL was conducted to identify studies reporting multivariate relationships between prespecified covariates and the risk of bleeding in patients receiving warfarin. The prespecified covariates were identified based on patient characteristics for bleeding listed in the warfarin package insert. Each covariate was evaluated for its association with specific types of bleeding. The quality of individual evaluations was rated as 'good', 'fair' or 'poor' using methods consistent with those recommended by the Agency for Healthcare Research and Quality (AHRQ). Overall strength of evidence was determined using the Grading of Recommendations Assessment, Development (GRADE) criteria and categorised as 'insufficient', 'very low', 'low', 'moderate' or 'high'. Thirty-four studies, reporting 134 multivariate evaluations of the association between a covariate and bleeding risk were identified. The majority of evaluations had a low strength of evidence for the association between covariates and bleeding and none had a high strength of evidence. Malignancy and renal insufficiency were the only two covariates that had a moderate strength of evidence for their association with major and minor bleeding respectively. The associations between covariates listed in the warfarin prescribing information and increased bleeding risk are not well supported by the medical literature.

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Achieved Anticoagulation vs Prosthesis Selection for Mitral Mechanical Valve Replacement

Cited by 24 publications

References 42 publications

Management of therapeutic anticoagulation in patients with intracerebral haemorrhage and mechanical heart valves

Management of therapeutic anticoagulation in patients with intracerebral haemorrhage and mechanical heart valves

Perioperative Management of Antithrombotic Therapy in Common Otolaryngologic Surgical Procedures

Are the risk factors listed in warfarin prescribing information associated with anticoagulation-related bleeding? A systematic literature review

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