Complications associated with the use of oral anticoagulation in patients with pulmonary arterial hypertension from two referral centers

Roldan, Tamara; Ríos, Juan José; Villamañán, Elena; Waxman, Aaron B.

doi:10.1177/2045893217721903

Cited by 9 publications

(13 citation statements)

References 38 publications

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“…As with all retrospective single-center studies, the results are weakened by a center bias (as illustrated by the INR target higher than usual, as well as the age which was younger than the age of patients included in multicenter prospective registries). Roldan et al confirmed these results in a retrospective study of 201 PAH patients, with an incidence rate for major bleeding of 4.7 per 100 patient-years (5.0 per 100 patient-years for idiopathic PAH), 31 but without the excess in major bleeding events for patients with CTD-PAH (6.3 per 100 patient-years). Baseline factors which were associated with the occurrence of bleeding were a HAS-BLED score equal or greater than 3, history of prior bleeding, poor anticoagulation control, and increased number of concomitant medications.…”

Section: Confirming the Safety Of Anticoagulant Therapy In Patients Wmentioning

confidence: 78%

“…30 This significant proportion was subsequently confirmed in another retrospective cohort study from the Unites States and Spain in which 60.2% of PAH patients were treated with oral anticoagulants. 31 Patients with Congenital Heart Disease-Related PAH…”

Section: Concomitant Validated Indication For Anticoagulant Therapymentioning

confidence: 99%

“…This is a problem, since anticoagulant treatment increases the risk of bleeding, including life-threatening bleeding associated with PAH and CTEPH per se, such as hemoptysis, 44 a situation which may particularly affect patients with PAH associated with congenital heart diseases. 33 All the published data come from retrospective analyses 31,45,46 of patients with PAH or CTEPH who received anticoagulant therapy. The first paper was a single-center retrospective study from Amsterdam.…”

Section: Confirming the Safety Of Anticoagulant Therapy In Patients Wmentioning

confidence: 99%

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Use of Anticoagulants in Patients with Pulmonary Hypertension

2020

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Since the earliest works on the understanding of different forms of pulmonary hypertension, thrombosis has been involved in the pathophysiology of the disease, both in pulmonary arterial hypertension (PAH) and in chronic thromboembolic pulmonary hypertension (CTEPH). Autopsy and then pathophysiological data paved the way for the use of anticoagulants as a treatment for PAH and CTEPH. In PAH their role has diminished with the advent of specific targeted therapies, but they are still prescribed in more than half of PAH patients, because of concomitant venous thromboembolism or atrial fibrillation. In CTEPH long-term anticoagulant therapy is the cornerstone of the management. The recent development of direct oral anticoagulants (DOACs) raises the question of the best anticoagulation strategy, both in patients with PAH and in patients with CTEPH. In this review, we present an overview of the history of anticoagulants in the management of patients suffering from PAH or CTEPH, an update of the available data on the underlying rationale of their use in these subjects, an alert on the potential risks of using DOACs in these poorly explored situations, and the setting up of dedicated trials to evaluate the best anticoagulant treatment strategies in patients suffering from PAH or CTEPH.

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Section: Confirming the Safety Of Anticoagulant Therapy In Patients Wmentioning

confidence: 78%

Section: Concomitant Validated Indication For Anticoagulant Therapymentioning

confidence: 99%

Section: Confirming the Safety Of Anticoagulant Therapy In Patients Wmentioning

confidence: 99%

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Use of Anticoagulants in Patients with Pulmonary Hypertension

2020

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“…1,7 As a result, considerable uncertainty exists on the benefits of offering systemic AC to all IPAH patients without a secondary indication for AC, and recent registry data indicate that only the minority of IPAH patients are placed on systemic AC. 10–14 Additionally, the benefits of systemic AC on PAH quality of life are not well defined, and recommendations for PAH therapy do not currently account for patient values and preferences as part of a shared decision-making model. 15–17…”

Section: Discussionmentioning

confidence: 99%

Anticoagulation in pulmonary arterial hypertension: a decision analysis

2019

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Systemic anticoagulation may be beneficial in pulmonary arterial hypertension, but there is no randomized clinical trial data to guide therapeutic decision making, and current guidelines do not account for patient preferences or quality of life. Decision analytic models to evaluate the potential risks and benefits of systemic anticoagulation in pulmonary arterial hypertension patients, focusing on the benefit in quality-adjusted life years, may be helpful in clarifying this uncertainty. We constructed a 31-state Markov decision analytic model to explore anticoagulation and no anticoagulation strategies. Modeled patient characteristics included gender, use of central catheter-based pulmonary arterial hypertension therapy, type of pulmonary arterial hypertension (idiopathic, idiopathic pulmonary arterial hypertension, or connective-tissue associated, connective tissue disease-pulmonary arterial hypertension), and use of oral contraceptive medication by females. Modeled events included mortality, thromboembolic complications, atrial fibrillation, stroke, and anticoagulation bleeding. Deterministic and probabilistic sensitivity analyses were performed. Anticoagulation was favored in all idiopathic pulmonary arterial hypertension cases, with a gain of 0.43–0.51 quality-adjusted life years, and detrimental in all connective tissue disease-pulmonary arterial hypertension cases, with a loss of 0.66–1.89 quality-adjusted life years. Anticoagulation would need to demonstrate a hazard ratio for pulmonary arterial hypertension mortality of 0.95 or better to be favored. In our model, idiopathic pulmonary arterial hypertension patients benefit from anticoagulation in terms of quality-adjusted life years, and connective tissue disease-pulmonary arterial hypertension patients were harmed, with a hazard ratio for pulmonary arterial hypertension mortality of 0.95 or better being required to favorably impact quality-adjusted life years. These results suggest that anticoagulation significantly improves quality adjusted life years and should be offered to all idiopathic pulmonary arterial hypertension patients. Shared decision models based on these results may help clarify therapeutic decision-making uncertainty in pulmonary arterial hypertension patients.

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“…We read with interest the retrospective study by Roldan et al. 1 assessing the safety of oral anticoagulation in 201 patients with pulmonary arterial hypertension (PAH). It is remarkable that while approximately 60% of patients with PAH are anticoagulated, consistent with prior data, half of them have a sole indication of PAH and possibly a higher incidence of major bleeding compared to other populations that require anticoagulation.…”

mentioning

confidence: 99%