Identification of risk factors for bleeding during treatment of acute venous thromboembolism with heparin or low molecular weight heparin

Nieuwenhuis, H. K.; Albada, J; Jd, Banga; Sixma, JJ

doi:10.1182/blood.v78.9.2337.2337

Cited by 197 publications

(103 citation statements)

References 27 publications

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“…A reasonable estimate of the incremental risk of major bleeding with the use of perioperative low molecular weight heparin (LMWH) is 0-2 per cent for non-major surgery and 2-4 per cent for major surgery 14,15 . The case fatality rate of a major bleeding episode is 3-8 per cent 16,17 . Factors such as the location and extent of surgery, and the accessibility of means of controlling bleeding by packing and suturing, may also influence management 11 .…”

Section: Bleeding Risk Of the Proceduresmentioning

confidence: 99%

Management of surgical patients receiving anticoagulation and antiplatelet agents

Thachil

Gatt

Martlew

2008

British Journal of Surgery

102

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Background: Temporary interruption of long-term anticoagulation and antiplatelet therapy during surgical procedures exposes patients to thrombotic risk. Continuation of these agents, however, is associated with an increased risk of bleeding. Managing anticoagulation can be a particular challenge in the emergency setting.Methods: A literature review of published articles sourced using the keywords heparin, warfarin, perioperative, antiplatelet, aspirin and surgery was undertaken. A management plan for all likely situations was developed. Results and conclusion:Based on an individual assessment of risk factors for arterial or venous thromboembolism and the risk of perioperative bleeding, it is possible to form an anticoagulant and antiplatelet management plan likely to achieve a low incidence of bleeding and thrombosis. A multidisciplinary approach is desirable.

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Section: Bleeding Risk Of the Proceduresmentioning

confidence: 99%

Management of surgical patients receiving anticoagulation and antiplatelet agents

Thachil

Gatt

Martlew

2008

British Journal of Surgery

102

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“…However, single measurements of anti-FXa activities most likely do not accurately reflect the true influence of enoxaparin on coagulation [12]. Lower anti-FXa activities indicate pharmacokinetic differences but might not imply less protection in critically ill patients as the association between plasma anti-FXa activity and clinical outcome is weak [13,14] However, the assessment and comparison of the antithrombotic bioactivity of enoxaparin in critically ill and 'normal' medical ward patients can be used as a surrogate for the pharmacologic comparison of LMWHs. The aim of this study was to determine if a single subcutaneous dose of 40 mg enoxaparin exerts equivalent antithrombotic effects on fibrin formation in critically ill and general medical ward patients with normal renal function under low shear-rate flow conditions in an ex vivo perfusion chamber model of thrombosis.…”

Section: Introductionmentioning

confidence: 99%

Bioactivity of enoxaparin in critically ill patients with normal renal function

Gouya¹,

Palkovits²,

Kapiotis³

et al. 2012

Brit J Clinical Pharma

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WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT • Venous thromboembolism is a frequent complication in critically ill patients that has a negative impact on patient outcomes. • Critically ill patients have significantly lower plasma anti‐factor‐Xa activity levels compared with control patients after administration of subcutaneous heparin. • The clinical relevance of the different anti‐factor‐Xa levels after prophylactic doses of low molecular weight heparin (LMWH) in critically ill patients is not completely understood. WHAT THIS STUDY ADDS • The standard dose of 40 mg enoxaparin led to a significant increase in anti‐FXa levels in this selected cohort of ICU patients with normal renal function. • This study found only subtle pharmacokinetic differences, but a comparable pharmacodynamic action, after enoxaparin administration in critically ill and normal medical ward patients. • Thrombin generation with TGA RC‐low and TGA RC‐high reagents was significantly reduced in ICU and normal ward patients after receiving LMWH. Both readouts appear equally useful for estimating the pharmacodynamics of enoxaparin. • The ex vivo model of thrombosis was used for the first time in patients to evaluate the anti‐thrombotic activity of LMWH. This method did not show any difference in thrombus formation after administration of enoxaparin in the individual group of patients. Aim In critically ill patients, reduced anti‐FXa plasma activity following subcutaneous administration of enoxaparin or nadroparin has been described. In this study, we aimed to investigate the bioactivity of enoxaparin in critically ill patients and controls. Methods A prospective, controlled, open label study was performed on a medical intensive care unit (ICU) and a general medical ward. Fifteen ICU patients (male = 12, median age 52 years [IQR 40−65], with a median Simplified Acute Physiology Score of 30 [IQR 18−52]) and sex‐ and age‐matched medical ward patients were included. The anti‐FXa plasma activity was measured after a single subcutaneous dose of 40 mg enoxaparin. The thrombus size of a clot formed in an ex vivo perfusion chamber and endogenous thrombin potential (ETP) were measured. Results The anti‐FXa plasma activity increased significantly after enoxaparin administration, with peak levels at 3 h after treatment, but was comparable between the ICU and medical ward groups (median 0.16 IU ml−1[IQR 0−0.22 IU ml−1]vs. 0.2 IU ml−1[IQR 0.15−0.27 IU ml−1], respectively, P= 0.13). The area under the anti‐FXa activity curve from 0–12 h was similar between the groups (median 0.97 IU ml−1 h [IQR 0.59−2.1] and 1.48 IU ml−1 h1[IQR 0.83−1.62], P= 0.42 for the ICU group compared with the control group, respectively). The ETP was lower in the ICU group (P < 0.05) at baseline, but it was comparable at 3 h between the groups. Thrombus size decreased at 3 h compared with predose (P= 0.029) and was not different between the groups. Conclusion Similar bioactivity was achieved with a standard dose of subcutaneous enoxaparin in this selected cohort of ICU and general ward patie...

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“…Many bleeding-risk prediction scores have been reported previously; however, most of them were derived and validated in Western AF or VTE patients. 1,[3][4][5][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25] To our knowledge, this study was the first to validate the four BRS in Chinese PE patients who received anticoagulant therapy. Several previous studies have been conducted to externally validate and compare the prediction values of these BRS in Western VTE patients; however, the conclusions were inconsistent.…”

Section: Discussionmentioning

confidence: 93%

“…Several risk factors have been identified to be associated with bleeding for PE patients treated with anticoagulant therapy, including advanced age, previous stroke, previous major bleeding (MB), anaemia, cancer and drug combination. 1,[3][4][5] However, most bleeding risk scores (BRS) were derived from Western patients; an appropriate BRS for predicting bleeding risk within Chinese PE patients has yet been established. It is important to find an accurate and validated BRS to assist clinicians to evaluate the individual bleeding risk for PE patients.…”

Section: Introductionmentioning

confidence: 99%

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Comparison of prediction value of four bleeding risk scores for pulmonary embolism with anticoagulation: A real‐world study in Chinese patients

Zhu

Lei

Zhai

et al. 2019

Clinical Respiratory J

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Background Major bleeding (MB) and clinically relevant bleeding (CRB) are the most common seen complications associated with anticoagulation treatment for pulmonary embolism (PE) patients. A bleeding risk score (BRS) may help to accurately determine the risk of bleeding and make better decisions for patients in clinical practice. Methods Patients diagnosed as acute PE and who met the inclusion criteria in Beijing Chao‐Yang Hospital from January 2009 to September 2013 were consecutively enrolled. Baseline data were collected. Four BRS (Kuijer score, RIETE score, Kearon score and Nieuwenhuis score) were assessed and compared using the area under the receiver operating characteristic curve (AUC). Results A total number of 563 patients were included in the study. Of which, 16 had MB and 89 had CRB within three months of anticoagulation treatment. Three months' cumulative incidence for MB and CRB events was 0.03 (95% CI 0.01‐0.05) and 0.17 (95% CI 0.12‐0.21), respectively. In our study population, the AUCs for Kuijer, RIETE, Kearon and Nieuwenhuis scores were 0.57 (95% CI 0.44~0.68), 0.56 (95% CI 0.45‐0.71), 0.75 (95% CI 0.60~0.89) and 0.59 (95% CI 0.41~0.74), respectively. In addition, the AUCs of four BRS for CRB were all poor, with values less than 0.65. Conclusions Only the Kearon score appeared to have more accuracy in predicting the risk of MB. Further large prospective studies are needed to externally validate a BRS for CRB.

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Identification of risk factors for bleeding during treatment of acute venous thromboembolism with heparin or low molecular weight heparin

Cited by 197 publications

References 27 publications

Management of surgical patients receiving anticoagulation and antiplatelet agents

Management of surgical patients receiving anticoagulation and antiplatelet agents

Bioactivity of enoxaparin in critically ill patients with normal renal function

Comparison of prediction value of four bleeding risk scores for pulmonary embolism with anticoagulation: A real‐world study in Chinese patients

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