Major bleeding in outpatients treated with warfarin: incidence and prediction by factors known at the start of outpatient therapy

Landefeld, C. Seth; Goldman, Lee

doi:10.1016/s0002-9343(89)80689-8

Cited by 675 publications

(50 citation statements)

References 36 publications

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“…Our data confirm that the use of anticoagulant therapy carries a higher risk to bleed than to recur in the elderly and in the renally impaired, as previously reported 14, 21, 22, 23, 24, 25. During initial therapy with LMWH, fragile patients weighing ≤50 kg received slightly higher (non‐significantly) mean daily doses per body weight of LMWH compared with non‐fragile patients.…”

Section: Discussionsupporting

confidence: 89%

Clinical outcomes during anticoagulant therapy in fragile patients with venous thromboembolism

Moustafa

Giorgi‐Pierfranceschi²,

Micco

et al. 2017

Research and Practice in Thrombosis and Haemostasis

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Essentials Recent randomized trials suggested fewer bleeding events in fragile patients with VTE receiving DOACs.The frequency, clinical characteristics and outcome of these patients have not been reported in real life.Fragile patients with VTE had a higher risk for major bleeding or death and a lower risk for recurrences than non‐fragile. BackgroundSubgroup analyses from randomized trials suggested favorable results for the direct oral anticoagulants in fragile patients with venous thromboembolism (VTE). The frequency and natural history of fragile patients with VTE have not been studied yet.ObjectivesTo compare the clinical characteristics, treatment and outcomes during the first 3 months of anticoagulation in fragile vs non‐fragile patients with VTE.MethodsRetrospective study using consecutive patients enrolled in the RIETE (Registro Informatizado Enfermedad TromboEmbolica) registry. Fragile patients were defined as those having age ≥75 years, creatinine clearance (CrCl) levels ≤50 mL/min, and/or body weight ≤50 kg.ResultsFrom January 2013 to October 2016, 15 079 patients were recruited. Of these, 6260 (42%) were fragile: 37% were aged ≥75 years, 20% had CrCl levels ≤50 mL/min, and 3.6% weighed ≤50 kg. During the first 3 months of anticoagulant therapy, fragile patients had a lower risk of VTE recurrences (0.78% vs 1.4%; adjusted odds ratio [OR]: 0.52; 95% confidence intervals [CI]: 0.37‐0.74) and a higher risk of major bleeding (2.6% vs 1.4%; adjusted OR: 1.41; 95% CI: 1.10‐1.80), gastrointestinal bleeding (0.86% vs 0.35%; adjusted OR: 1.84; 95% CI: 1.16‐2.92), haematoma (0.51% vs 0.07%; adjusted OR: 5.05; 95% CI: 2.05‐12.4), all‐cause death (9.2% vs 3.5%; adjusted OR: 2.02; 95% CI: 1.75‐2.33), or fatal PE (0.85% vs 0.35%; adjusted OR: 1.77; 95% CI: 1.10‐2.85) than the non‐fragile.ConclusionsIn real life, 42% of VTE patients were fragile. During anticoagulation, they had fewer VTE recurrences and more major bleeding events than the non‐fragile.

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Section: Discussionsupporting

confidence: 89%

Clinical outcomes during anticoagulant therapy in fragile patients with venous thromboembolism

Moustafa

Giorgi‐Pierfranceschi²,

Micco

et al. 2017

Research and Practice in Thrombosis and Haemostasis

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“…CDRs can estimate the likelihood of a particular diagnosis, the potential value of a laboratory test, or beneficial or adverse effects of a particular treatment 28,29 or program element. 23,24,27 CDRs often provide clinicians with a range of probabilities as to the outcome.…”

Section: Develop and Test Clinical Decision Rulesmentioning

confidence: 99%

Narrowing the Gaps Between What We Know and What We Do in Psychiatry

Rush¹

2015

J. Clin. Psychiatry

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This report examines the nature, importance, and reasons for the gaps between what we know from research, what we need to know, and what we do in the clinic: research-practice gaps. It also makes suggestions for how to narrow these gaps. Patients, families, clinicians, care system managers, regulators, health care policy makers, and payers are all stakeholders in patient-oriented research. Different types of patient-oriented research address their diverse interests. For example, regulators and industry sponsors focus largely on efficacy and safety issues for new medications and devices via phase 1-3 studies. Clinicians and patients want to know how, when, for whom, and under what conditions both new and current treatments are best provided-questions not addressed by trials conducted for regulatory approval. Managers and policy makers understandably want to know about tradeoffs and costs, especially the value added (or not) by new, potentially more expensive treatments. This report will focus on patient and clinician perspectives, which substantially overlap. Figure 1A summarizes common clinical tasks such as screening, diagnosing, treatment targeting, and monitoring outcomes. Treatment targeting entails the selection of the best treatment for specific patients or, conversely, the avoidance of treatments that are rather certain to fail for specific patients (the core of personalized medicine). WHY ARE THERE RESEARCH-PRACTICE GAPS?Both conceptual and operational factors contribute to these gaps. Conceptual challenges include historical factors; scientific and academic incentives; intellectual silos among clinicians, researchers, and other stakeholders; and the failure to adequately recognize and address the tension entailed in nomothetic and ideographic perspectives in the development, reporting, and application of evidence. Operational challenges include budgets, funding priorities, costs, publication practices, and the growing research burdens placed on both patients and researchers. Conceptual FactorsHistorical assumptions. We have generally assumed that mental health, medical, and surgical practitioners, once armed with a new clinical test or treatment, will figure out by clinical experience how to best use it. Clinical experience would result in consequent wisdom (ie, the "art of medicine"), so research would not be needed.Once, the surprisingly wide practice variations were recognized. The potential benefit of reducing ineffective or unsafe variations was clear. Practice guidelines were developed to summarize the evidence and recommend evidence-based practices. These recommendations, while helpful, have been of limited value due to the dearth of empirical evidence regarding who, how, when, and in what contexts any specific treatment or clinical test should be selected, avoided, placed in a sequence, combined, or otherwise personalized. This evidence is often just not available.Scientific and academic incentives. Historically, academic incentives have been highly focused on individual researchers, but this fo...

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“…The risk of ICH in patients on long-term anticoagulation is 8 to 11 times higher than that of age-matched cohorts not taking anticoagulants [13,14]. Advanced age (≥70 years) [15,16], hypertension [9,14,15,17] and concurrent use of single or dual antiplatelets [18] are risk factors for WRICH. Other established risk factors include the early period after warfarin initiation [9,13,19], supratherapeutic levels of anticoagulation [9,14,17,20-23] and associated leukoaraiosis [21,23].…”

Section: Epidemiologymentioning

confidence: 99%

Management of anticoagulant-related intracranial hemorrhage: an evidence-based review

Ray

Keyrouz

2014

Crit Care

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The increased use of anticoagulants for the prevention and treatment of thromboembolic diseases has led to a rising incidence of anticoagulant-related intracranial hemorrhage (AICH) in the aging western population. High mortality accompanies this form of hemorrhagic stroke, and significant and debilitating long-term consequences plague survivors. Although management guidelines for such hemorrhages are available for the older generation anticoagulants, they are still lacking for newer agents, which are becoming popular among physicians. Supportive care, including blood pressure control, and reversal of anticoagulation remain the cornerstone of acute management of AICH. Prothrombin complex concentrates are gaining popularity over fresh frozen plasma, and reversal agents for newer anticoagulation agents are being developed. Surgical interventions are options fraught with complications, and are decided on a case-by-case basis. Our current state of understanding of this condition and its management is insufficient. This deficit calls for more population-based studies and therapeutic trials to better evaluate risk factors for, and to prevent and treat AICH.

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Major bleeding in outpatients treated with warfarin: incidence and prediction by factors known at the start of outpatient therapy

Cited by 675 publications

References 36 publications

Clinical outcomes during anticoagulant therapy in fragile patients with venous thromboembolism

Clinical outcomes during anticoagulant therapy in fragile patients with venous thromboembolism

Narrowing the Gaps Between What We Know and What We Do in Psychiatry

Management of anticoagulant-related intracranial hemorrhage: an evidence-based review

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