ObjectivesTo develop a tool to assess the credibility of cohort studies regarding anticoagulants treatment for patients with atrial fibrillation.MethodsMEDLINE, EMbase and CBM databases were retrieved for eligible studies on the methodological quality and credibility of the cohort study. The retrieval period was from inception to December 19th, 2017, and the languages were limited to Chinese and English. Based on the search results, the items on the methodology quality of the research or the credibility of the results were collected. Through brainstorming of the core group, the collected items were expanded and sorted out to a preliminary scale. Furthermore, we conducted 4 rounds of internal expert seminars to discuss and evaluate the preliminary scale content and discuss the scale framework. Finally, we organized domestic authoritative experts to conduct 4 external evaluations on the scale and formed the final scale.ResultsA total of 7 734 literatures were obtained from primary search, in which 17 of which were included. Fifty-five tools with 780 items for the quality assessment of observational studies were collected from the included studies. After removing duplicated keywords with similar meanings, we obtained the " keyword pool” with 46 keywords, which were preliminarily formed 46 items. After discussion of the core group, which aimed to supplement the potential items, eliminate the items irrelevant to methodology, and integrate the items with partial overlapping meanings, a preliminary scale of 43 items was formed. According to the four rounds of internal expert consultative meetings, these items were integrated to form a preliminary scale of 40 items. After further evaluation by four rounds of external expert consultative meetings, a consensus was reached and a scale of 21 items from seven domains (i.e., definition of question, measurement, follow-up, confounder, missing data, statistical analysis, and results assessment) was finally formed.ConclusionsThis study developed an assessment tool for the credibility of the results from the cohort studies regarding anticoagulants treatment in patients with atrial fibrillation, which has practical clinical value. Clinicians can refer to the results of credibility assessment by using this tool to better assist clinical decision-making in clinical practice. In addition, in the preparation of relevant guidelines, this tool can be used to assess the credibility of results from cohort studies.
ObjectiveTo evaluate the venous thromboembolism (VTE) risk and anticoagulant therapy in patients with coronavirus disease 2019 (COVID-19).MethodsThe patients with COVID-19 in Optics Valley Hospital of Wuhan Tongji Hospital from February 9, 2020 to March 29, 2020 were collected and analyzed. Padua scores were performed within 24 hours after admission. The relationship between Padua score, disease severity and 28 day prognosis was analyzed.ResultsCOVID-19 was diagnosed in 102 cases. The age, fibrinogen and mortality of the severe group were significantly higher than those of the common group. The Padua score of the severe group was higher than that of the common group, but there was no statistical difference. The platelet count in the critical group was significantly lower than that in the severe group, while the prothrombin time (PT), activated partial thromboplastin time (APTT), and D dimer were significantly higher than that in the severe group, and the Padua score, anticoagulation ratio, and mortality were significantly higher than those in the severe group. According to Padua score 4, it was divided into VTE high risk group (≥ 4 points) and VTE low risk group (<4 points). The mortality, APTT, D dimer and fibrinogen of high risk group were significantly higher than those of low risk group. In the high-risk group of VTE, the anticoagulation rate was significantly higher than that in the low-risk group of VTE, but it was still only 41.7%. The mortality of patients with anticoagulation was lower than that of patients without anticoagulation.ConclusionsSevere and critical novel coronavirus pneumonia patients have obvious coagulation dysfunction and high risk of VTE. Anticoagulant therapy may be associated with low mortality in patients with high risk of VTE, but the proportion of drug-induced anticoagulant intervention still needs to be improved.
Objective To evaluate the efficacy and safety of anticoagulant agents, such as aspirin and heparin, in women with a history of at least two spontaneous miscarriages or one later intrauterine fetal death without apparent causes other than inherited thrombophilias. Methods We searched the Cochrane Pregnancy and Childbirth Group trials register (March 2004), the Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2004), MEDLINE (January 1966 to March 2004), and EMBASE (1980 to March 2004). We scanned bibliographies of all located articles for any unidentified articles. Randomised and quasi-randomised controlled trials that assessed the effect of anticoagulant treatment on the live-birth rate in women with a history of at least two spontaneous miscarriages or one later intrauterine fetal death without apparent causes other than inherited thrombophilias were eligible. Interventions included aspirin, unfractionated heparin, and low molecular weight heparin for the prevention of birth loss. One treatment could be compared with another or with placebo. Two authors assessed the trials for inclusion in the review and extracted the data. Data were entered into the Review Manager software and double checked. Results Two studies (242 participants) were included in the review and for both of them data were extracted for the subgroups of women fulfiling the inclusion criteria of the review. In one study, 54 pregnant women with recurrent spontaneous abortion without detectable anticardiolipin antibodies were randomised to low-dose aspirin or placebo. Similar live-birth rates were observed with aspirin and placebo [relative risk (RR) 1.00, 95% confidence interval (CI) 0.78 to 1.29]. In another study, a subgroup of 20 women who had had a previous fetal loss after the 20th week and had a thrombophilic defect were randomised to enoxaparin or aspirin. Enoxaparin treatment resulted in an increased live-birth rate, as compared to low-dose aspirin, RR 10.00, 95% CI 1.56 to 64.20). Conclusions The evidence on the efficacy and safety of thromboprophylaxis with aspirin and heparin in women with a history of at least two spontaneous miscarriages or one later intrauterine fetal death without apparent causes other than inherited thrombophilias is too limited to recommend the use of anticoagulants in this setting. Large, randomised, placebo-controlled trials are urgently needed.
ObjectiveTo investigate long-term outcomes of patients without warfarin anticoagulation after isolated prosthetic aortic valve replacement (AVR) and evaluate the feasibility of short-term instead of lifelong anticoagulation therapy for low-risk AVR patients.
MethodsSeven patients who underwent prosthetic AVR in Guangdong General Hospital between 1996 and 1999 but discontinued warfarin anticoagulation 3 years after surgery were regularly followed up. There were 6 male and 1 female patients with their age of 25-75 (40.0±11.4) years. These patients received warfarin anticoagulation during the first 3 years after surgery but discontinued oral anticoagulant 3 years after surgery (discontinued anticoagulation group). Fifteen patients who underwent prosthetic AVR during the same period and continued warfarin anticoagulation were enrolled as the control group (continuing anticoagulation group). International normalized ratio (INR) was set between 1.8 and 2.5 during warfarin anticoagulation period in both groups. Survival rate and the incidence of severe adverse events were compared between the 2 groups.
ResultsIn the discontinued anticoagulation group,1 patient was lost during follow-up. No thromboembolic event,death or prosthetic valve thrombosis was observed. All the patients were in NYHA class Ⅰ. In the continuing anticoagulation group,3 patients were lost during follow-up. Eleven patients were in NYHA class Ⅰ and 2 patients were in NYHA class Ⅱ. Severe anticoagulation-related bleeding events occurred in 3 patients with gastrointestinal bleeding. One patient died of massive outbreak of vomiting blood,and another patient had sudden death. Ten-year survival rate was 100.0% and 86.7% in the discontinued anticoagulation group and continuing anticoagulation group, respectively.
ConclusionFor low-risk patients after isolated prosthetic AVR,short-term warfarin anticoagulation may be acceptable, which means warfarin is administered only in the first 3 years after surgery and discontinued 3 years after surgery.
In the intensive care units of Japan, nafamostat mesilate (NM) is the most used anticoagulant of continuous blood purification, with the rate of up to 85%. Its biggest characteristic is not to reduce the life of the filter in the group of patients with high risk of bleeding, and it can be safely used. However, there are not a few reports about severe anaphylaxis, when the symptoms of anaphylaxis is recognized after the start of continuous renal replacement therapy, it should be kept in mind that it is NM hypersensitivity. In addition, for an expensive drug, it may be required to be limited in the cases of risk of bleeding complications. NM has been developed for nearly 30 years, so it has high reliability in Japan. However, in the same case, regional citrate anticoagulation is recommended internationally. It may need a randomized controlled trial with regional citrate anticoagulation to prove the real effectiveness of NM.
Objective To assess different anticoagulant regimens in pregnant women with mechanical heart valves: taking oral warfarin throughout the pregnancy, or heparin in the 1st trimester and oral warfarin for the other trimesters. The main outcome measures were major maternal complications and perinatal outcomes. Methods The MEDLINE, EMbase, CBM and CNKI were searched. The quality of the included studies was evaluated and data were extracted by two reviewers independently. Meta-analyses were performed on the results of homogeneous studies. Result Seven studies involving 629 pregnancies in 469 patients met the inclusion criteria for this review, all of which were retrospective surveys. The comparison between the administration of heparin in the 1st trimester plus oral warfarin for the other trimesters and warfarin throughout the pregnancy showed that, there are not significant different in the incidence of major maternal complications and the incidence of adverse perinatal outcomes. Conclusion Compared with the administration of warfarin throughout the pregnancy, the administration of heparin in the 1st trimester and oral warfarin for the other trimesters might increase the incidence of major maternal complications, but with a similar incidence of adverse perinatal outcomes.
Heparin has long been a preferred anticoagulant during cardiovascular surgery, although limitations exist, including heparin-induced thrombocytopenia (HIT) and/or anti-platelet factor Ⅳ/heparin (anti-PF4/H) antibodies. Bivalirudin is a direct thrombin inhibitor, which can overcome the shortcoming of heparin. This article reviewed the application of bivalirudin in the field of cardiac surgery, its safety and effectiveness in various surgical treatments as well as summarized the standard protocol, doses, monitoring parameters and targets of bivalirudin for anticoagulation in cardiac surgery and mechanical circulation support. Bivalirudin as an alternative to heparin provides a new selection for anticoagulation in cardiac surgery.
ObjectiveTo summarize the clinical characteristics and mid-long term efficacy of children under 15 years with mechanical valve replacement.
Methods We retrospectively analyzed the clinical data of 51 children aged 1 to 15 years underwent mechanical valve replacement in Xinhua Hospital between January 2006 and January 2014. There were 32 males and 19 females with mean age of 9.6±4.0 years (ranged 1-15 years).
ResultsThe average cardiopulmonary bypass time was 120.50±61.02 minutes, and average aortic cross-clamping time was 68.35±42.68 minutes. One patient died in hospital. There were 6 patients (11.8%) with complications including mitral paravalvular leakage in 1 patient, malignant ventricular arrhythmia in 1 patient, respiratory failure in 1 patient, acute renal failure in 2 patients, and delayed thoracic close in 1 patient. All the children cured and were followed up for 1-96 months. One patient died during the follow-up time. No other redo-valve replacement or complications correlated to anticoagulant occurred.
ConclusionsMechanical valve replacement may be necessary in children with extremely dysplastic valves and severe hemodynamic impairment or after failed repair. With appropriate selection of the prosthetic valve and intensive care therapy during the peroperative period, the mid to long term efficacy is optimistic.
Objective To formulate an evidence-based treatment plan for a patient with ischemic stroke accompanied by hypertension and atrial fibrillation. Methods We searched The Cochrane Library (Issue 4, 2006), SUMsearch (January 1980 to December 2006) and PubMed (January 1980 to December 2006) to identify randomized controlled trials (RCTs), systematic reviews (SRs) and meta-analyses about the efficacy and safety of anticoagulant therapy for ischemic stroke coupled with atrial fibrillation, and blood pressure lowering therapy for ischemic stroke coupled with hypertension. We evaluated the validity, reliability and feasibility of each study to identify the current best evidence. Results Four guidelines, 3 SRs and 6 RCTs were included. The evidence showed that low-intensity anticoagulant therapy was safe and effective for this patient, and that rapid blood pressure lowering therapy was not suitable for acute ischemic stroke. According to the current evidence, as well as the patient’s clinical condition and preference, low-intensity warfarin was given with a target INR (international normalized ratio) of 2.0. During convalescence, he was given oral fosinopril and indapamide. His symptoms were relieved after two weeks of treatment, and follow-up at one month indicated that this plan was suitable for the patient. Conclusions Anticoagulant therapy is still preferred for acute ischemic stroke accompanied by hypertension and atrial fibrillation. The current evidence suggests that warfarin is superior to other anticoagulants. The target INR should be adjusted individually, especially in old patients. The maintenance of a low INR level, if necessary, could maximise utility and minimise the risk of hemorrhage. Aspirin is recommended when anticoagulants cannot be tolerated. Intensive blood pressure lowering therapy is not reasonable for patients with acute ischemic stroke. Antihypertensive drugs like ACEI and low-dose diuretics may be chosen during convalescence.
To evaluate the effectiveness and safety of anticoagulants in ischaemic stroke primary or secondary prevention and treatment, we searched The Cochrane Library and MEDLINE to find high quality evidence and summarized the available evidence. The results showed that routine immediate anticoagulant therapy in patients with acute ischaemic stroke should not be recommended because it increased the risk of hemorrhage with ineffective reduction to the risk of death or disability. For the high risk group with cardiogenic embolism, anticoagulant therapy could safely and effectively reduce the incidence of stroke or other vascular events. However, for non-cardiogenic embolism group, anticoagulant therapy was hard to balance the benefits and harms.
