Early systemic anticoagulation reduces hospital readmission in acute necrotizing pancreatitis patients:A retrospective cohort study

Background:Early systemic anticoagulation(SAC)is a common practice in acute necrotizing pancreatitis(ANP),and its impact on in-hospital clinical outcomes had been assessed.However,whether it affects long-term outcomes is unknown.This study aimed to evaluate the effect of SAC on 90-day readmission and other long-term outcomes in ANP patients.Methods:During January 2013 and December 2018,ANP patients admitted within 7 days from the onset of abdominal pain were screened.The primary outcome was 90-day readmission after discharge.Cox proportional-hazards regression model and mediation analysis were used to define the relationship between early SAC and 90-day readmission.Results:A total of 241 ANP patients were enrolled,of whom 143 received early SAC during their hospitalization and 98 did not.Patients who received early SAC experienced a lower incidence of splanchnic venous thrombosis(SVT)[risk ratio(RR)=0.40,95%CI:0.26-0.60,P<0.01]and lower 90-day readmission with an RR of 0.61(95%CI:0.41-0.91,P=0.02)than those who did not.For the quality of life,patients who received early SAC had a significantly higher score in the subscale of vitality(P=0.03)while the other subscales were all comparable between the two groups.Multivariable Cox regression model showed that early SAC was an independent protective factor for 90-day readmission after adjusting for potential confounders with a hazard ratio of 0.57(95%CI:0.34-0.96,P=0.04).Mediation analysis showed that SVT mediated 37.0%of the early SAC-90-day readmission causality.Conclusions:The application of early SAC may reduce the risk of 90-day readmission in the survivors of ANP patients,and reduced SVT incidence might be the primary contributor.

Bivalirudin for anticoagulation in elderly acute coronary syndrome:Effects on myocardial microcirculation and adverse events

The management of acute coronary syndrome(ACS)in older patients remains challenging because standard anticoagulants often fail to yield optimal outcomes.Bivalirudin,a direct inhibitor of thrombin,serves as an alternative to traditional therapies.This drug is particularly effective in enhancing myocardial microcircu-lation and reducing adverse events after clinical interventions.The present article explores the findings of a recent study that highlighted the clinical benefits of bivalirudin by investigating its effects on myocardial microcirculation and adverse cardiac events after percutaneous coronary intervention in older patients with ACS.Compared with unfractionated heparin,bivalirudin markedly reduced the emergency response time and improved cardiac function indicators.It further mitigated the risks of cardiovascular events and recurrent myocardial infarctions.These findings suggest that bivalirudin can enhance myocardial perfusion and reduce bleeding complications,thus serving as a safe,effective anticoagulation agent for older patients with ACS.Nonetheless,further large-scale,high-quality trials are needed to establish optimal usage guidelines and assess long-term outcomes.Integrating bivalirudin into ACS treatment protocols for older patients may help optimize patient care,balancing efficacy and safety.Continual research and consensus building are necessary for the widespread clinical application of bivalirudin and the improvement of ACS outcomes in older patients.

Dual versus single antiplatelet therapy for patients with long-term oral anticoagulation undergoing coronary intervention： a systematic review and meta-analysis

Objective The main aim of this meta-analysis is to compare the efficacy and safety of dual versus single antiplatelet therapy for pa- tients taking oral anticoagulation （OAC） after coronary intervention. Background The optimal regimen remains controversial for patients taking OAC after coronary intervention. Methods PubMed, Embase and Cochrane Central Register of Controlled Trials were searched for eligible studies including data of triple therapy （TT） versus OAC plus single antiplatelet therapy for patients requiring OAC after coronary intervention. The primary outcome was major adverse cardiac and cerebrovascular event （MACCE）. The safety outcome was major bleeding. Results Fourteen studies with 32,825 patients were included. Among prospective studies, patients with TT had a trend toward a higher risk of major bleeding [odds ratios （OR）： 1.56, 95% confidence interval （CI）： 0.98-2.49, P = 0.06] and a markedly higher risk of all-cause death （OR; 2.11, 95% CI： 1.10-4.06 P = 0.02） compared with OAC plus clopidogrel. Meanwhile, TT was associated with decreased risks of MACCE （OR： 0.63, 95% CI： 051-0.77 P 〈 0.0001）, all-cause death （OR： 0.45, 95% CI： 0.20-0.97, P = 0.04）, and stroke/transient ischemic attack （TIA）/peripheral embolism （PE） （OR= 0.29, 95% CI： 0.09~3.96, P = 0.04） compared with OAC plus aspirin. Conclusions For pa- tients requiring OAC after coronary intervention, OAC plus clopidogrel may bring more clinical net benefit than TT, whereas OAC plus aspirin should be the last choice. More large-size randomized control trials are needed to confirm these findings.

The Effects of Lower Intensity Anticoagulation Therapy on Coagulation System in Patients With Mechanical Prosthetic Valves

Summary: To evaluate the effect of lower intensity anticoagulation therapy in patients with mechanical prosthetic valves, laboratory based hematological assays including prothrombin time (PT), activity of factor X, antithrombin Ⅲ (AT Ⅲ), D dimer, fibrinogen (Fg) and platel et al pha granular membrane protein (GMP 140) were performed in 65 patients who had been on warfarin treatment for over one month. The patients were assigned to 3 groups on the basis of their International Normalized Ratios (INR), ranging from 2.00 to 2.50; 2.51 to 3.00; 3.01 to 4.50, respectively. The results showed that the D dimer, Fg, GMP 140 levels were higher after mechanical valve replacement than those before operation, indicating the activation of coagulation and fibrinolysis system and the damage of platelets. Lower intensity anticoagulation therapy (INR 2 00 to 2.50) could effectively inhibit the activity of factor X and increase the level of AT Ⅲ. There were no appreciable differences among D dimer, Fg, GMP 140 and AT Ⅲ in the 3 anticoagulation intensity groups. These results suggest that in patients with new generation mechanical prosthetic valves, target anticoagulation level (INR 2 00 to 2.50) may result in good protection from thrombo embolism.

The diagnostic yield for computed tomography pulmonary angiography in patients with anticoagulation

BACKGROUND:Patients who present to the emergency department(ED)for suspected pulmonary embolism(PE)are often on active oral anticoagulation(AC).However,the diagnostic yield of computed tomography pulmonary angiography(CTPA)in screening for PE in patients who present on AC has not been well characterized.We aim to investigate the diagnostic yield of CTPA in diagnosing PE depending on AC status.METHODS:We reviewed and analyzed the electronic medical records of patients who underwent CTPA for PE at a university hospital ED from June 1,2019,to March 25,2022.Primary outcome was the incidence of PE on CTPA depending on baseline AC status and indication for AC.RESULTS:Of 2,846 patients,242 were on AC for a history of venous thromboembolism(VTE),210 were on AC for other indications,and 2,394 were not on AC.The incidence of PE on CTPA was significantly lower in patients on AC for other indications(5.7%)when compared to patients on AC for prior VTE(24.3%)and patients not on AC at presentation(9.8%)(P<0.001).In multivariable analysis among the whole cohort,AC was associated with a positive CTPA(odds ratio[OR]0.26,95%confidence interval[CI]:0.15-0.45,P<0.001).CONCLUSION:The incidence of PE among patients undergoing CTPA in the ED is lower in patients previously on AC for indications other than VTE when compared to those not on AC or those on AC for history of VTE.AC status and indication for AC may affect pre-test probability of a positive CTPA,and AC status therefore warrants consideration as part of future diagnostic algorithms among patients with suspected PE.

Challenging anticoagulation therapy for multiple primary malignant tumors combined with thrombosis:A case report and review of literature

BACKGROUND Venous thromboembolism significantly contributes to patient deterioration and mortality.Management of its etiology and anticoagulation treatment is intricate,necessitating a comprehensive consideration of various factors,including the bleeding risk,dosage,specific anticoagulant medications,and duration of therapy.Herein,a case of lower extremity thrombosis with multiple primary malignant tumors and high risk of bleeding was reviewed to summarize the shortcomings of treatment and prudent anticoagulation experience.CASE SUMMARY An 83-year-old female patient was admitted to the hospital due to a 2-wk history of left lower extremity edema that had worsened over 2 d.Considering her medical history and relevant post-admission investigations,it was determined that the development of left lower extremity venous thrombosis and pulmonary embolism in this case could be attributed to a combination of factors,including multiple primary malignant tumors,iliac venous compression syndrome,previous novel coronavirus infection,and inadequate treatment for prior thrombotic events.However,the selection of appropriate anticoagulant medications,determination of optimal drug dosages,and establishment of an appropriate duration of anticoagulation therapy were important because of concurrent thrombocytopenia,decreased quantitative fibrinogen levels,and renal insufficiency.CONCLUSION Anticoagulant prophylaxis should be promptly initiated in cases of high-risk thrombosis.Individualized anticoagulation therapy is required for complex thrombosis.

Anticoagulant use before COVID-19 diagnosis prevent COVID-19 associated acute venous thromboembolism or not:A systematic review and meta-analysis

BACKGROUND Coagulopathy and thromboembolic events are associated with poor outcomes in coronavirus disease 2019(COVID-19)patients.There is conflicting evidence on the effects of chronic anticoagulation on mortality and severity of COVID-19 disease.AIM To summarize the body of evidence on the effects of pre-hospital anticoagulation on outcomes in COVID-19 patients.METHODS A Literature search was performed on LitCovid PubMed,WHO,and Scopus databases from inception(December 2019)till June 2023 for original studies reporting an association between prior use of anticoagulants and patient outcomes in adults with COVID-19.The primary outcome was the risk of thromboembolic events in COVID-19 patients taking anticoagulants.Secondary outcomes included COVID-19 disease severity,in terms of intensive care unit admission or invasive mechanical ventilation/intubation requirement in patients hospitalized with COVID-19 infection,and mortality.The random effects models were used to calculate crude and adjusted odds ratios(aORs)with 95%confidence intervals(95%CIs).RESULTS Forty-six observational studies met our inclusion criteria.The unadjusted analysis found no association between prior anticoagulation and thromboembolic event risk[n=43851,9 studies,odds ratio(OR)=0.67(0.22,2.07);P=0.49;I2=95%].The association between prior anticoagulation and disease severity was non-significant[n=186782;22 studies,OR=1.08(0.78,1.49);P=0.64;I2=89%].However,pre-hospital anticoagulation significantly increased all-cause mortality risk[n=207292;35 studies,OR=1.72(1.37,2.17);P<0.00001;I2=93%].Pooling adjusted estimates revealed a statistically non-significant association between pre-hospital anticoagulation and thromboembolic event risk[aOR=0.87(0.42,1.80);P=0.71],mortality[aOR=0.94(0.84,1.05);P=0.31],and disease severity[aOR=0.96(0.72,1.26);P=0.76].CONCLUSION Prehospital anticoagulation was not significantly associated with reduced risk of thromboembolic events,improved survival,and lower disease severity in COVID-19 patients.

Analysis of the Effect of High-Dose Segmental Citrate Anticoagulation in High Flux Hemodialysis

Objective:To analyze the clinical effect of high-dose citrate in segmental extracorporeal anticoagulation for high-throughput hemodialysis.Methods:The subjects included in this study were admitted to the hospital for maintenance hemodialysis treatment from January 2021 to January 2023.All patients had a high risk of bleeding and received 4%trisodium citrate anticoagulant treatment,administered at a rate of 200 mL/h before and after the dialyzer.The anticoagulant effects achieved by the patients were observed and analyzed.Results:The total number of patients who received high-dose segmented citrate extracorporeal anticoagulation dialysis treatment was 50,with each patient undergoing 100 treatments.During the treatment,2 patients had to end the treatment early due to transmembrane pressure exceeding 30 mmHg and an increase in venous pressure exceeding 250 mmHg;the treatment times for these patients were 20 minutes and 200 minutes,respectively.The remaining patients successfully completed the 4-hour treatment.Blood pH and calcium ion concentration in the venous pot were monitored.It was observed that before dialysis,after 2 hours of dialysis,and at the end of dialysis,the blood pH of the patients remained within a relatively normal range.Although some patient levels changed after dialysis,they remained within the normal range.No adverse reactions(such as numbness of the limbs or convulsions)were observed during the anticoagulant treatment.Conclusion:Administering 4%trisodium citrate at a rate of 200 mL/h before and after the dialyzer achieves a good anticoagulant effect,maintains the patient’s blood gas levels within the normal range at the end of dialysis,and causes no adverse reactions.

Spectrum of venous thromboembolism in adult patients with ulcerative colitis in Pakistan:A single center retrospective study

BACKGROUND Patients with inflammatory bowel disease are at a 2-8-fold higher risk of deve-loping venous thromboembolism(VTE)as compared to the general population.Although the exact pathogenesis is unclear,the literature suggests that increased risk of thromboembolic events in such patients occurs as a result of increased coagulation factors,inflammatory cytokines,and reduction in anticoagulants leading to a prothrombotic state.AIM To assess the prevalence,risk factors,management,and outcome of ulcerative colitis(UC)patients who develop VTE.METHODS This was a retrospective chart review done in The Gastroenterology Department of The Aga Khan University Hospital.Data was collected from medical records for all patients admitted with a diagnosis of UC from January 2012 to December 2022.RESULTS Seventy-four patients fulfilled the inclusion criteria.The mean±SD of age at presentation of all UC patients was 45 years±10 years whereas for those who developed VTE,it was 47.6 years±14.7 years.Hypertension and diabetes were the most common co-morbid seen among UC patients with a frequency of 17(22.9%)and 12(16.2%),respectively.A total of 5(6.7%)patients developed VTE.Deep venous thrombosis was the most common thromboembolic phenomenon seen in 3(60%)patients.All the patients with UC and concomitant VTE were discharged home(5;100%).CONCLUSION The prevalence of VTE with UC in Pakistani patients corresponds with the international literature.However,multi-centric studies are required to further explore these results.

Current role of extracorporeal membrane oxygenation for the management of trauma patients:Indications and results

Extracorporeal membrane oxygenation(ECMO)has emerged as a vital circulatory life support measure for patients with critical cardiac or pulmonary conditions unresponsive to conventional therapies.ECMO allows blood to be extracted from a patient and introduced to a machine that oxygenates blood and removes carbon dioxide.This blood is then reintroduced into the patient’s circulatory system.This process makes ECMO essential for treating various medical conditions,both as a standalone therapy and as adjuvant therapy.Veno-venous(VV)ECMO primarily supports respiratory function and indicates respiratory distress.Simultaneously,veno-arterial(VA)ECMO provides hemodynamic and respiratory support and is suitable for cardiac-related complications.This study reviews recent literature to elucidate the evolving role of ECMO in trauma care,considering its procedural intricacies,indications,contraindications,and associated complications.Notably,the use of ECMO in trauma patients,particularly for acute respiratory distress syndrome and cardiogenic shock,has demonstrated promising outcomes despite challenges such as anticoagulation management and complications such as acute kidney injury,bleeding,thrombosis,and hemolysis.Some studies have shown that VV ECMO was associated with significantly higher survival rates than conventional mechanical ventilation,whereas other studies have reported that VA ECMO was associated with lower survival rates than VV ECMO.ECMO plays a critical role in managing trauma patients,particularly those with acute respiratory failure.Further research is necessary to explore the full potential of ECMO in trauma care.Clinicians should have a clear understanding of the indications and contraindications for the use of ECMO to maximize its benefits in treating trauma patients.

World scenario of earthworms’prowess as a remedy to a spectrum of diseases-a glimpse on related nanoformulations

Earthworms are known to possess magnificent enzymes that hold their importance in a variety of diseases.The ancient traditional medicines in Southeast Asia have also evidenced the beneficial effects of earthworm extract consumption in various ailments.Analgesic,antipyretic,anticoagulant,antiepileptic,antimicrobial,antioxidant,and antiamyloid activities are a few applications along with anticancer and wound healing activities.Earthworm extracts have been consumed in the form of tea,Dilong tea,as well as dried powder,depending on the remedy necessary.In this review,we have discussed the worldwide concept of earthworm extract as medicine and have encompassed the scientific evidence obtained to support the notion about the earthworm extract’s health effect.

Anticoagulation therapy prevents portal-splenic vein thrombosis after splenectomy with gastroesophageal devascularization

AIM:To compare the incidence of early portal or splenic vein thrombosis(PSVT) in patients treated with irregular and regular anticoagulantion after splenectomy with gastroesophageal devascularization.METHODS:We retrospectively analyzed 301 patients who underwent splenectomy with gastroesophageal devascularization for portal hypertension due to cirrhosis between April 2004 and July 2010.Patients were categorized into group A with irregular anticoagulation and group B with regular anticoagulation,respectively.Group A(153 patients) received anticoagulant monotherapy for an undesignated time period or with aspirin or warfarin without low-molecular-weight heparin(LMWH) irregularly.Group B(148 patients) received subcutaneous injection of LMWH routinely within the first 5 d after surgery,followed by oral warfarin and aspirin for one month regularly.The target prothrombin time/international normalized ratio(PT/INR) was 1.25-1.50.Platelet and PT/INR were monitored.Color Doppler imaging was performed to monitor PSVT as well as the effectiveness of thrombolytic therapy.RESULTS:The patients' data were collected and analyzed retrospectively.Among the patients,94 developed early postoperative mural PSVT,including 63 patients in group A(63/153,41.17%) and 31 patients in group B(31/148,20.94%).There were 50(32.67%) patients in group A and 27(18.24%) in group B with mural PSVT in the main trunk of portal vein.After the administration of thrombolytic,anticoagulant and antiaggregation therapy,complete or partial thrombus dissolution achieved in 50(79.37%) in group A and 26(83.87%) in group B.CONCLUSION:Regular anticoagulation therapy can reduce the incidence of PSVT in patients who undergo splenectomy with gastroesophageal devascularization,and regular anticoagulant therapy is safer and more effective than irregular anticoagulant therapy.Early and timely thrombolytic therapy is imperative and feasible for the prevention of PSVT.

Anticoagulation and delayed bowel resection in the management of mesenteric venous thrombosis

Acute mesenteric venous thrombosis is potentially lethal because it can result in mesenteric ischemia and,ultimately,bowel infarction requiring surgical intervention.Systemic anticoagulation for the prevention of thrombus propagation is a well-recognized treatment modality and the current mainstay therapy for patients with acute mesenteric venous thrombosis.However,the decision between prompt surgical exploration vs conservative treatment with anticoagulation is somewhat difficult in patients with suspected bowel ischemia.Here we describe a patient with acute mesenteric venous thrombosis who presented with bowel ischemia and was treated with anticoagulation and delayed short-segment bowel resection.

Deep vein thrombosis and pulmonary embolism in cirrhotic patients:Systematic review

Patients with liver cirrhosis were traditionally believed to be protected against development of blood clots.Lately,studies have shown that these patients may probably be at an increased risk of venous thrombotic complications.Although the hemostatic changes in the chronic liver disease patients and the factors that may predict bleeding vs thrombotic complications remains an area of active research,it is believed that the coagulation cascade is delicately balanced in these patients because of parallel reduced hepatic synthesis of pro and anticoagulant factors.Thrombotic state in cirrhotic patients is responsible for not only portal or non-portal thrombosis[deep vein thrombosis(DVT)and pulmonary embolism(PE)];it has also been associated with progression of liver fibrosis.The use of anticoagulants in cirrhosis patients is a challenging,and often a scary situation.This review summarizes the current literature on the prevalence of venous thrombosis(DVT and PE),risk factors and safety of prophylactic and therapeutic anticoagulation in patients with chronic liver disease.

Management of regional citrate anticoagulation for continuous renal replacement therapy:guideline recommendations from Chinese emergency medical doctor consensus

Continuous renal replacement therapy(CRRT)is widely used for treating critically-ill patients in the emergency department in China.Anticoagulant therapy is needed to prevent clotting in the extracorporeal circulation during CRRT.Regional citrate anticoagulation(RCA)has been shown to potentially be safer and more effective,and is now recommended as the preferred anticoagulant method for CRRT.However,there is still a lack of unified standards for RCA management in the world,and there are many problems in using this method in clinical practice.The Emergency Medical Doctor Branch of the Chinese Medical Doctor Association(CMDA)organized a panel of domestic emergency medicine experts and international experts of CRRT to discuss RCA-related issues,including the advantages and disadvantages of RCA in CRRT anticoagulation,the principle of RCA,parameter settings for RCA,monitoring of RCA(mainly metabolic acid-base disorders),and special issues during RCA.Based on the latest available research evidence as well as the paneled experts'clinical experience,considering the generalizability,suitability,and potential resource utilization,while also balancing clinical advantages and disadvantages,a total of 16 guideline recommendations were formed from the experts'consensus.

Atractylenolide Ⅰ protects against lipopolysaccharide-induced disseminated intravascular coagulation by anti-inflammatory and anticoagulation effect

Objective:To investigate whether atractylenolide Ⅰ(ATL-Ⅰ) has protective effect on lipopolysaccharide(LPS)-induced disseminated intravascular coagulation(DIC) in vivo and in vitro,and explore whether NF-κB signaling pathway is involved in ATL-Ⅰ treatment.Methods:New Zealand white rabbits were injected with LPS through marginal ear vein over a period of 6h at a rate of 600 μg/kg(10 mL/h).Similarly,in the treatment groups,1.0,2.0,or 5.0 mg/kg ATL-Ⅰ were given.Both survival rate and organ function were tested,including the level of alanine aminotransferase(ALT),blood urine nitrogen(BUN),and TNF-α were examined by ELISA.Also haemostatic and fibrinolytic parameters in serum were measured.RAW 264.7 macrophage cells were administered with control,LPS,LPS + ATL-Ⅰ and ATL-Ⅰ alone,and TNF-α,phosphorylation(P)-IκBα,phosphorylation(P)-NF-κB(P65) and NF-κB(P65) were determined by Western blot.Results:The administration of LPS resulted in 73.3%mortality rate,and the increase of serum TNF-α,BUN and ALT levels.When ATL-Ⅰ treatment significantly increased the survival rate of LPS-induced DIC model,also improved the function of blood coagulation.And protein analysis indicated that ATL-Ⅰ remarkably protected liver and renal as decreasing TNF-α expression.In vitro,ATL-Ⅰ obviously decreased LPS-induced TNF-αproduction and the expression of P-NF-κB(P65),with the decrease of P-IκBα.Conclusions:ATL-Ⅰ has protective effect on LPS-induced DIC,which can elevate the survival rate,reduce organ damage,improve the function of blood coagulation and suppress TNF-α expression by inhibiting the activation of NF-κB signaling pathway.

Compliance and adherence to oral anticoagulation therapy in elderly patients with atrial fibrillation in the era of direct oral anticoagulants

Thromboembolic complications represent a substantial problem in patients with atrial fibrillation （AF）. The prevalence of AF burden and associated arterial and venous thrombosis progressively increases with age. At the same time, representative national data regarding stroke incidence in AF patients aged 80 and older are limited.

Cognitive function and adherence to anticoagulation treatment in patients with atrial fibrillation

Background Medication adherence is an integral part of the comprehensive care of patients with atrial fibrillation （AF） receiving oral anticoagulations （OACs） therapy. Many patients with AF are elderly and may suffer from some form of cognitive impairment. This study was conducted to investigate whether cognitive impairment affects the level of adherence to anticoagulation treatment in AF patients. Me- thods The study involved 111 AF patients （mean age, 73.5±8.3 years） treated with OACs. Cognitive function was assessed using the Mini Mental State Examination （MMSE）. The level of adherence was assessed by the 8-item Mot^sky Medication Adherence Scale （MMAS-8）. Scores on the MMAS-8 range from 0 to 8, with scores 〈 6 reflecting low adherence, 6 to 〈 8 medium adherence, and 8 high adherence. Re- sults 46.9% of AF patients had low adherence, 18.8% had moderate adherence, and 33.3% had high adherence to OACs. Patients with lower adherence were older than those with moderate or high adherence （76.6 ±8.7 vs. 71.3 ~ 6.4 vs. 71.1 ± 6.7 years） and obtained low MMSE scores, indicating cognitive disorders or dementia （MMSE = 22.3 ± 4.2）. Patients with moderate or high adherence obtained high MMSE test results （27.5 ±1.7 and 27,5 ± 3.6）. According to Spearman＇s rank correlation, worse adherence to treatment with OACs was determined by older age （rs = -0.372） and lower MMSE scores （rs = 0.717）. According to multivariate regression analysis, the level of cognitive function was a significant independent predictor of adherence （b = 1.139）. Conclusions Cognitive impairment is an independent determinant of compliance with pharmacological therapy in elderly patients with AF. Lower adherence, beyond the assessment of cognitive function, is related to the age of patients.

Acute upper gastrointestinal bleeding in patients on long-term oral anticoagulation therapy: Endoscopic findings, clinical management and outcome

AIM: Acute gastrointestinal bleeding is a severe complication in patients receiving long-term oral anticoagulant therapy. The purpose of this study was to describe the causes and clinical outcome of these patients. METHODS: From January 1999 to October 2003, 111 patients with acute upper gastrointestinal bleeding (AUGIB) were hospitalized while on oral anticoagulants. The causes and clinical outcome of these patients were compared with those of 604 patients hospitalized during 2000-2001 with AUGIB who were not taking warfarin. RESULTS: The most common cause of bleeding was peptic ulcer in 51 patients (45%) receiving anticoagulants compared to 359/604 (59.4%) patients not receiving warfarin (P<0.05). No identifiable source of bleeding could be found in 33 patients (29.7%) compared to 31/604 (5.1%) patients not receiving anticoagulants (P=0.0001). The majority of patients with concurrent use of non-steroidal anti-inflammatory drugs (NSAIDs) (26/35, 74.3%) had a peptic ulcer as a cause of bleeding while 32/76 (40.8%) patients not taking a great dose of NSAIDs had a negative upper and lower gastrointestinal endoscopy. Endoscopic hemostasis was applied and no complication was reported. Six patients (5.4%) were operated due to continuing or recurrent hemorrhage, compared to 23/604 (3.8%) patients not receiving anticoagulants. Four patients died, the overall mortality was 3.6% in patients with AUGIB due to anticoagulants, which was not different from that in patients not receiving anticoagulant therapy. CONCLUSION: Patients with AUGIB while on long-term anticoagulant therapy had a clinical outcome, which is not different from that of patients not taking anticoagulants. Early endoscopy is important for the management of these patients and endoscopic hemostasis can be safely applied.

Incidence, clinical impact and risk of bleeding during oral anticoagulation therapy

Bleeding is the most important complication of oral anticoagulation (OAC) with vitamin K-antagonists. Whilst bleeding is unavoidably related to OAC, it may have a great impact on the prognosis of treated subjects by leading to discontinuation of treatment, permanent disability or death. The yearly incidence of bleeding during OAC is 2%-5% for major bleeding, 0.5%-1% for fatal bleeding, and 0.2%-0.4% for intracranial bleeding. While OAC interruption and/or antagonism, as well as administration of coagulation factors, represent the necessary measures for the management of bleeding, proper stratification of the individual risk of bleeding prior to start OAC is of paramount importance. Several factors, including advanced age, female gender, poor control and higher intensity of OAC, associated diseases and medications, as well as genetic factors, have been proven to be associated with an increased risk of bleeding. Most of these factors have been included in the development of bleeding prediction scores, which should now be used by clinicians when prescribing and monitoring OAC. Owing to the many limitations of OAC, including a narrow therapeutic window, cumber-some management, and wide interand intra-individual variability, novel oral anticoagulants, such as factor Xa inhibitors and direct thrombin inhibitors, have been recently developed. These agents can be given in f ixed doses, have little interaction with foods and drugs, and do not require regular monitoring of anticoagulation. While the novel oral anticoagulants show promise for effective thromboprophylaxis in atrial f ibrillation and venous thromboembolism, def initive data on their safety and eff icacy are awaited.