Stroke
Review (26 RCTs; n= 124 495) found compared to controls, addition of aspirin to ticagrelor reduced risk of ischemic stroke (RR, 0.80; 95% CI, 0.71–0.89 vs 0.88; 0.77–1.00 for ticagrelor monotherapy; P=0.05) but was associated with increased bleeding risk.
Trends in the pharmacological management of atrial fibrillation in UK general practice 2008–2018
Heart
There was increase in patients with AF appropriately prescribed anticoagulants (from 45.3 to 71.1%) following NICE and ESC guidelines, which correlates with improvements in mortality and stroke outcomes. Beta-blockers appear increasingly favoured over digoxin for rate control.
JAMA Neurology
Sub-group analysis (n= 9983) ticagrelor plus aspirin showed similar efficacy and safety vs aspirin alone in patients presenting with moderate acute ischemic stroke and those presenting with less severe ischemic cerebrovascular events.
Aspirin versus P2Y12 inhibitors with anticoagulation therapy for atrial fibrillation
Heart
Study (n= 1075 of which ~60% on PPI) found no significant differences in CV and bleeding events in patients with AF and stable CAD taking rivaroxaban with P2Y12 inhibitors or aspirin in chronic phase (efficacy HR: 1.31; 95% CI 0.88 to 1.94; safety HR: 0.79; 95% CI 0.43 to 1.47).
Inappropriate anticoagulation of patients with a mechanical heart valve
Medicines and Healthcare products Regulatory Agency
This alert asks GPs and other NHS providers of anticoagulation services to identify patients with a record of a mechanical heart valve and receiving a DOAC, and to urgently review these patients to ensure they are on the most appropriate anticoagulation therapy and monitoring.
The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:
http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services
US Food and Drug Administration
Approval is for oral pellets to treat children age 3 months to <12 years and for capsules to treat patients age ≥8 years, with VTE after parenteral anticoagulation for ≥5 days, and also for prevention of recurrent clots in those who have completed treatment for their first VTE.
British Journal of Clinical Pharmacology
Study (n=2185) of dialysis patients with ACS found at 12 months, ticagrelor group had higher risk for major adverse CV event (aHR 1.29; 95% CI 1.16–1.44) and also higher risk of major bleeding event vs clopidogrel group (sHR 1.49; 95% CI 1.34–1.65).
European Heart Journal
Spanish retrospective study identified 368 PE in 74,814 patients with COVID-19 attending A+E (~ 0.5%), the incidence of which is ~ninefold higher than in the general (non-COVID-19) population. It notes that mortality is higher in COVID-19 than in non-COVID-19 patients with PE.
British Journal of Clinical Pharmacology
Post-hoc analysis demonstrated potential clinical applicability of the NNT for net benefit approach; the Calculator of Absolute Stroke Risk was used to show that the NNTnet of anticoagulation therapy at 1-year was 34 in a real-world cohort and 46 in a clinical trial population.
JAMA Cardiology
Analysis (n=3024) found incidence of primary composite end point (all-cause death, MI or stroke) at 12 months occurred less frequently in prasugrel vs. ticagrelor group (120 [7.1%] vs 162 [9.8%], respectively; HR 1.41; 95% CI, 1.11-1.78; p= 0.005); bleeding events were comparable.
Biospace Inc.
Patients who receive stents are typically on DAPT for 6 to 12 months but may cause bleeding in HBR patients. According to Abbott, the XIENCE 28 and XIENCE 904 studies showed that DAPT can be safely discontinued early (as short as 28 days) with no increased risk in adverse events.
New England Journal of Medicine
This review covers diagnosis, based on clinical and imaging features, and treatments that have become available since the subject was last reviewed, in light of current interest, due to rare cases associated with certain of the Covid-19 vaccines.
DTB select: Aspirin and gastrointestinal bleeding risk in older people
Drug and Therapeutics Bulletin
Summary and context is provided for an analysis of data from the ASPREE study, which found the 5-year risk of a gastrointestinal bleed in older people taking low-dose aspirin (100mg) ranged from 0.40% in those aged 70 years to 5% in those aged 80 years with multiple risk factors.
The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:
http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services
British Journal of Clinical Pharmacology
Registry study of data between 2005 and 2018 found an increase in the use of oral anticoagulants of 94%, mainly fuelled by use of DOACs. Ischaemic stroke rates did not reduce, however the percentage of patients with a stroke diagnosed with AF decreased between 2013 and 2018.
British Medical Journal
Meta-analysis (6 trials;n=24 096) found P2Y12 inhibitor monotherapy linked to similar risk of death, MI, or stroke, with evidence this may be modified by sex & lower bleeding risk vs. dual antiplatelet therapy (primary outcome occurred in 2.94 vs. 3.36%;HR 0.90, 95% CI 0.77-1.08).
The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:
http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services
Updated COVID-19 vaccination guidance: blood clotting information for healthcare professionals
Public Health England
This guidance has been updated to include antiphospholipid syndrome, interchangeability of COVID-19 vaccines, samples required for whole genome sequencing and the latest MHRA data.
British Medical Journal
RCT (n=1471, Canada & India) found that in patients with AF or mechanical heart valves who had warfarin interrupted for a procedure, no significant benefit was found for postop dalteparin bridging to prevent major thromboembolism (occurred in 1.0% vs. 1.2% placebo within 90 days).
The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:
http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services
Critical Care Medicine
Review of 21 studies (n=1716) found haemostatic effectiveness of 71% & 76% for andexanet & prothrombin complex concentrate respectively at 24hrs. Mortality rate was 23.3% & 15.8%. Analysis for controlling confounders did not demonstrate significant differences between treatments.
British Journal of Clinical Pharmacology
Review of cohort studies (total n=227,679) found apixaban had a lower rate of ischaemic stroke or thromboembolism (HR 0.85, 95%CI 0.74-0.99) and major bleeding (0.61, 0.53-0.70) vs rivaroxaban. There were no significant differences in risk between apixaban and dabigatran.
Which is the best model to assess risk for venous thromboembolism in hospitalised patients?
British Medical Journal
Practice article notes risk assessment models (RAMs) help clinicians decide who should be offered pharmacological thromboprophylaxis, but variation exists in their composition of risk factors and thresholds for high and low risk, and there is uncertainty over the most optimal RAM.
The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:
http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services
Systematic review of machine learning models for personalised dosing of heparin
British Journal of Clinical Pharmacology
Review concluded that there are limited studies of machine learning models for unfractionated heparin dosing, and none report a model ready for routine clinical use. Studies are low quality, inadequately report study factors and lack of external validation and impact analysis.
American Journal of Cardiology
Sub-analysis (n=6564) found rivaroxaban plus aspirin reduced total primary events (acute limb ischemia, major amputation, MI, ischemic stroke, or CV death; HR 0.86,95% CI 0.75-0.98; p=0.02) and peripheral revascularizations and VTE (0.86; 0.79-0.95; p=0.003) vs aspirin alone.
Heart
Korean study (n=4294; 94% with drug-eluting coronary stents) showed similar efficacy in preventing ischaemic events in the DOAC monotherapy vs DOAC plus antiplatelet group (HR 0.828, 95% CI 0.660 to 1.038) with lower risk of major bleeding (HR 0.690, 95% CI 0.481 to 0.989).
JAMA Cardiology
Analysis (n= 7119) found women had a higher bleeding risk vs men, which was mostly attributable to baseline differences, whereas ischemic events were similar. Benefits of early aspirin withdrawal with continuation of ticagrelor were generally comparable in women and men.
Comparative Effectiveness of Aspirin Dosing in Cardiovascular Disease
New England Journal of Medicine
Open-label pragmatic trial found no differences in cardiovascular events (event rate 7.28% vs 7.51%; HR 1.02; 95% CI 0.91 to 1.14) or major bleeding (0.63% vs 0.60%; HR 1.18; 95% CI, 0.79 to 1.77) in patients with CVD assigned to 81 mg or 325 mg of aspirin daily, respectively.
The Lancet
Korean study found clopidogrel vs aspirin monotherapy significantly reduced composite of all-cause death, non-fatal MI, stroke, readmission due to acute coronary syndrome, and bleeding (n=5530; 24 month follow up; event rate 5.7% vs 7.7%; HR 0.73; 95% CI 0.59–0.90).
The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:
http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services
British Journal of Clinical Pharmacology
Review of 22 studies (n=110 to 104,505 of which 183,612 women [45%]) found an association between female sex and worse oral anticoagulation control (OR for TTR=0.87; 95% CI=0.78-0.96; p=0.006, based on meta-analysis of 15 studies).
Anticoagulant Use for Atrial Fibrillation Among Persons With Advanced Dementia at the End of Life
JAMA Internal Medicine
Study of 15,217 nursing home residents with AF and advanced dementia in US found ~30% remained on anticoagulation (AC) in last 6 months of life, underscoring fact that whilst there is well-defined threshold for starting AC for AF, there is no clear standard for stopping it.
PLOS Medicine
RCT (n=218) found use of 10% tranexamic acid mouthwash does not seem to reduce rate of periprocedural or early postop oral bleeding (OB) up to day 7 vs. placebo (occurred in 26.4% vs 28.6%,respectively), but appears to reduce delayed bleeds & postop OB if multiple teeth extracted.
The Lancet
This Seminar focuses on recent (past 5 years) advances in epidemiology, pathophysiology, diagnosis, treatment, and prevention of deep vein thrombosis of the legs and pulmonary embolism. Future directions are also discussed.
Andexanet alfa for reversing anticoagulation from apixaban or rivaroxaban - guidance (TA697)
National Institute for Health and Care Excellence
Andexanet alfa is recommended as an option for reversing anticoagulation from apixaban or rivaroxaban in adults with life-threatening or uncontrolled bleeding, only if requirements met as outlined in guidance.
Effectiveness and safety of oral anticoagulants in elderly patients with atrial fibrillation
Heart
Nationwide cohort study of patients ≥75 years (n=30,401) found that when initiating oral anticoagulation for AF, standard and reduced dose DOACs had similar risks of stroke/systemic embolism as warfarin and lower or similar risks of bleeding.
The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:
http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services
British Journal of Clinical Pharmacology
Retrospective Dutch study (n=1154) found no associations between prior therapeutic anticoagulation use (16% of population) and mortality (RR 1.02; 95% CI; 0.80‐1.30) or length of hospital stay (7.0 vs 7.0 days, p=0.69), except lower risk of pulmonary embolism (0.19; 0.05‐0.80).
Atrial fibrillation: diagnosis and management- Updated guidance (NG196)
National Institute for Health and Care Excellence
Updates include use of tools to calculate risk of bleeding when considering use of anticoagulants, role of newer anti-clotting drugs, and use of treatments that aim to destroy or isolate the abnormal sources of electrical impulses in the heart that may be driving AF (ablation).
Is there a circannual variation in the anticoagulation control of warfarin?
European Journal of Hospital Pharmacy
This retrospective study (n=204) found no significant intra-individual differences in mean time in therapeutic range. Patients with poor anticoagulation control, high INR variability and high warfarin sensitivity index was not significantly different between the seasons.
British Journal of Clinical Pharmacology
Review of 16 studies (n=10,561, 8 studies were RCTs) found lower rates of major adverse cardiovascular events (RR 0.56, 95%CI 0.44‐0.73), stent thrombosis (0.40, 0.24‐0.67) and myocardial infarction (0.45, 0.35‐0.58) with genotype‐guided vs conventional treatment.
Tranexamic Acid for the Prevention of Blood Loss after Cesarean Delivery
New England Journal of Medicine
RCT (n=4551) found tranexamic acid resulted in a significantly lower incidence (LI) of calculated estimated blood loss >1000ml or red-cell transfusion by day 2 vs. placebo (26.7% vs. 31.6%, risk ratio, 0.84; 95% CI, 0.75-0.94; p=0.003), but not LI of haemorrhage-related outcomes.
British Medical Journal
Study (n=281,264) notes increased rates of VTE events (standardised morbidity ratio 1.97; 95% CI, 1.50 to 2.54 and 11 [5.6 to 17.0] excess events per 100 000 vaccinations) including cerebral venous thrombosis, but the absolute risks were small.
The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:
http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services
Announcement regarding AstraZeneca vaccine and next steps
NHS England
This letter which follows the updated guidance from the MHRA and the independent Joint Committee on Vaccination and Immunisation, sets out the criteria for administration of the Astra Zeneca vaccine following reports of concurrent thrombosis and thrombocytopenia.
Thrombosis and Thrombocytopenia after ChAdOx1 nCoV-19 Vaccination
New England Journal of Medicine
Article reports 5 Norwegian cases (age 32 to 54 years) of severe venous thrombosis and thrombocytopenia 7 to 10 days after first vaccine dose, all whom had high level of antibodies to platelet factor 4–polyanion complexes, but no previous exposure to heparin.
Thrombotic Thrombocytopenia after ChAdOx1 nCov-19 Vaccination
New England Journal of Medicine
Report describes 11 German/Austrian pts (9 women; median age 36 years) who developed immune thrombotic thrombocytopenia mediated by platelet-activating antibodies against PF4, which clinically mimics autoimmune heparin-induced thrombocytopenia, 5 to 16 days after vaccination.
Screening and management of atrial fibrillation in primary care
British Medical Journal
This review explores the epidemiology, screening, and risk assessment of AF, as well as management of its symptoms (rate and various rhythm control options) and stroke risk (anticoagulation and other treatments), and offers a model for integration of components of AF care.
Circulation
Data from 2 trials(n=4305) found the ABC-AF scores showed better discrimination vs traditional risk scores & were recalibrated for precise risk estimation in patients not on anticoagulants & could provide improved decision support regarding treatment of individual patient with AF.
The Lancet
Review (11 RCTs, 3 observational) found guided selection of antiplatelets was associated with a reduction in major adverse cardiovascular events (RR 0.78, 95% CI 0.63–0.95, p=0.015) and other individual outcomes vs standard therapy; outcomes varied according to strategy used.
JAMA Internal Medicine
Cohort study (n=3280 at 4 anticoag clinics in Michigan) found ~one-third of patients with AF and/or VTE on a DOAC received aspirin without clear indication, and concurrent use was linked to increased bleeding vs. DOAC monotherapy (6.0 vs. 31.6 bleeds/100 patient years, p= 0.01).
microINR for anticoagulation therapy (MIB257)
National Institute for Health and Care Excellence
Evidence summary is provided for this portable device for self-measurement of INR. Reduced blood sample size is an innovative aspect. Evidence comes from 5 observational comparative studies vs laboratory-based and alternative point-of-care meters.
The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:
http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services
Andexanet alfa for reversing anticoagulation: Final appraisal document
National Institute for Health and Care Excellence
In DRAFT guidance, NICE recommends andexanet alfa as an option for reversing anticoagulation from apixaban or rivaroxaban in adults with life-threatening or uncontrolled bleeding in the gastrointestinal tract, if the company provides it according to the commercial arrangement.
MHRA reports latest Yellow Card reporting data on blood clots in recipients of Covid-19 vaccines
Medicines and Healthcare products Regulatory Agency
As of 24 March, the MHRA received 22 reports of cerebral venous sinus thrombosis and 8 reports of other thrombosis events with low platelets, out of a total of 18.1 million doses of COVID-19 Vaccine AstraZeneca. The benefits of Covid-19 vaccines continue to outweigh any risks.
Circulation
This scientific statement summarises established risk factors for perioperative stroke, preoperative & intraoperative strategies to mitigate risk of stroke, suggestions for postop assessments, & treatment approaches for minimising permanent neurological dysfunction in this group.
European Heart Journal
Recommendations of latest 2017 ESC/EACTS guidelines are mostly based on expert opinion. This viewpoint provides updated therapeutic insights on antithrombotic treatment during and after transcatheter aortic valve implantation, based on recent studies and RCTs.
JCVI statement on use of the AstraZeneca COVID-19 vaccine: 7 April 2021
Joint Committee on Vaccination and Immunisation
JCVI has advised that it is preferable for adults aged <30 years without underlying health conditions that put them at higher risk of severe COVID-19 disease, to be offered an alternative COVID-19 vaccine, if available.
The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:
http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services
