Thrombosis and haemostasis
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AbstractGeorg Thieme Verlag KG Stuttgart · New York.
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Most international guidelines recommend pharmacological thromboprophylaxis after total hip and knee arthroplasty (THA/TKA) for 10 to 35 days. However, a recent cohort study on fast-track THA and TKA questioned the need for prolonged thromboprophylaxis when length of stay (LOS) is ≤ 5 days. We aimed at re-investigating the incidence of venous thromboembolism (VTE) in fast-track THA and TKA with in-hospital only thromboprophylaxis when LOS was ≤ 5 days. ⋯ VTE-associated risk factors with in-hospital only thromboprophylaxis were age > 85 years, odds ratio (OR) of 3.74 (95% confidence interval: 1.15-12.14, p = 0.028), body mass index (BMI) of 35 to 40, OR of 2.55 (1.02-6.35, p = 0.045) and BMI > 40, OR of 3.28 (1.02-10.56, p = 0.046). In conclusion, 90-day incidence of VTE after fast-track THA and TKA with in-hospital thromboprophylaxis only was 0.40%. Prolonged thromboprophylaxis may be reserved for LOS > 5 days or specific high-risk patients, but requires further studies regarding optimal type and duration of thromboprophylaxis.
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Clinical Trial
In Vitro Reversal of the Anti-Aggregant Effect of Ticagrelor Using Untreated Platelets.
Ticagrelor is an anti-platelet agent that is indicated for prevention of thrombosis after acute coronary syndrome or intra-coronary artery stent implantation, but it increases the risk of bleeding. Platelet transfusion has the potential to treat or prevent bleeding in patients taking ticagrelor, but the optimal quantity of platelets and timing of administration have not been fully defined. ⋯ Donor platelets enhance reversal of the anti-aggregant effect of ticagrelor in vitro. Donor platelets given in clinically relevant amounts partially reversed ticagrelor at 10 hours after the last dose, and almost fully reversed ticagrelor at 24 hours. The results inform on the potential to reverse ticagrelor in patients who develop bleeding or require emergency surgery.
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Patients at high risk for venous thrombosis (VT) following knee arthroscopy could potentially benefit from thromboprophylaxis. We explored the predictive values of environmental, genetic risk factors and levels of coagulation markers to integrate these into a prediction model. Using a population-based case-control study into the aetiology of VT, we developed a Complete (all variables), Screening (easy to use in clinical practice) and Clinical (only environmental risk factors) model. ⋯ Twelve predictor variables (8 environmental, 3 haemorheological and 1 genetic) were selected from 52 candidates and incorporated into the Complete model (area under the curve [AUC] of 0.81, 95% confidence interval [CI], 0.76-0.86). The Screening model (9 predictors: environmental factors plus factor VIII activity) reached an AUC of 0.76 (95% CI, 0.64-0.88) and the Clinical (and corresponding L-TRiP(ascopy)) model an AUC of 0.72 (95% CI, 0.60-0.83). In the internal and external validation, the Complete model reached an AUC of 0.78 (95% CI, 0.52-0.98) and 0.75 (95% CI, 0.42-1.00), respectively, while the other models performed slightly less well.
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Randomized Controlled Trial
Apixaban versus Dalteparin for the Treatment of Acute Venous Thromboembolism in Patients with Cancer: The Caravaggio Study.
International and national guidelines recommend low-molecular-weight heparin for the treatment of venous thromboembolism (VTE) in patients with cancer. The aim of the Caravaggio study is to assess whether oral apixaban is non-inferior to subcutaneous dalteparin for the treatment of acute proximal deep vein thrombosis and/or pulmonary embolism in patients with cancer. The study is an investigator-initiated, multi-national, prospective, randomized, open-label with blind end-point evaluation (PROBE), non-inferiority clinical trial (NCT03045406). ⋯ The primary safety outcome is major bleeding defined according to the guidelines of the International Society of Thrombosis and Haemostasis. Assuming a 6-month incidence of the primary outcome of 7% with dalteparin and an upper limit of the two-sided 95% confidence interval of the hazard ratio below the pre-specified margin of 2.00, 1,168 patients will be randomized considering an up to 20% loss in total patient-years (β = 80%; α one-sided = 0.025). The Caravaggio study has the potential, along with other recently performed or on-going studies, to make less cumbersome the management of VTE in patients with cancer by replacing parenteral with oral anticoagulation.