Journal of thrombosis and thrombolysis
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J. Thromb. Thrombolysis · Jun 2006
Comparative Study Clinical TrialLow-molecular-weight heparin compared with unfractionated heparin for patients with non-ST-segment elevation acute coronary syndromes treated with glycoprotein IIb/IIIa inhibitors: results from the CRUSADE initiative.
Both heparin and glycoprotein (GP) IIb/IIIa inhibitor therapy and early invasive management strategies are recommended by the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for the treatment of patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS). However, controversy exists about which form of heparin-unfractionated (UF) or low-molecular-weight (LMW)-is preferable. We sought to compare the efficacy and safety of these treatment strategies in a large contemporary population of patients with NSTE ACS. ⋯ In routine clinical practice, patients treated with GP IIb/IIIa inhibitors have slightly improved outcomes and similar bleeding risks with LMWH than with UFH. These findings are consistent with current ACC/AHA guidelines but raise important questions about the safety and effectiveness of antithrombotic therapy in real-world clinical practice. Using data from the CRUSADE Initiative, we evaluated low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) in high-risk patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS) who received early (<24 hours) glycoprotein (GP) IIb/IIIa inhibitors and early invasive management. In-hospital outcomes were compared among treatment groups. LMWH was associated with slightly improved clinical outcomes and similar rates of transfusion compared with UFH. Our results support the current ACC/AHA guidelines recommendations but raise concerns about the safety and efficacy of UFH in the setting of background use of upstream GP IIb/IIIa inhibitors for patients with NSTE ACS in routine clinical practice.
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J. Thromb. Thrombolysis · Apr 2006
ReviewProinflammatory, immunomodulating, and prothrombotic properties of anemia and red blood cell transfusions.
For many years, the traditional treatment for hospitalized patients in the United States who have developed anemia, whether associated with medical illness, surgical procedures or trauma, has been red blood cell transfusion, despite the absence of supporting data in many patient populations. Emerging evidence suggests that transfusions may, in fact, be associated with risk beyond commonly held concerns of microbial transmission and acute antigen-antibody reactions. The following overview represents a biological paradigm for understanding the relationship between medical illness, surgical procedures, inflammatory states, anemia, red blood cell transfusion and immunothrombotic phenomena among hospitalized patients.
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J. Thromb. Thrombolysis · Apr 2006
The use of a HEMOCHRON JR. HEMONOX point of care test in monitoring the anticoagulant effects of enoxaparin during interventional coronary procedures.
Enoxaparin is increasingly used for the anticoagulation of patients undergoing percutaneous coronary intervention (PCI). Several reports have suggested the utility of using point of care tests in monitoring the anticoagulation levels of enoxaparin in patients undergoing PCI. The objective of this study was to evaluate a new point-of-care test (POCT) HEMONOX in monitoring the anticoagulant effect of enoxaparin in non citrated fresh whole blood samples from patients undergoing elective PCI procedure. ⋯ The HEMONOX test may be able to guide anticoagulation with enoxaparin during PCI. The HEMONOX assay is a one step whole blood coagulation test performed on the HEMOCHRON Jr. Signature + POC system. The method was evaluated to monitor the anticoagulant level of enoxaparin in blood samples from patients undergoing PCI after receiving an intravenous dose of 0.5 mg/kg. The results suggest a clear distinction of HEMONOX CT between the baseline value of untreated patients and patients achieving therapeutic enoxaparin levels.
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J. Thromb. Thrombolysis · Feb 2006
ReviewPerioperative management of oral anticoagulation: when and how to bridge.
The management of patients on oral anticoagulation (OAC) who need to undergo surgery or invasive procedures is problematic. "Bridging" the subtherapeutic periods with either intravenous unfractionated heparin or subcutaneous treatment-dose low-molecular-weight heparin (LMWH) decreases the amount of time patients are not anticoagulated but may increase the risk of postoperative bleeding and is costly. The available literature does not provide sufficient information to allow clinicians to choose an optimal perioperative strategy. Recent studies primarily have examined the perioperative use of LMWH, and have found arterial thromboembolic rates of 0.4-1.5%. ⋯ For most patients at low or moderate stroke risk, bridging will be unnecessary and may be harmful. Bridging is recommended for patients who have a high annual risk of stroke and thus have a more appreciable perioperative stroke risk. Postoperative anticoagulation must be used cautiously and patients monitored closely after major surgery due to the risk of postoperative major bleeding.
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J. Thromb. Thrombolysis · Feb 2006
ReviewManaging oral anticoagulation requires expert experience and clinical evidence.
The management of patients on chronic oral anticoagulant therapy, namely Vitamin K antagonists such as warfarin, is often associated with difficult and challenging issues for the healthcare practitioner. Many of these issues, such as warfarin failure or resistance, the optimal warfarin initiation dose, the optimal target International Normalized Ratio in antiphospholipid syndrome, the optimal monitoring frequency and use of point-of-care monitoring, the management of oral anticoagulation during invasive procedures, and the management of over-anticoagulation, have not been evaluated in rigorously-designed clinical trials. The latest American College of Chest Physician recommendations concerning these issues are Grade 2C, the weakest recommendations available. It remains up to the experience and expertise of the individual practitioner along with whatever clinical evidence is available in a particular healthcare environment-especially one associated with an anticoagulant management service-to implement management strategies with respect to these issues in patients on oral anticoagulation.