Influence of Anticoagulant Drugs on the Occurrence of Chronic Subdural Hematoma
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Abstract:
Introduction: The chronic subdural hematomas (HSCH) usually occur as a result of minor trauma with older people. However, it has been noted that there is an increase in the number of patients with chronic subdural hematoma who were on a regular anticoagulant therapy. To show that a use of anticoagulant drugs of the older generation in a much higher percentage leads to the appearance of HSCH due to the difficulty of controlling the INR and drug overdose. Methods: The research has been conducted on the Department of Neurosurgery, in Clinical Center Nis in the period from January 2010 until December 2015. Results: The largest number of these patients was 24.71% at anticoagulant therapy and belonged to the age group of 51 to 60 years. In 37.07% of cases, patients who were treated with anticoagulant therapy had INR values in the normal range, while 35.95% of them had INR over third. In 19 patients we have the fatalities occurred and all of them were on anticoagulant therapy for older generation. Conclusion: Wide application anticoagulant therapy, as in protective and therapeutic purposes tip to the frequent occurrence of HSCH. Irregular appropriate use of anticoagulant therapy, overuse of long words, anticoagulant iholder generation of drugs leads to an increased incidence of HSCH. The use of anticoagulant therapy of new generation is preferred because it does not require frequent laboratory analyses. Monitoring INRa.Keywords:
Anticoagulant Therapy
Chronic Subdural Hematoma
Anticoagulant drug
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We conducted an audit on the contribution of failure of control of anticoagulant therapy to acute hospital admissions. Over a period of 3 months there were 1480 acute admissions. One-hundred-and-twelve (7.6%) of these patients were on anticoagulant therapy. One-hundred-and-three of these 112 patients were evaluated, 74 patients had international normalized ratios (INRs) in the therapeutic range, of whom four (5.4%) bled from causes unlikely to be due directly to anticoagulant therapy. Twenty-nine patients were over-anticoagulated. Of these, 17 (59%) were admitted with bleeding symptoms, which may have been a consequence of high INR, while one had a very high INR but no bleeding. Eleven more patients were admitted for reasons unrelated to anticoagulant therapy but were found to have over-therapeutic INRs, which may have influenced their subsequent hospital management. The only clear difference between the bleeding and nonbleeding groups was age. Reasons for over-anticoagulation were poor patient compliance in 31%, influence of other medications in 17, congestive heart failure in 28%, and unknown in 24%. In conclusion, 22/1480 hospital admissions (1.5%) were due to warfarin complications and 16/21 bleeding patients had INRs > 4.5. These are admissions that could potentially be avoided with better anticoagulation control.
Anticoagulant Therapy
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Treatment of acute deep vein thrombosis and pulmonary embolism-often denominated together as venous thromboembolism (VTE)- consists of parenteral administration of heparin (usually low-molecular-weight heparin or alternatively unfractionated heparin or fondaparinux) overlapped and followed by oral vitamin K antagonists that are administered for a certain period (usually 3 to 12 months). Recommended or suggested durations differ according to guidelines. Practically, the clinical decision in an individual patient depends upon the estimated risks of VTE recurrence and treatment-induced bleeding. The risk of VTE recurrence is higher in idiopathic events (about 10% per year during the first two years and 3% per year thereafter) (odds ratio of 2.4, compared to secondary events); in male subjects (at least before the age of 60, with an odds ratio of 2-4); in patients with persistently elevated D-dimer level (odds ratio of 2.3, compared with normal level); and during the first two years after discontinuation of treatment. The annual risk of major bleeding on anticoagulant treatment vary largely in observational studies with figures of 2% to 29%, depending on the patient characteristics. The case-fatality rate is 8% (DVT), 12% (PE) for recurrent VTE, and about 10% for major bleed. These figures do not support long-term anticoagulant therapy, except in those patients exhibiting a very high risk of recurrence and/or a very low risk of bleeding. New therapeutic aspects might impact on the duration of anticoagulant therapy after a venous thromboembolic event. They include the possibility of pursuing anticoagulant treatment at a reduced INR after an initial period with an INR 2-3, and the advent of new, more specific and orally active anticoagulants. These features might modify the risk-benefit balance of extending anticoagulant therapy beyond the usual, limited duration.
Fondaparinux
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Acenocoumarol
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Background: Bleedings are well known risks of both antiplatelet and anticoagulant therapy and both therapies have historically been considered as risk factors for CSDH. The aim of the study was to evaluate the association between exposure to anticoagulant/antiplatelet therapy and chronic subdural haematoma (CSDH).Methods: Single institution case-control study was conducted in patients older than 60 years who visited our academic tertiary care Emergency Department from January 2012 to December 2016. Patients with CSDH were identified by review of case and controls were selected with a 1:3 ratio for gender, age (60 years), year of admission and recent trauma.Results: There were 124 cases and 372 controls included in the study. Both anticoagulant and antiplatelet agents were associated with an increased risk of CSDH with an OR of 1.22 (CI 95% 0.66-1.54) and 1.12 (CI 95% 0.68-1.54), respectively. While OR was 1.11 (CI 95% 0.54-2.32), 1.21 (CI 95% 0.61-2.45), and 0.53 (CI 95% 0.33-0.78) for patients receiving oral anticoagulants, ADP-antagonists, and Cox-inhibitors, respectively. History of recent trauma was an effective modifier of the association between anticoagulants and CSDH. OR of 1.69 (CI 95% 0.99-2.96) was found for patients with history of trauma and OR of 4.27 (CI 95% 2.23-8.32) for patients without history of trauma.Conclusions: Anticoagulant and antiplatelet therapy have a significant association with an increased risk of CSDH. This association appears even stronger in those patients under anticoagulant therapy, who develop a CSDH in the absence of a recent trauma.
Chronic Subdural Hematoma
Tertiary care
Anticoagulant Therapy
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The incidence of major thromboembolic complications in patients on oral anticoagulant therapy (OAT) and the correlation of this with the intensity of the OAT and the INR level at the time of the episode have been assessed in our study.We have carried out a retrospective study including 1350 patients with an overall follow-up period of 6432 patient-years. The mean INR level throughout OAT and at the time of the mayor thromboembolic event were considered. The statistical analysis was performed by means of a survival analysis test.The incidence of major thromboembolic complications found in our study was 1.18/100 patient-years. Those patients with a mean INR below the therapeutic range showed significantly a higher risk (3.31 times higher) of suffering from some sort of major thromboembolic complication. Mean INR level at the time of the event was 1.9 and 47% of those patients had an INR level < 2 at the time of the thromboembolic complication.The probability of suffering a major thromboembolic complication for those subjects on OAT increases as the INR falls below the therapeutic range; therefore we must pay special attention to this factor in order to avoid any further recurrences.
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Vitamin K-antagonists are recommended for the prevention of stroke in patients with chronic atrial fibrillation, recent myocardial infarction or prostatic heart valves. Anticoagulant therapy is seldom prescribed, however, presumably for fear of haemorrhagic sequelae. The risk of bleeding during anticoagulant therapy has been evaluated in 10 recent studies of warfarin treatment for the prevention of arterial thromboembolism. The mean annual incidences of fatal and major bleeding was 0.5 percent and 1.6 percent, respectively, as compared with the placebo figures of 0.1 percent and 0.6 percent, respectively. In 3 studies where the effect of aspirin has been evaluated the mean annual incidence of fatal and major bleeding was 0.2 percent and 0.8 percent, respectively. The figures for warfarin therapy where lower than those reported from older studies. The reasons for the reduction in incidence may be less intensive anticoagulant treatment than formerly, improved laboratory control by the introduction of the International Normalized Ratio, and careful pretreatment evaluation of patients selected for clinical trials.
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The present study evaluated the anticoagulant course of 580 patients (21% of the total number of patients, 317 males, half of them aged > 70 years) with atrial fibrillation (AF) enrolled in the ISCOAT study. During the 469 patient-years of follow-up 35 bleeding (7.6%; 2 fatal, 8 major) and 17 thrombotic events (3.6%) occurred. Bleeding was more frequent when AF was associated with other cardiovascular diseases (9.8%) and occurred even if the anticoagulation level was low (9% when INR was < 2), probably due to the presence of individual risk factors. As expected, thrombotic events were also more frequent when INR level was < 2. We conclude that in patients with AF the recommended therapeutic range seems to be INR 2-3, since this range proved to be safe and more effective than lower anticoagulation levels.
Anticoagulant Therapy
Oral anticoagulant
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Forty-nine patients aged 65-89 years, treated for 6 months-6 years (mean 3.9 years) over a total of 195 patient years, were studied. The efficacy of anticoagulant control or the occurrence of complications or treatment failures did not vary with the age, sex, social status, mobility, visual acuity, domiciliary supervision of medication or the indication for anticoagulation. A significant correlation was observed between the concomitant drug therapy and anticoagulant control (P less than 0.001) but not with the occurrence of complications and treatment failures. Poor anticoagulant control was observed particularly in those receiving drugs known to potentiate warfarin effect and in whom more changes were made to their concomitant drug therapy. Five patients who experienced six non-fatal haemorrhages (two major and four minor) showed poor overall anticoagulant control from the outset (P less than 0.01). The treatment failure rate was 4%.
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Bleeding is one of the main concerns in patients undergoing oral anticoagulation therapy.To investigate the determinant causes of bleeding in patients undergoing oral anticoagulant therapy.A total of 360 patients with atrial fibrillation (AF) undergoing oral anticoagulant (ACo) therapy, with a target INR of 2.0-3.5, were followed prospectively for a period of 48 +/- 7.2 months. The patients were evaluated on average every 30 days and were investigated regarding the presence of associated pathology that could lead to bleeding.A total of 338 patients participated in the present study. Of these, 210 (62.13%) were females. Mitral stenosis was present in 218 patients (64.4%), a mitral biological prosthesis in 64 (18.9%) and mitral valve failure in 56 (16.5%) patients. Bleeding occurred in 65 patients (19.2%), being severe in 7 (10%) patients. In 38/65 patients, a new associated disease was identified, which facilitated bleeding. An associated disease was identified in 100% of the patients with bleeding within the therapeutic range, against 49.05% of associated disease diagnosis in those with an INR > 3.5 (p=0.001).The diagnosis of a local disease associated to the bleeding was frequent among those patients undergoing oral anticoagulant therapy (58.5%). There was an association between bleeding with an INR within the therapeutic range (INR=2.0-3.5) and the diagnosis of a pathology predisposing to bleeding (p<0.001). It is mandatory to investigate the cause of bleeding in patients undergoing oral anticoagulant therapy, especially if the INR is within the therapeutic range.
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In patients with artificial heart valve prosthesis oral anticoagulants reduce but not eliminate the thromboembolic complications however, they do increase the risk of bleeding. In the present study, the incidence of thromboembolic and hemorrhagic complications in two homogeneous groups of patients with artificial heart valves on long term oral anticoagulant treatment has been evaluated. Group A (99 patients; total follow-up = 309 years) were resident in the Triveneto regions and received a questionnaire while group B (104 patients; total follow-up = 370 years) were referred to our department's centre for the control of oral anticoagulant treatment. Both groups were kept at a therapeutic range of 20-30% in terms of prothrombin activity. The incidence of thromboembolic and hemorrhagic complications is expressed as the number of episodes per 100 patient/years. Thromboembolic episodes were 2.6 (1.3 fatal) in group A while they were 1.08 (0.27 fatal) in group B; the reduction of fatal thromboembolic events was statistically significant (p less than 0.05). Hemorrhagic episodes were 1.9 (0.63 fatal) in group A while they were 0.81 (0 fatal) in group B. We concluded that an organized control of oral anticoagulant treatment in patients with artificial heart valves is advantageous as it significantly reduces fatal thromboembolism. Moreover, it could reduce the incidence of total thromboembolic and hemorrhagic episodes by more than 50%.
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Background:
Now a days use of anticoagulant for various condition such as atrial fibrillation, ischemic heart disease and ischemic stroke has increased to prevent further disease related complication leading to increased frequency for anticoagulant induced coagulopathy. Intracranial hemorrhage is most lethal complication with mortality rate around 60%. The characteristic and management of patient who suffer life threatening bleeding complication related anticoagulant are relatively unreported. To address some of these issue, we have studied such 22 patients for demographic data, coagulation profile, outcome, requirement of blood and blood products.
Material and method:
Patient who were taking anticoagulant and developed coagulopathy were included in our study. Patients excluded were transfusion related coagulopathy, congenital coagulopathy and patient who were not willing for study. Data in form of age, sex, clinical presentation related to coagulopathy, diagnosis, comorbid condition, initial coagulation profile (PT, INR, APTT, Platelet count) and related management coagulation profile after treatment and outcome were collected from patient, relative, and case papers. Data was entered in MS Excel and analysed.
RESULT
In our 22 patients, 13 were male and 9 were female with maximum no from 41-60 years of age group. They were presented with limb weakness, hematuria and altered sensorium. The main anticoagulants was warfarin followed by aspirin and others. In treatment withdrawal of drug done in all and vitamin K was given in 13 patients.16 patients were discharged while 2 patients expired. Hospital stay was 3 weeks.
CONCLUSION
Warfarin is the main anticoagulant causing coagulopathy in our study. ICH is a serious complication with high case-fatality rate.Given the increasing use of anticoagulants mainly for cardiovascular problems, the relative benefits and risks of this therapy must be weighed carefully and monitored frequently.
Stroke
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