Primary studies included in this broad synthesis

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Primary study

Unclassified

Journal British journal of anaesthesia
Year 2010
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<b>BACKGROUND: </b>Major adverse cardiac events (MACEs) are a common cause of death after non-cardiac surgery. Despite evidence for the benefit of aspirin for secondary prevention, it is often discontinued in the perioperative period due to the risk of bleeding.<b>METHODS: </b>We conducted a randomized, double-blind, placebo-controlled trial in order to compare the effect of low-dose aspirin with that of placebo on myocardial damage, cardiovascular, and bleeding complications in high-risk patients undergoing non-cardiac surgery. Aspirin (75 mg) or placebo was given 7 days before surgery and continued until the third postoperative day. Patients were followed up for 30 days after surgery.<b>RESULTS: </b>A total of 220 patients were enrolled, 109 patients received aspirin and 111 received placebo. Four patients (3.7%) in the aspirin group and 10 patients (9.0%) in the placebo group had elevated troponin T levels in the postoperative period (P=0.10). Twelve patients (5.4%) had an MACE during the first 30 postoperative days. Two of these patients (1.8%) were in the aspirin group and 10 patients (9.0%) were in the placebo group (P=0.02). Treatment with aspirin resulted in a 7.2% absolute risk reduction [95% confidence interval (CI), 1.3-13%] for postoperative MACE. The relative risk reduction was 80% (95% CI, 9.2-95%). Numbers needed to treat were 14 (95% CI, 7.6-78). No significant differences in bleeding complications were seen between the two groups.<b>CONCLUSIONS: </b>In high-risk patients undergoing non-cardiac surgery, perioperative aspirin reduced the risk of MACE without increasing bleeding complications. However, the study was not powered to evaluate bleeding complications.

Primary study

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CONTEXTE: Combler le traitement par héparine de bas poids moléculaire est généralement recommandé chez les patients qui doivent cesser anticoagulants oraux avant une intervention chirurgicale ou invasive. À ce jour, il n'existe aucun régime de transition acceptée universellement adapté à risque thromboembolique du patient. Cette étude de la gestion de la cohorte initiale prospective a été conçue pour évaluer l'efficacité et l'innocuité d'un protocole de transition individualisé appliqué aux patients ambulatoires. MÉTHODES ET RÉSULTATS: anticoagulants oraux ont été arrêtés 5 jours avant la procédure. Héparine de bas poids moléculaire a démarré il ya 3 à 4 jours avant l'intervention et poursuivi pendant 6 jours après la chirurgie à 70 anti-facteur Xa U / kg deux fois par jour chez les patients à haut risque thromboembolique-et une dose quotidienne prophylactiques modérée à faible patients à risque. Anticoagulation orale a été reprise le lendemain de l'intervention avec un complément de dose de 50% pendant 2 jours et des doses d'entretien plus tard. Les patients ont été suivis pendant 30 jours. Sur les 1262 patients inclus dans l'étude (seulement 15% de valves mécaniques), 295 (23,4%) étaient des patients à haut risque thromboembolique-et 967 (76,6%) étaient des modérés aux patients à faible risque. Dans l'intention de traiter l'analyse, il ya eu 5 accidents thromboemboliques (0,4%, intervalle de confiance à 95%, 0,1 à 0,9), tous les patients à haut risque thromboembolique-. Il y avait 15 majeure (1,2%, intervalle de confiance à 95%, 0,7 à 2,0) et 53 mineurs (4,2%, intervalle de confiance à 95%, 3,2 à 5.5) épisodes de saignement. Les saignements majeurs a été associée à l'administration d'héparine de bas poids moléculaire deux fois par jour (patients à haut risque), mais pas avec le risque de saignement de la procédure. CONCLUSIONS: Ce protocole de pontage de gestion, adaptée au risque thromboembolique des patients, semble réalisable, efficace et sûre pour de nombreux patients, mais la sécurité chez les patients atteints prothèses valvulaires mécaniques n'a pas été établi de façon concluante.

Primary study

Unclassified

Journal Retina (Philadelphia, Pa.)
Year 2007
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PURPOSE: To describe the clinical course of patients undergoing vitreoretinal procedures while receiving systemic anticoagulation with warfarin. METHODS: We reviewed patient demographics, ocular findings, and clinical courses for 25 patients receiving systemic anticoagulation with warfarin who subsequently underwent vitreoretinal surgery. RESULTS: Patient ages ranged from 49 years to 81 years (median, 69 years). Indications for anticoagulation included atrial fibrillation, cerebrovascular disease, deep vein thrombosis, prosthetic heart valves, and hypercoagulable state. Follow-up ranged from 4 months to 36 months (median, 19.5 months). The international normalized ratio ranged from 1.5 to 3.1 (median, 2.0). Final vision after surgery ranged from 20/20 to 20/400 (median, 20/100). One patient who underwent scleral buckling and external drainage of subretinal fluid had an intraoperative subretinal hemorrhage associated with the drainage procedure. In all other patients, no intraoperative complications occurred. CONCLUSION: Cessation of therapy with warfarin may not be necessary in patients receiving anticoagulation who are undergoing vitreoretinal procedures. Successful visual and anatomical results may be achieved after vitreoretinal surgery for patients receiving anticoagulation with warfarin. The management of anticoagulation should occur in conjunction with the patient's internist to allow a clear understanding of the potential systemic risks of cessation of warfarin treatment preoperatively.

Primary study

Unclassified

Journal Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons
Year 2007
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PURPOSE: Conflicting opinions exist in literature concerning the management of oral surgery in patients on oral anticoagulants because no consensus on perioperative protocols is available, including precise guidelines regarding the need for therapy modification or withdrawal. The aim of this study was to evaluate bleeding complications associated with oral surgery performed on patients on oral anticoagulants without therapy modification or withdrawal but following a standardized comprehensive perioperative management protocol. PATIENTS AND METHODS: Patients on oral anticoagulant therapy with warfarin and in need of oral surgery underwent a thorough general and oral clinical evaluation to assess thromboembolic and bleeding risk; 255 subjects who, on the morning of surgery, had INR values <or=5.5 were included in the study. An atraumatic surgical technique was carried out and all patients received postoperative careful instructions. RESULTS: Five cases (1.96%) of bleeding complication were observed in patients with moderate to high thromboembolic and bleeding risk. CONCLUSION: The findings from this study suggest that a comprehensive perioperative management protocol for oral surgery in patients on oral anticoagulants including 1) thromboembolic and bleeding risk assessment, 2) an atraumatic surgical technique, and 3) postoperative careful instructions, can lead to safe and successful results with minimal complications.

Primary study

Unclassified

Journal Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology
Year 2007
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OBJECTIVE:To evaluate whether or not it is possible to perform oral surgery in patients on oral anticoagulant therapy (OAT) without stopping treatment. STUDY DESIGN:A prospective randomized open-label study was designed to evaluate the outcome of oral surgery in patients on OAT, operated upon in conditions of reduced international normalized ratio (INR), compared with patients maintained in their usual therapeutic ranges of the prothrombin time INR. The INR target in the group with reduced OAT was 1.8, and the INR target of the group without reduced OAT was 2.5 or more in carriers of artificial valves. RESULTS:One hundred thirty-one patients on OAT were randomized to reduced anticoagulation or to full anticoagulation, and 511 teeth were extracted by the same surgeon. Mild bleeding, but excessive enough to warrant adoption of supplementary local hemostatic measures, was observed in 10 cases (15.1%) in the reduced dosage group and in 6 cases (9.2%) in the unmodified dosage group, which was a nonsignificant difference. There were no thrombotic complications in either group. CONCLUSIONS:This randomized study shows that, using simple measures for local hemostasis, it is not necessary to reduce OAT in patients undergoing routine dental extractions.

Primary study

Unclassified

Auteurs Hirschman DR , Morby LJ
Journal Nursing forum
Year 2006
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Cataract surgery is the most common procedure performed on Medicare recipients. Many of these patients have been on anticoagulation therapy (ACT) regimens, but no consistent standard currently governs the use or cessation of ACT prior to surgery. This study evaluated the safety of continuing ACT in cataract surgery patients (of ASA III physical status) at seven centers. There was a 53% incidence of previous ACT among the 1,842 individuals sampled. During 2,241 procedures, only two patients (one on ACT) experienced abnormal surgical bleeding, noted as hyphemas. Seventeen (0.9%), nine on ACT and eight not on it, had some type of bleeding related to regional anesthesia; of these, nine had bruising and eight had subconjunctival hemorrhage. No major complications were noted in the ACT group during surgery, or at visits 1 day and 1 week postoperatively.

Primary study

Unclassified

Auteurs Friedland S , Soetikno R
Journal Gastrointestinal endoscopy
Year 2006
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BACKGROUND: According to current practice guidelines for performance of colonoscopy in patients requiring long-term anticoagulation, polypectomy is considered a high-risk procedure for which anticoagulation must temporarily be discontinued. However, these guidelines are based on expert opinion, and the bleeding risk after polypectomy in anticoagulated patients is not known. OBJECTIVE: Measure the risk of postpolypectomy bleeding in patients who undergo colonoscopic polypectomy while anticoagulated. DESIGN: Retrospective review of patients who underwent polypectomy without discontinuation of anticoagulation. SETTING: Veterans Administration Palo Alto Health Care System. PATIENTS: Forty-one polypectomies were performed in 21 patients. All patients had been receiving long-term anticoagulation with warfarin; the average international normalized ratio was 2.3 (range 1.4-4.9; normal 0.9-1.2). To prevent supratherapeutic anticoagulation, warfarin was withheld for 36 hours before the procedure while the patients were on a liquid diet. The average polyp size was 5 mm (range 3-10 mm). INTERVENTIONS: All patients underwent polypectomy followed immediately by prophylactic application of one or two clips to prevent bleeding. MAIN OUTCOME MEASUREMENTS: Rate of postpolypectomy bleeding. RESULTS: There were no episodes of postpolypectomy bleeding. The 95% CI for the risk of bleeding was 0% to 8.6% when analyzed per polypectomy and 0% to 15% when analyzed per patient. LIMITATIONS: Small single-center retrospective study. CONCLUSIONS: Our experience suggests that small polyps can be removed with a very low risk of bleeding when clips are applied immediately after polypectomy. If these results can be confirmed in a larger multicenter study, our protocol may become an alternative to withholding anticoagulation in patients at high risk of thrombosis.

Primary study

Unclassified

Journal Kardiologia polska
Year 2005
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INTRODUCTION: Patients who receive oral anticoagulants generally undergo oral surgery procedures, especially teeth extractions. Because the withdrawal of anticoagulant therapy may lead to severe thromboembolic complications, an attempt to perform oral surgery procedures without discontinuation of anticoagulation, based on the published reports, was made. AIM: To present our own experience with the maintenance of anticoagulant therapy with oral coumarin-type drugs and/or acetylsalicylic acid in patients with cardiovascular diseases who undergo oral surgical procedures. METHODS: The group consisted of 40 patients (12 females and 28 males) aged 39-83 years (mean age 58 years) hospitalised in the 1st Department of Oral and Maxillofacial Surgery in Zabrze from January 2000 to June 2003. The following paper presents the results of the treatment of patients with cardiovascular diseases, who are on oral coumarin-type anticoagulants and/or acetylsalicylic acid, performed without modification of the treatment/anticoagulant therapy. RESULTS: The level of anticoagulation defined as the INR (International Normalized Ratio) and measured in all patients on the day of surgery ranged from 1.0 to 4.0. Activated Partial Thromboplastin Time (aPTT) was between 26 and 88 seconds, with a reference range in healthy subjects of 42-65 seconds. The prothrombin time ratio ranged from 26% to 100% (N: 80-120%). Only 8% of patients developed minor bleeding complications which were promptly controlled with additional haemostasis. CONCLUSIONS: Teeth extractions and other oral surgical procedures may be performed without discontinuation of anticoagulants.

Primary study

Unclassified

Journal European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery
Year 2005
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PURPOSE: To investigate whether a single pre-operative dose of 120 mg acetylsalicylic acid (ASA) decreased either (1) emboli rate, as detected by transcranial Doppler (TCD), during and early after carotid endarterectomy (CEA) and (2) clinical intra- and post-operative signs suggestive of embolism or increased bleeding tendency. DESIGN: Prospective, double-blind placebo controlled trial. PATIENTS AND METHODS: One-hundred consecutive patients were randomised to receive either 120 mg ASA (n = 48) or placebo (n = 49) by suppository on the night before CEA; three patients were excluded. Emboli were counted and expressed as emboli rate (ER). The incidence of bleeding complications was assessed. Surgeons were asked to indicate which patients had received ASA or placebo. RESULTS: There were no significant differences between the ASA and placebo groups in ER in the intraoperative and postoperative periods. ER higher than 0.9 min(-1) was associated with a significantly increased risk of complications (26 vs. 0%, P < 0.01). No extra bleeding complications were observed in the ASA group. Surgeon assessment of whether or not ASA had been administered had a sensitivity of 42% and a specificity of 70%. CONCLUSION: A single pre-operative dose of ASA (120 mg) did not reduce significantly the emboli rate during and after CEA and surgeons could not correctly identify whether or not ASA had been administered.

Primary study

Unclassified

Auteurs Ramli R , Abdul Rahman R
Journal Singapore dental journal
Year 2005
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Minor oral surgery in warfarinized patients can be performed without stopping or altering the dose of the drug. Thirty patients underwent various types of oral surgical procedures without interruption of their anticoagulant therapy and their therapeutic international normalized ratio maintained. Local measures such as pressure, packing the sockets with oxidized regenerated cellulose, and suturing were applied. In some patients, tranexamic acid mouthwashes were prescribed to further enhance haemostasis. Four patients had minimal postoperative bleeding in the form of bloodstained saliva, which lasted for 24 hours. This study highlights the importance of local measures in controlling postoperative bleeding in warfarinized patients undergoing minor oral surgical procedures.