Delayed bleeding is a major and serious adverse event of endoscopic submucosal dissection(ESD)for early-stage gastrointestinal tumors.The rate of post-ESD bleeding for gastric cancer is higher(around 5%-8%)than that f...Delayed bleeding is a major and serious adverse event of endoscopic submucosal dissection(ESD)for early-stage gastrointestinal tumors.The rate of post-ESD bleeding for gastric cancer is higher(around 5%-8%)than that for esophagus,duodenum and colon cancer(around 2%-4%).Although investigations into the risk factors for post-ESD bleeding have identified several procedure-,lesion-,physician-and patient-related factors,use of antithrombotic drugs,especially anticoagulants[direct oral anticoagulants(DOACs)and warfarin],is thought to be the biggest risk factor for post-ESD bleeding.In fact,the post-ESD bleeding rate in patients receiving DOACs is 8.7%-20.8%,which is higher than that in patients not receiving anticoagulants.However,because clinical guidelines for management of ESD in patients receiving DOACs differ among countries,it is necessary for endoscopists to identify ways to prevent post-ESD delayed bleeding in clinical practice.Given that the pharmacokinetics(e.g.,plasma DOAC level at both trough and T_(max))and pharmacodynamics(e.g.,anti-factor Xa activity)of DOACs are related to risk of major bleeding,plasma DOAC level and anti-FXa activity may be useful parameters for monitoring the anti-coagulate effect and identifying DOAC patients at higher risk of post-ESD bleeding.展开更多
Splanchnic vein thrombosis(SVT)is a manifestation of venous thromboembolism in an unusual site.Portal,mesenteric,and splenic veins are the most common vessels involved in SVT which occurs mainly in patients with liver...Splanchnic vein thrombosis(SVT)is a manifestation of venous thromboembolism in an unusual site.Portal,mesenteric,and splenic veins are the most common vessels involved in SVT which occurs mainly in patients with liver cirrhosis,although non-cirrhotic patients could be affected as well.Thrombosis of hepatic veins,also known as Budd-Chiari syndrome,is another manifestation of SVT.Prompt diagnosis and intervention are mandatory in order to increase the recalization rate and reduce the risk of thrombus progression and hypertensive complications.Traditional anticoagulation with heparin and vitamin-K antagonists is the treatment of choice in these cases.However,recent studies have shown promising results on the efficacy and safety of direct oral anticoagulants(DOACs)in this setting.Available results are mainly based on retrospective studies with small sample size,but first clinical trials have been published in the last years.This manuscript aims to provide an updated overview of the current evidence regarding the role of DOACs for SVT in both cirrhotic and non-cirrhotic patients.展开更多
BACKGROUND Congenitally corrected levo-transposition of the great arteries(L-TGA)is a congenital heart disease in which the ventricles and great arteries are transposed from their typical anatomy.In L-TGA,the double d...BACKGROUND Congenitally corrected levo-transposition of the great arteries(L-TGA)is a congenital heart disease in which the ventricles and great arteries are transposed from their typical anatomy.In L-TGA,the double discordance,atrioventricular and ventriculoarterial,create an acyanotic milieu which allows patients to survive their early decades,however,progressive systemic right ventricle(sRV)dys-function creates complications later in life.sRV dysfunction and remodeling predisposes patients to intracardiac thrombus(ICT)formation.CASE SUMMARY A 40-year-old male with L-TGA presented with symptoms of acute decom-pensated heart failure.In childhood,he had surgical repair of a ventricular septal defect.In adulthood,he developed sRV dysfunction,systemic tricuspid valve(sTV)regurgitation,and left-bundle branch block for which he underwent cardiac resynchronization therapy.Transthoracic echocardiogram showed a sRV ejection fraction of 40%,severe sTV regurgitation,and a newly identified sRV ICT.ICT was confirmed by ultrasound-enhancing agents and transesophageal echocardio-graphy.Our patient was optimized with guideline-directed medical therapy and diuresis.Anticoagulation was achieved with a vitamin K antagonist(VKA)and he was later referred for evaluation by advanced heart failure and heart transplant services.CONCLUSION Anticoagulation with VKA is the mainstay of treatment in the absence of conclusive data supporting direct oral anticoagulant use in ICT in patients with congenital heart disease.This case illustrates the natural history of L-TGA and highlights the importance of surveillance and monitoring with dedicated cardiac imaging to identify complications.展开更多
BACKGROUND Randomized controlled trials(RCTs)of direct oral anticoagulants(DOACs)included a low proportion of atrial fibrillation(AF)patients with chronic kidney disease(CKD),and suggested that DOACs are safe and effe...BACKGROUND Randomized controlled trials(RCTs)of direct oral anticoagulants(DOACs)included a low proportion of atrial fibrillation(AF)patients with chronic kidney disease(CKD),and suggested that DOACs are safe and effective in patients with mild-to-moderate CKD.In a metanalysis of RCTs and observational studies,DOACs were associated with better efficacy(vs warfarin)in early CKD and had similar efficacy and safety profiles in patients with stages IV-V CKD.But few studies have provided data on the safety and effectiveness of each DOAC vs warfarin in patients with stage III CKD.The effectiveness and safety of DOACs in those patients are still subject to debate.AIM To assess and compare the effectiveness and safety of apixaban and rivaroxaban vs warfarin in this patient population.METHODS A cohort of patients with an inpatient or outpatient code for AF and stage III CKD who were newly prescribed apixaban and rivaroxaban was created using the administrative databases from the Quebec province of Canada between 2013 and 2017.The primary effectiveness outcome was a composite of ischemic stroke,systemic embolism,and death,whereas the primary safety outcome was a composite of major bleeding within a year of DOAC vs warfarin initiation.Treatment groups were compared in an under-treatment analysis using inverse probability of treatment weighting and Cox proportional hazards.RESULTS A total of 8899 included patients filled out a new oral anticoagulation therapy claim;3335 for warfarin and 5564 for DOACs.Compared with warfarin,15 mg and 20 mg rivaroxaban presented a similar effectiveness and safety composite risk.Apixaban 5.0 mg was associated with a lower effectiveness composite risk[Hazard ratio(HR)0.76;95%confidence interval(CI):0.65-0.88]and a similar safety risk(HR 0.94;95%CI:0.66-1.35).Apixaban 2.5 mg was associated with a similar effectiveness composite(HR 1.00;95%CI:0.79-1.26)and a lower safety risk(HR 0.65;95%CI:0.43-0.99.Although,apixaban 5.0 mg was associated with a better effectiveness(HR 0.76;95%CI:0.65-0.88),but a similar safety risk profile(HR 0.94;95%CI:0.66-1.35).The observed improvement in the effectiveness composite for apixaban 5.0 mg was driven by a reduction in mortality(HR 0.61;95%CI:0.43-0.88).CONCLUSION In comparison with warfarin,rivaroxaban and apixaban appear to be effective and safe in AF patients with stage III CKD.展开更多
BACKGROUND Most of the randomized clinical trials that led to the wide use of non-vitamin K antagonist oral anticoagulants for stroke prevention in patients with atrial fibrillation(AF)originated from western countrie...BACKGROUND Most of the randomized clinical trials that led to the wide use of non-vitamin K antagonist oral anticoagulants for stroke prevention in patients with atrial fibrillation(AF)originated from western countries.AIM To systematically review and quantitatively synthesize the real-world data regarding the efficacy and safety of dabigatran,rivaroxaban,and apixaban compared to warfarin for stroke prevention in Asian patients with non-valvular AF.METHODS Medline,Cochrane,and ClinicalTrial.gov databases were reviewed.A randomeffect model meta-analysis was used and I-square was utilized to assess the heterogeneity.The primary outcome was ischemic stroke.The secondary outcomes were all-cause mortality,major bleeding,intracranial hemorrhage,and gastrointestinal bleeding.RESULTS Twelve studies from East Asia or Southeast Asia and 441450 patients were included.Dabigatran,rivaroxaban,and apixaban were associated with a significant reduction in the incidence of ischemic stroke[hazard ratio(HR)=0.78,95%confidence interval(CI):0.65-0.94;HR=0.79,95%CI:0.74-0.85,HR=0.70,95%CI:0.62-0.78;respectively],all-cause mortality(HR=0.68,95%CI:0.56-0.83;HR=0.66,95%CI:0.52-0.84;HR=0.66,95%CI:0.49-0.90;respectively),and major bleeding(HR=0.61,95%CI:0.54-0.69;HR=0.70,95%CI:0.54-0.90;HR=0.58,95%CI:0.43-0.78;respectively)compared to warfarin.CONCLUSION Dabigatran,rivaroxaban,and apixaban appear to be superior to warfarin in both efficacy and safety in Asians with non-valvular AF.展开更多
Pancreatic cancer(PC)is a devastating malignancy with fewer than 10%of patients being alive at 5 years after diagnosis.Venous thromboembolism(VTE)occurs in approximatively 20%of patients with PC,resulting in increased...Pancreatic cancer(PC)is a devastating malignancy with fewer than 10%of patients being alive at 5 years after diagnosis.Venous thromboembolism(VTE)occurs in approximatively 20%of patients with PC,resulting in increased morbidity,mortality and significant health care costs.The management of VTE is particularly challenging in these frail patients.Adequate selection of the most appropriate anticoagulant for each individual patient according to the current international guidelines is warranted for overcoming treatment challenges.The International Initiative on Thrombosis and Cancer multi-language web-based mobile application(downloadable for free at www.itaccme.com)has been developed to help clinicians in decision making in the most complex situations.In this narrative review,we will discuss the contemporary epidemiology and burden of VTE in PC patients,the performances and limitations of current risk assessment models to predict the risk of VTE,as well as evidence from recent clinical trials for the primary prophylaxis and treatment of cancer-associated VTE that support updated clinical practice guidelines.展开更多
基金Supported by the Grant-in-Aid for Scientific Research in Japan,No.21K07949.
文摘Delayed bleeding is a major and serious adverse event of endoscopic submucosal dissection(ESD)for early-stage gastrointestinal tumors.The rate of post-ESD bleeding for gastric cancer is higher(around 5%-8%)than that for esophagus,duodenum and colon cancer(around 2%-4%).Although investigations into the risk factors for post-ESD bleeding have identified several procedure-,lesion-,physician-and patient-related factors,use of antithrombotic drugs,especially anticoagulants[direct oral anticoagulants(DOACs)and warfarin],is thought to be the biggest risk factor for post-ESD bleeding.In fact,the post-ESD bleeding rate in patients receiving DOACs is 8.7%-20.8%,which is higher than that in patients not receiving anticoagulants.However,because clinical guidelines for management of ESD in patients receiving DOACs differ among countries,it is necessary for endoscopists to identify ways to prevent post-ESD delayed bleeding in clinical practice.Given that the pharmacokinetics(e.g.,plasma DOAC level at both trough and T_(max))and pharmacodynamics(e.g.,anti-factor Xa activity)of DOACs are related to risk of major bleeding,plasma DOAC level and anti-FXa activity may be useful parameters for monitoring the anti-coagulate effect and identifying DOAC patients at higher risk of post-ESD bleeding.
文摘Splanchnic vein thrombosis(SVT)is a manifestation of venous thromboembolism in an unusual site.Portal,mesenteric,and splenic veins are the most common vessels involved in SVT which occurs mainly in patients with liver cirrhosis,although non-cirrhotic patients could be affected as well.Thrombosis of hepatic veins,also known as Budd-Chiari syndrome,is another manifestation of SVT.Prompt diagnosis and intervention are mandatory in order to increase the recalization rate and reduce the risk of thrombus progression and hypertensive complications.Traditional anticoagulation with heparin and vitamin-K antagonists is the treatment of choice in these cases.However,recent studies have shown promising results on the efficacy and safety of direct oral anticoagulants(DOACs)in this setting.Available results are mainly based on retrospective studies with small sample size,but first clinical trials have been published in the last years.This manuscript aims to provide an updated overview of the current evidence regarding the role of DOACs for SVT in both cirrhotic and non-cirrhotic patients.
文摘BACKGROUND Congenitally corrected levo-transposition of the great arteries(L-TGA)is a congenital heart disease in which the ventricles and great arteries are transposed from their typical anatomy.In L-TGA,the double discordance,atrioventricular and ventriculoarterial,create an acyanotic milieu which allows patients to survive their early decades,however,progressive systemic right ventricle(sRV)dys-function creates complications later in life.sRV dysfunction and remodeling predisposes patients to intracardiac thrombus(ICT)formation.CASE SUMMARY A 40-year-old male with L-TGA presented with symptoms of acute decom-pensated heart failure.In childhood,he had surgical repair of a ventricular septal defect.In adulthood,he developed sRV dysfunction,systemic tricuspid valve(sTV)regurgitation,and left-bundle branch block for which he underwent cardiac resynchronization therapy.Transthoracic echocardiogram showed a sRV ejection fraction of 40%,severe sTV regurgitation,and a newly identified sRV ICT.ICT was confirmed by ultrasound-enhancing agents and transesophageal echocardio-graphy.Our patient was optimized with guideline-directed medical therapy and diuresis.Anticoagulation was achieved with a vitamin K antagonist(VKA)and he was later referred for evaluation by advanced heart failure and heart transplant services.CONCLUSION Anticoagulation with VKA is the mainstay of treatment in the absence of conclusive data supporting direct oral anticoagulant use in ICT in patients with congenital heart disease.This case illustrates the natural history of L-TGA and highlights the importance of surveillance and monitoring with dedicated cardiac imaging to identify complications.
文摘BACKGROUND Randomized controlled trials(RCTs)of direct oral anticoagulants(DOACs)included a low proportion of atrial fibrillation(AF)patients with chronic kidney disease(CKD),and suggested that DOACs are safe and effective in patients with mild-to-moderate CKD.In a metanalysis of RCTs and observational studies,DOACs were associated with better efficacy(vs warfarin)in early CKD and had similar efficacy and safety profiles in patients with stages IV-V CKD.But few studies have provided data on the safety and effectiveness of each DOAC vs warfarin in patients with stage III CKD.The effectiveness and safety of DOACs in those patients are still subject to debate.AIM To assess and compare the effectiveness and safety of apixaban and rivaroxaban vs warfarin in this patient population.METHODS A cohort of patients with an inpatient or outpatient code for AF and stage III CKD who were newly prescribed apixaban and rivaroxaban was created using the administrative databases from the Quebec province of Canada between 2013 and 2017.The primary effectiveness outcome was a composite of ischemic stroke,systemic embolism,and death,whereas the primary safety outcome was a composite of major bleeding within a year of DOAC vs warfarin initiation.Treatment groups were compared in an under-treatment analysis using inverse probability of treatment weighting and Cox proportional hazards.RESULTS A total of 8899 included patients filled out a new oral anticoagulation therapy claim;3335 for warfarin and 5564 for DOACs.Compared with warfarin,15 mg and 20 mg rivaroxaban presented a similar effectiveness and safety composite risk.Apixaban 5.0 mg was associated with a lower effectiveness composite risk[Hazard ratio(HR)0.76;95%confidence interval(CI):0.65-0.88]and a similar safety risk(HR 0.94;95%CI:0.66-1.35).Apixaban 2.5 mg was associated with a similar effectiveness composite(HR 1.00;95%CI:0.79-1.26)and a lower safety risk(HR 0.65;95%CI:0.43-0.99.Although,apixaban 5.0 mg was associated with a better effectiveness(HR 0.76;95%CI:0.65-0.88),but a similar safety risk profile(HR 0.94;95%CI:0.66-1.35).The observed improvement in the effectiveness composite for apixaban 5.0 mg was driven by a reduction in mortality(HR 0.61;95%CI:0.43-0.88).CONCLUSION In comparison with warfarin,rivaroxaban and apixaban appear to be effective and safe in AF patients with stage III CKD.
文摘BACKGROUND Most of the randomized clinical trials that led to the wide use of non-vitamin K antagonist oral anticoagulants for stroke prevention in patients with atrial fibrillation(AF)originated from western countries.AIM To systematically review and quantitatively synthesize the real-world data regarding the efficacy and safety of dabigatran,rivaroxaban,and apixaban compared to warfarin for stroke prevention in Asian patients with non-valvular AF.METHODS Medline,Cochrane,and ClinicalTrial.gov databases were reviewed.A randomeffect model meta-analysis was used and I-square was utilized to assess the heterogeneity.The primary outcome was ischemic stroke.The secondary outcomes were all-cause mortality,major bleeding,intracranial hemorrhage,and gastrointestinal bleeding.RESULTS Twelve studies from East Asia or Southeast Asia and 441450 patients were included.Dabigatran,rivaroxaban,and apixaban were associated with a significant reduction in the incidence of ischemic stroke[hazard ratio(HR)=0.78,95%confidence interval(CI):0.65-0.94;HR=0.79,95%CI:0.74-0.85,HR=0.70,95%CI:0.62-0.78;respectively],all-cause mortality(HR=0.68,95%CI:0.56-0.83;HR=0.66,95%CI:0.52-0.84;HR=0.66,95%CI:0.49-0.90;respectively),and major bleeding(HR=0.61,95%CI:0.54-0.69;HR=0.70,95%CI:0.54-0.90;HR=0.58,95%CI:0.43-0.78;respectively)compared to warfarin.CONCLUSION Dabigatran,rivaroxaban,and apixaban appear to be superior to warfarin in both efficacy and safety in Asians with non-valvular AF.
文摘Pancreatic cancer(PC)is a devastating malignancy with fewer than 10%of patients being alive at 5 years after diagnosis.Venous thromboembolism(VTE)occurs in approximatively 20%of patients with PC,resulting in increased morbidity,mortality and significant health care costs.The management of VTE is particularly challenging in these frail patients.Adequate selection of the most appropriate anticoagulant for each individual patient according to the current international guidelines is warranted for overcoming treatment challenges.The International Initiative on Thrombosis and Cancer multi-language web-based mobile application(downloadable for free at www.itaccme.com)has been developed to help clinicians in decision making in the most complex situations.In this narrative review,we will discuss the contemporary epidemiology and burden of VTE in PC patients,the performances and limitations of current risk assessment models to predict the risk of VTE,as well as evidence from recent clinical trials for the primary prophylaxis and treatment of cancer-associated VTE that support updated clinical practice guidelines.
