The Experts below are selected from a list of 10278 Experts worldwide ranked by ideXlab platform
Gordon H Guyatt - One of the best experts on this subject based on the ideXlab platform.
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Antithrombotic Therapy and prevention of thrombosis 9th ed american college of chest physicians evidence based clinical practice guidelines
2013Co-Authors: Gordon H Guyatt, Mark Crowther, Elie A Akl, David D Gutterman, Holger Schu J NemannAbstract:T article provides the rationale for the Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (AT9) approach to estimating the effect of Antithrombotic prophylaxis on patient-important outcomes of pulmonary embolism (PE) and symptomatic venous thrombosis. 1.0 Thromboprophylaxis Reduces Fatal PE in Medical and Surgical Patients
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methodology for the development of Antithrombotic Therapy and prevention of thrombosis guidelines Antithrombotic Therapy and prevention of thrombosis 9th ed american college of chest physicians evidence based clinical practice guidelines
Chest, 2012Co-Authors: Gordon H Guyatt, Mark H Eckman, Sam Schulman, Per Olav Vandvik, Mark Crowther, Jack Hirsh, Elie A Akl, Susan L Norris, John W EikelboomAbstract:Background To develop the Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: ACCP Evidence-Based Clinical Practice Guidelines (AT9), the American College of Chest Physicians (ACCP) assembled a panel of clinical experts, information scientists, decision scientists, and systematic review and guideline methodologists. Methods Clinical areas were designated as articles, and a methodologist without important intellectual or financial conflicts of interest led a panel for each article. Only panel members without significant conflicts of interest participated in making recommendations. Panelists specified the population, intervention and alternative, and outcomes for each clinical question and defined criteria for eligible studies. Panelists and an independent evidence-based practice center executed systematic searches for relevant studies and evaluated the evidence, and where resources and evidence permitted, they created standardized tables that present the quality of the evidence and key results in a transparent fashion. Results One or more recommendations relate to each specific clinical question, and each recommendation is clearly linked to the underlying body of evidence. Judgments regarding the quality of evidence and strength of recommendations were based on approaches developed by the Grades of Recommendations, Assessment, Development, and Evaluation Working Group. Panel members constructed scenarios describing relevant health states and rated the disutility associated with these states based on an additional systematic review of evidence regarding patient values and preferences for Antithrombotic Therapy. These ratings guided value and preference decisions underlying the recommendations. Each topic panel identified questions in which resource allocation issues were particularly important and, for these issues, experts in economic analysis provided additional searches and guidance. Conclusions AT9 methodology reflects the current science of evidence-based clinical practice guideline development, with reliance on high-quality systematic reviews, a standardized process for quality assessment of individual studies and the body of evidence, an explicit process for translating the evidence into recommendations, disclosure of financial as well as intellectual conflicts of interest followed by management of disclosed conflicts, and extensive peer review.
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introduction to the ninth edition Antithrombotic Therapy and prevention of thrombosis 9th ed american college of chest physicians evidence based clinical practice guidelines
Chest, 2012Co-Authors: Gordon H Guyatt, Mark Crowther, Elie A Akl, David D Gutterman, Holger J Schunemann, Sandra Zelman LewisAbstract:The Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines differs substantially from the prior versions both in process and in content. In this introduction, we describe some of the differences and the rationale for the changes.
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evidence based management of anticoagulant Therapy Antithrombotic Therapy and prevention of thrombosis 9th ed american college of chest physicians evidence based clinical practice guidelines
Chest, 2012Co-Authors: Anne Holbrook, Sam Schulman, David L Veenstra, Per Olav Vandvik, Mark Crowther, Daniel M Witt, Jason S Fish, Michael J Kovacs, Peter Svensson, Gordon H GuyattAbstract:Background High-quality anticoagulation management is required to keep these narrow therapeutic index medications as effective and safe as possible. This article focuses on the common important management questions for which, at a minimum, low-quality published evidence is available to guide best practices. Methods The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. Results Most practical clinical questions regarding the management of anticoagulation, both oral and parenteral, have not been adequately addressed by randomized trials. We found sufficient evidence for summaries of recommendations for 23 questions, of which only two are strong rather than weak recommendations. Strong recommendations include targeting an international normalized ratio of 2.0 to 3.0 for patients on vitamin K antagonist Therapy (Grade 1B) and not routinely using pharmacogenetic testing for guiding doses of vitamin K antagonist (Grade 1B). Weak recommendations deal with such issues as loading doses, initiation overlap, monitoring frequency, vitamin K supplementation, patient self-management, weight and renal function adjustment of doses, dosing decision support, drug interactions to avoid, and prevention and management of bleeding complications. We also address anticoagulation management services and intensive patient education. Conclusions We offer guidance for many common anticoagulation-related management problems. Most anticoagulation management questions have not been adequately studied.
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patient values and preferences in decision making for Antithrombotic Therapy a systematic review Antithrombotic Therapy and prevention of thrombosis 9th ed american college of chest physicians evidence based clinical practice guidelines
Chest, 2012Co-Authors: Samantha Maclean, Per Olav Vandvik, Elie A Akl, Sohail M Mulla, Milosz Jankowski, Shanil Ebrahim, Shelley Mcleod, Neera Bhatnagar, Gordon H GuyattAbstract:Background Development of clinical practice guidelines involves making trade-offs between desirable and undesirable consequences of alternative management strategies. Although the relative value of health states to patients should provide the basis for these trade-offs, few guidelines have systematically summarized the relevant evidence. We conducted a systematic review relating to values and preferences of patients considering Antithrombotic Therapy. Methods We included studies examining patient preferences for alternative approaches to Antithrombotic prophylaxis and studies that examined, in the context of Antithrombotic prophylaxis or treatment, how patients value alternative health states and experiences with treatment. We conducted a systematic search and compiled structured summaries of the results. Steps in the process that involved judgment were conducted in duplicate. Results We identified 48 eligible studies. Sixteen dealt with atrial fibrillation, five with VTE, four with stroke or myocardial infarction prophylaxis, six with thrombolysis in acute stroke or myocardial infarction, and 17 with burden of Antithrombotic treatment. Conclusion Patient values and preferences regarding thromboprophylaxis treatment appear to be highly variable. Participant responses may depend on their prior experience with the treatments or health outcomes considered as well as on the methods used for preference elicitation. It should be standard for clinical practice guidelines to conduct systematic reviews of patient values and preferences in the specific content area.
Mark Crowther - One of the best experts on this subject based on the ideXlab platform.
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Antithrombotic Therapy and prevention of thrombosis 9th ed american college of chest physicians evidence based clinical practice guidelines
2013Co-Authors: Gordon H Guyatt, Mark Crowther, Elie A Akl, David D Gutterman, Holger Schu J NemannAbstract:T article provides the rationale for the Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (AT9) approach to estimating the effect of Antithrombotic prophylaxis on patient-important outcomes of pulmonary embolism (PE) and symptomatic venous thrombosis. 1.0 Thromboprophylaxis Reduces Fatal PE in Medical and Surgical Patients
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Antithrombotic Therapy for vte disease Antithrombotic Therapy and prevention of thrombosis 9th ed american college of chest physicians evidence based clinical practice guidelines
Chest, 2012Co-Authors: Clive Kearon, Anthony J Comerota, Paolo Prandoni, Henri Bounameaux, Samuel Z Goldhaber, Michael E Nelson, Philip S Wells, Michael K Gould, Francesco Dentali, Mark CrowtherAbstract:Background This guideline focuses on Antithrombotic drug therapies for primary and secondary prevention of cardiovascular disease as well as for the relief of lower-extremity symptoms and critical ischemia in persons with peripheral arterial disease (PAD). Methods The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. Results The most important of our 20 recommendations are as follows. In patients aged ≥ 50 years with asymptomatic PAD or asymptomatic carotid stenosis, we suggest aspirin (75-100 mg/d) over no Therapy (Grade 2B) for the primary prevention of cardiovascular events. For secondary prevention of cardiovascular disease in patients with symptomatic PAD (including patients before and after peripheral arterial bypass surgery or percutaneous transluminal angioplasty), we recommend long-term aspirin (75-100 mg/d) or clopidogrel (75 mg/d) (Grade 1A). We recommend against the use of warfarin plus aspirin in patients with symptomatic PAD (Grade 1B). For patients undergoing peripheral artery percutaneous transluminal angioplasty with stenting, we suggest single rather than dual antiplatelet Therapy (Grade 2C). For patients with refractory claudication despite exercise Therapy and smoking cessation, we suggest addition of cilostazol (100 mg bid) to aspirin (75-100 mg/d) or clopidogrel (75 mg/d) (Grade 2C). In patients with critical limb ischemia and rest pain unable to undergo revascularization, we suggest the use of prostanoids (Grade 2C). In patients with acute limb ischemia due to acute thrombosis or embolism, we recommend surgery over peripheral arterial thrombolysis (Grade 1B). Conclusions Recommendations continue to favor single antiplatelet Therapy for primary and secondary prevention of cardiovascular events in most patients with asymptomatic PAD, symptomatic PAD, and asymptomatic carotid stenosis. Additional therapies for relief of limb symptoms should be considered only after exercise Therapy, smoking cessation, and evaluation for peripheral artery revascularization.
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methodology for the development of Antithrombotic Therapy and prevention of thrombosis guidelines Antithrombotic Therapy and prevention of thrombosis 9th ed american college of chest physicians evidence based clinical practice guidelines
Chest, 2012Co-Authors: Gordon H Guyatt, Mark H Eckman, Sam Schulman, Per Olav Vandvik, Mark Crowther, Jack Hirsh, Elie A Akl, Susan L Norris, John W EikelboomAbstract:Background To develop the Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: ACCP Evidence-Based Clinical Practice Guidelines (AT9), the American College of Chest Physicians (ACCP) assembled a panel of clinical experts, information scientists, decision scientists, and systematic review and guideline methodologists. Methods Clinical areas were designated as articles, and a methodologist without important intellectual or financial conflicts of interest led a panel for each article. Only panel members without significant conflicts of interest participated in making recommendations. Panelists specified the population, intervention and alternative, and outcomes for each clinical question and defined criteria for eligible studies. Panelists and an independent evidence-based practice center executed systematic searches for relevant studies and evaluated the evidence, and where resources and evidence permitted, they created standardized tables that present the quality of the evidence and key results in a transparent fashion. Results One or more recommendations relate to each specific clinical question, and each recommendation is clearly linked to the underlying body of evidence. Judgments regarding the quality of evidence and strength of recommendations were based on approaches developed by the Grades of Recommendations, Assessment, Development, and Evaluation Working Group. Panel members constructed scenarios describing relevant health states and rated the disutility associated with these states based on an additional systematic review of evidence regarding patient values and preferences for Antithrombotic Therapy. These ratings guided value and preference decisions underlying the recommendations. Each topic panel identified questions in which resource allocation issues were particularly important and, for these issues, experts in economic analysis provided additional searches and guidance. Conclusions AT9 methodology reflects the current science of evidence-based clinical practice guideline development, with reliance on high-quality systematic reviews, a standardized process for quality assessment of individual studies and the body of evidence, an explicit process for translating the evidence into recommendations, disclosure of financial as well as intellectual conflicts of interest followed by management of disclosed conflicts, and extensive peer review.
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introduction to the ninth edition Antithrombotic Therapy and prevention of thrombosis 9th ed american college of chest physicians evidence based clinical practice guidelines
Chest, 2012Co-Authors: Gordon H Guyatt, Mark Crowther, Elie A Akl, David D Gutterman, Holger J Schunemann, Sandra Zelman LewisAbstract:The Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines differs substantially from the prior versions both in process and in content. In this introduction, we describe some of the differences and the rationale for the changes.
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treatment and prevention of heparin induced thrombocytopenia Antithrombotic Therapy and prevention of thrombosis 9th ed american college of chest physicians evidence based clinical practice guidelines
Chest, 2012Co-Authors: Loriann Linkins, Sam Schulman, Antonio L Dans, Lisa K Moores, Robert D Bona, Bruce L Davidson, Mark CrowtherAbstract:Background Heparin-induced thrombocytopenia (HIT) is an antibody-mediated adverse drug reaction that can lead to devastating thromboembolic complications, including pulmonary embolism, ischemic limb necrosis necessitating limb amputation, acute myocardial infarction, and stroke. Methods The methods of this guideline follow the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. Results Among the key recommendations for this article are the following: For patients receiving heparin in whom clinicians consider the risk of HIT to be > 1%, we suggest that platelet count monitoring be performed every 2 or 3 days from day 4 to day 14 (or until heparin is stopped, whichever occurs first) (Grade 2C). For patients receiving heparin in whom clinicians consider the risk of HIT to be Conclusions Further studies evaluating the role of fondaparinux and the new oral anticoagulants in the treatment of HIT are needed.
Gregory Y H Lip - One of the best experts on this subject based on the ideXlab platform.
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temporal trends of Antithrombotic Therapy for stroke prevention in korean patients with non valvular atrial fibrillation in the era of non vitamin k antagonist oral anticoagulants a nationwide population based study
PLOS ONE, 2017Co-Authors: So Ryoung Lee, Eue Keun Choi, Kyung Do Han, Myung Jin Cha, Gregory Y H LipAbstract:BACKGROUND Following their introduction, the non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly prescribed in Asia for stroke prevention in patients with non-valvular atrial fibrillation (AF). Few contemporary data are available on temporal trends in Antithrombotic Therapy use in Asian countries, in the era of NOACs. METHODS AND RESULTS Using the National Health Insurance Service database of the entire Korean adult AF population, the use of aspirin, vitamin K antagonist, and NOACs between 2008 and 2015 were analyzed (n = 276,246 in 2015). Most of the included cohort had CHA2DS2-VASc score ≥ 2 (78.2% in 2008 and 83.2% in 2015), yet approximately 17% were prescribed no Antithrombotic Therapy throughout the study period. Aspirin prescription consistently decreased (from 48.2% to 31.5%) over time, while OAC prescription significantly increased from 34.7% to 50.6%. NOAC prescriptions accounted for 50% of total OAC prescription in 2015. Similar trends in Antithrombotic Therapy were found both in men and in women, but women were more likely to be undertreated with OAC. Female gender, presence of vascular disease and prior intracranial hemorrhage were associated with OAC underuse. CONCLUSIONS Between 2008 and 2015, a greater proportion of AF patients received OAC treatment with increasing NOAC prescription trends in the recent 3 years. A substantial proportion (approx. 50%) of Korean patients with AF still remain undertreated.
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dual Antithrombotic Therapy with dabigatran after pci in atrial fibrillation
The New England Journal of Medicine, 2017Co-Authors: Christopher P Cannon, Deepak L Bhatt, Jonas Oldgren, Gregory Y H Lip, Stephen G Ellis, Takeshi Kimura, Michael Maeng, Bela Merkely, Uwe Zeymer, Savion GropperAbstract:BackgroundTriple Antithrombotic Therapy with warfarin plus two antiplatelet agents is the standard of care after percutaneous coronary intervention (PCI) for patients with atrial fibrillation, but this Therapy is associated with a high risk of bleeding. MethodsIn this multicenter trial, we randomly assigned 2725 patients with atrial fibrillation who had undergone PCI to triple Therapy with warfarin plus a P2Y12 inhibitor (clopidogrel or ticagrelor) and aspirin (for 1 to 3 months) (triple-Therapy group) or dual Therapy with dabigatran (110 mg or 150 mg twice daily) plus a P2Y12 inhibitor (clopidogrel or ticagrelor) and no aspirin (110-mg and 150-mg dual-Therapy groups). Outside the United States, elderly patients (≥80 years of age; ≥70 years of age in Japan) were randomly assigned to the 110-mg dual-Therapy group or the triple-Therapy group. The primary end point was a major or clinically relevant nonmajor bleeding event during follow-up (mean follow-up, 14 months). The trial also tested for the noninferio...
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relation of nonsteroidal anti inflammatory drugs to serious bleeding and thromboembolism risk in patients with atrial fibrillation receiving Antithrombotic Therapy a nationwide cohort study
Annals of Internal Medicine, 2014Co-Authors: Morten Lamberts, Gregory Y H Lip, Morten Lock Hansen, Jesper Lindhardsen, Jonas Bjerring Olesen, Jakob Raunso, Annemarie Olsen, Per Kragh Andersen, Thomas A Gerds, Emil L FosbolAbstract:Background Nonsteroidal anti-inflammatory drugs (NSAIDs) are assumed to increase bleeding risk, but their actual relation to serious bleeding in patients with atrial fibrillation (AF) who are receiving Antithrombotic medication is unknown. Objective To investigate the risk for serious bleeding and thromboembolism associated with ongoing NSAID and Antithrombotic Therapy. Design Observational cohort study. Setting Nationwide registries. Patients Danish patients with AF hospitalized between 1997 and 2011. Measurements Absolute risk for serious bleeding and thromboembolism with ongoing NSAID and Antithrombotic Therapy, assessed by using Cox models. Results Of 150 900 patients with AF (median age, 75 years [interquartile range, 65 to 83 years]; 47% female), 53 732 (35.6%) were prescribed an NSAID during a median follow-up of 6.2 years (interquartile range, 2.1 to 14.0 years). There were 17 187 (11.4%) and 19 561 (13.0%) occurrences of serious bleeding and thromboembolism, respectively. At 3 months, the absolute risk for serious bleeding within 14 days of NSAID exposure was 3.5 events per 1000 patients compared with 1.5 events per 1000 patients without NSAID exposure. The risk difference was 1.9 events per 1000 patients. In patients selected for oral anticoagulant Therapy, the absolute risk difference was 2.5 events per 1000 patients. Use of NSAIDs was associated with increased absolute risks for serious bleeding and thromboembolism across all Antithrombotic regimens and NSAID types. An NSAID dosage above the recommended minimum was associated with a substantially increased hazard ratio for bleeding. Limitation Observational design and unmeasured confounders. Conclusion Use of NSAIDs was associated with an independent risk for serious bleeding and thromboembolism in patients with AF. Short-term NSAID exposure was associated with increased bleeding risk. Physicians should exercise caution with NSAIDs in patients with AF. Primary funding source None.
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increased major bleeding complications related to triple Antithrombotic Therapy usage in patients with atrial fibrillation undergoing percutaneous coronary artery stenting
Chest, 2008Co-Authors: Sergio Manzanofernandez, Francisco Marin, Francisco J Pastor, Francisco Cambronero, Cesar Caro, Domingo A Pascualfigal, Iris P Garrido, Eduardo Pinar, Mariano Valdes, Gregory Y H LipAbstract:Background The optimal Antithrombotic Therapy strategy for atrial fibrillation (AF) patients who undergo percutaneous coronary intervention with stent implantation (PCI-S) is unknown. We assessed the safety of Antithrombotic Therapy strategies in AF patients with indication for oral anticoagulation (OAC) undergoing PCI-S. Methods We studied consecutive AF patients with indication for OAC who underwent PCI-S. We compared patients that received triple Antithrombotic Therapy (TT) [aspirin, clopidogrel, and coumadin] against other regimes (non-TT) after PCI-S. The primary end point was defined as the occurrence of major bleeding complications that were termed as early major bleeding (EMB) [≤ 48 h] or late major bleeding (LMB) [> 48 h]. Clinical follow-up was performed, and complications were recorded. Results We studied 104 patients (mean age ± SD, 72 ± 8 years; 70% men); TT was used in 51 patients (49%). TT was associated with a higher incidence of LMB (21.6% vs non-TT, 3.8%; p=0.006) but not of EMB (5.8% vs non-TT, 11.3%; p=0.33). In multivariate analyses, glycoprotein (GP) IIb/IIIa inhibitor use (hazard ratio [HR], 13.5; 95% confidence interval [CI], 1.7 to 108.3; p=0.014) and PCI-S of three vessels or left main artery disease (HR, 7.9; 95% CI, 1.6 to 39.2; p=0.01) were independent predictors for EMB. TT use (HR, 7.1; 95% CI, 1.5 to 32.4; p=0.012), the occurrence of EMB (HR, 6.7; 95% CI, 1.8 to 25.3; p=0.005), and baseline anemia (HR, 3.8; 95% CI, 1.2 to 12.5; p=0.027) were independent predictors for LMB. No differences in major cardiovascular events were observed in patients treated with TT vs non-TT (25.5% vs 21.0%; p=0.53). Conclusion A high rate of major bleeding is observed in AF patients with indication for OAC undergoing PCI-S who receive TT. GP IIb/IIIa inhibitor use and multivessel/left main artery disease during PCI-S were independent predictors for EMB, while TT use, occurrence of EMB, and baseline anemia were independent predictors for LMB.
Francisco Marin - One of the best experts on this subject based on the ideXlab platform.
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Antithrombotic Therapy in Patients with Peripheral Artery Disease: A Focused Review on Oral Anticoagulation
'MDPI AG', 2021Co-Authors: José Miguel Rivera-caravaca, Anny Camelo-castillo, Inmaculada Ramírez-macías, Pablo Gil-pérez, Cecilia López-garcía, María Asunción Esteve-pastor, Esteban Orenes-piñero, Antonio Tello-montoliu, Francisco MarinAbstract:Peripheral artery disease (PAD) is a major cause of morbidity and mortality but it is usually underdiagnosed and undertreated. Patients with PAD present dysregulated procoagulant, anticoagulant, and fibrinolytic pathways leading to arterial and venous thrombosis. The risk of several ischemic-related complications could be mitigated with appropriate Antithrombotic Therapy, which plays a central role in all types of PAD. For years, antiplatelets have been indicated in patients with symptomatic PAD or those who have undergone revascularization. Unfortunately, a non-negligible proportion of patients with PAD will suffer from adverse events during the follow-up, even despite proper medical therapies for the prevention of PAD complications. Thus, there is room for improving clinical outcomes in these patients. Given the implication of both, primary and secondary hemostasis in arterial thrombosis and the pathophysiology of PAD, the combination of antiplatelets and anticoagulants has emerged as a potential Antithrombotic alternative to antiplatelets alone. In this narrative review article, we have highlighted the most recent evidence about Antithrombotic Therapy in PAD patients, with a special focus on oral anticoagulation. Certainly, COMPASS and VOYAGER PAD trials have shown promising results. Thus, rivaroxaban in combination with aspirin seem to reduce cardiovascular outcomes with a similar bleeding risk compared to aspirin alone. Nevertheless, results from real-world studies are needed to confirm these observations, and other trials will provide novel evidence about the safety and efficacy of emerging anticoagulant agents
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management of Antithrombotic Therapy in atrial fibrillation patients presenting with acute coronary syndrome and or undergoing percutaneous coronary intervention stenting
Thrombosis and Haemostasis, 2010Co-Authors: Kurt Huber, Felicita Andreotti, Harald Arnesen, K J Airaksinen, Thomas Cuisset, Paulus Kirchhof, Francisco MarinAbstract:There remains uncertainty over optimal Antithrombotic management strategy for patients with atrial fibrillation (AF) presenting with an acute coronary syndrome and/or undergoing percutaneous coronary intervention/stenting. Clinicians need to balance the risk of stroke and thromboembolism against the risk of recurrent cardiac ischaemia and/or stent thrombosis, and the risk of bleeding. This consensus document comprehensively reviews the published evidence and presents a consensus statement on a ‘best practice’ Antithrombotic Therapy guideline for the management of Antithrombotic Therapy in such AF patients.
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increased major bleeding complications related to triple Antithrombotic Therapy usage in patients with atrial fibrillation undergoing percutaneous coronary artery stenting
Chest, 2008Co-Authors: Sergio Manzanofernandez, Francisco Marin, Francisco J Pastor, Francisco Cambronero, Cesar Caro, Domingo A Pascualfigal, Iris P Garrido, Eduardo Pinar, Mariano Valdes, Gregory Y H LipAbstract:Background The optimal Antithrombotic Therapy strategy for atrial fibrillation (AF) patients who undergo percutaneous coronary intervention with stent implantation (PCI-S) is unknown. We assessed the safety of Antithrombotic Therapy strategies in AF patients with indication for oral anticoagulation (OAC) undergoing PCI-S. Methods We studied consecutive AF patients with indication for OAC who underwent PCI-S. We compared patients that received triple Antithrombotic Therapy (TT) [aspirin, clopidogrel, and coumadin] against other regimes (non-TT) after PCI-S. The primary end point was defined as the occurrence of major bleeding complications that were termed as early major bleeding (EMB) [≤ 48 h] or late major bleeding (LMB) [> 48 h]. Clinical follow-up was performed, and complications were recorded. Results We studied 104 patients (mean age ± SD, 72 ± 8 years; 70% men); TT was used in 51 patients (49%). TT was associated with a higher incidence of LMB (21.6% vs non-TT, 3.8%; p=0.006) but not of EMB (5.8% vs non-TT, 11.3%; p=0.33). In multivariate analyses, glycoprotein (GP) IIb/IIIa inhibitor use (hazard ratio [HR], 13.5; 95% confidence interval [CI], 1.7 to 108.3; p=0.014) and PCI-S of three vessels or left main artery disease (HR, 7.9; 95% CI, 1.6 to 39.2; p=0.01) were independent predictors for EMB. TT use (HR, 7.1; 95% CI, 1.5 to 32.4; p=0.012), the occurrence of EMB (HR, 6.7; 95% CI, 1.8 to 25.3; p=0.005), and baseline anemia (HR, 3.8; 95% CI, 1.2 to 12.5; p=0.027) were independent predictors for LMB. No differences in major cardiovascular events were observed in patients treated with TT vs non-TT (25.5% vs 21.0%; p=0.53). Conclusion A high rate of major bleeding is observed in AF patients with indication for OAC undergoing PCI-S who receive TT. GP IIb/IIIa inhibitor use and multivessel/left main artery disease during PCI-S were independent predictors for EMB, while TT use, occurrence of EMB, and baseline anemia were independent predictors for LMB.
Per Olav Vandvik - One of the best experts on this subject based on the ideXlab platform.
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vte thrombophilia Antithrombotic Therapy and pregnancy Antithrombotic Therapy and prevention of thrombosis 9th ed american college of chest physicians evidence based clinical practice guidelines
Chest, 2012Co-Authors: Shannon M Bates, Ian A Greer, Saskia Middeldorp, David L Veenstra, Annemarie Prabulos, Per Olav VandvikAbstract:Background The use of anticoagulant Therapy during pregnancy is challenging because of the potential for both fetal and maternal complications. This guideline focuses on the management of VTE and thrombophilia as well as the use of Antithrombotic agents during pregnancy. Methods The methods of this guideline follow the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. Results We recommend low-molecular-weight heparin for the prevention and treatment of VTE in pregnant women instead of unfractionated heparin (Grade 1B). For pregnant women with acute VTE, we suggest that anticoagulants be continued for at least 6 weeks postpartum (for a minimum duration of Therapy of 3 months) compared with shorter durations of treatment (Grade 2C). For women who fulfill the laboratory criteria for antiphospholipid antibody (APLA) syndrome and meet the clinical APLA criteria based on a history of three or more pregnancy losses, we recommend antepartum administration of prophylactic or intermediate-dose unfractionated heparin or prophylactic low-molecular-weight heparin combined with low-dose aspirin (75-100 mg/d) over no treatment (Grade 1B). For women with inherited thrombophilia and a history of pregnancy complications, we suggest not to use Antithrombotic prophylaxis (Grade 2C). For women with two or more miscarriages but without APLA or thrombophilia, we recommend against Antithrombotic prophylaxis (Grade 1B). Conclusions Most recommendations in this guideline are based on observational studies and extrapolation from other populations. There is an urgent need for appropriately designed studies in this population.
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methodology for the development of Antithrombotic Therapy and prevention of thrombosis guidelines Antithrombotic Therapy and prevention of thrombosis 9th ed american college of chest physicians evidence based clinical practice guidelines
Chest, 2012Co-Authors: Gordon H Guyatt, Mark H Eckman, Sam Schulman, Per Olav Vandvik, Mark Crowther, Jack Hirsh, Elie A Akl, Susan L Norris, John W EikelboomAbstract:Background To develop the Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: ACCP Evidence-Based Clinical Practice Guidelines (AT9), the American College of Chest Physicians (ACCP) assembled a panel of clinical experts, information scientists, decision scientists, and systematic review and guideline methodologists. Methods Clinical areas were designated as articles, and a methodologist without important intellectual or financial conflicts of interest led a panel for each article. Only panel members without significant conflicts of interest participated in making recommendations. Panelists specified the population, intervention and alternative, and outcomes for each clinical question and defined criteria for eligible studies. Panelists and an independent evidence-based practice center executed systematic searches for relevant studies and evaluated the evidence, and where resources and evidence permitted, they created standardized tables that present the quality of the evidence and key results in a transparent fashion. Results One or more recommendations relate to each specific clinical question, and each recommendation is clearly linked to the underlying body of evidence. Judgments regarding the quality of evidence and strength of recommendations were based on approaches developed by the Grades of Recommendations, Assessment, Development, and Evaluation Working Group. Panel members constructed scenarios describing relevant health states and rated the disutility associated with these states based on an additional systematic review of evidence regarding patient values and preferences for Antithrombotic Therapy. These ratings guided value and preference decisions underlying the recommendations. Each topic panel identified questions in which resource allocation issues were particularly important and, for these issues, experts in economic analysis provided additional searches and guidance. Conclusions AT9 methodology reflects the current science of evidence-based clinical practice guideline development, with reliance on high-quality systematic reviews, a standardized process for quality assessment of individual studies and the body of evidence, an explicit process for translating the evidence into recommendations, disclosure of financial as well as intellectual conflicts of interest followed by management of disclosed conflicts, and extensive peer review.
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evidence based management of anticoagulant Therapy Antithrombotic Therapy and prevention of thrombosis 9th ed american college of chest physicians evidence based clinical practice guidelines
Chest, 2012Co-Authors: Anne Holbrook, Sam Schulman, David L Veenstra, Per Olav Vandvik, Mark Crowther, Daniel M Witt, Jason S Fish, Michael J Kovacs, Peter Svensson, Gordon H GuyattAbstract:Background High-quality anticoagulation management is required to keep these narrow therapeutic index medications as effective and safe as possible. This article focuses on the common important management questions for which, at a minimum, low-quality published evidence is available to guide best practices. Methods The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. Results Most practical clinical questions regarding the management of anticoagulation, both oral and parenteral, have not been adequately addressed by randomized trials. We found sufficient evidence for summaries of recommendations for 23 questions, of which only two are strong rather than weak recommendations. Strong recommendations include targeting an international normalized ratio of 2.0 to 3.0 for patients on vitamin K antagonist Therapy (Grade 1B) and not routinely using pharmacogenetic testing for guiding doses of vitamin K antagonist (Grade 1B). Weak recommendations deal with such issues as loading doses, initiation overlap, monitoring frequency, vitamin K supplementation, patient self-management, weight and renal function adjustment of doses, dosing decision support, drug interactions to avoid, and prevention and management of bleeding complications. We also address anticoagulation management services and intensive patient education. Conclusions We offer guidance for many common anticoagulation-related management problems. Most anticoagulation management questions have not been adequately studied.
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patient values and preferences in decision making for Antithrombotic Therapy a systematic review Antithrombotic Therapy and prevention of thrombosis 9th ed american college of chest physicians evidence based clinical practice guidelines
Chest, 2012Co-Authors: Samantha Maclean, Per Olav Vandvik, Elie A Akl, Sohail M Mulla, Milosz Jankowski, Shanil Ebrahim, Shelley Mcleod, Neera Bhatnagar, Gordon H GuyattAbstract:Background Development of clinical practice guidelines involves making trade-offs between desirable and undesirable consequences of alternative management strategies. Although the relative value of health states to patients should provide the basis for these trade-offs, few guidelines have systematically summarized the relevant evidence. We conducted a systematic review relating to values and preferences of patients considering Antithrombotic Therapy. Methods We included studies examining patient preferences for alternative approaches to Antithrombotic prophylaxis and studies that examined, in the context of Antithrombotic prophylaxis or treatment, how patients value alternative health states and experiences with treatment. We conducted a systematic search and compiled structured summaries of the results. Steps in the process that involved judgment were conducted in duplicate. Results We identified 48 eligible studies. Sixteen dealt with atrial fibrillation, five with VTE, four with stroke or myocardial infarction prophylaxis, six with thrombolysis in acute stroke or myocardial infarction, and 17 with burden of Antithrombotic treatment. Conclusion Patient values and preferences regarding thromboprophylaxis treatment appear to be highly variable. Participant responses may depend on their prior experience with the treatments or health outcomes considered as well as on the methods used for preference elicitation. It should be standard for clinical practice guidelines to conduct systematic reviews of patient values and preferences in the specific content area.
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Antithrombotic and thrombolytic Therapy for ischemic stroke Antithrombotic Therapy and prevention of thrombosis 9th ed american college of chest physicians evidence based clinical practice guidelines
Chest, 2012Co-Authors: Maarten G Lansberg, Sam Schulman, Per Olav Vandvik, Martin Odonnell, Pooja Khatri, Eddy Lang, Mai N Nguyenhuynh, Neil E Schwartz, Frank A Sonnenberg, Frederick A SpencerAbstract:Objectives This article provides recommendations on the use of Antithrombotic Therapy in patients with stroke or transient ischemic attack (TIA). Methods We generated treatment recommendations (Grade 1) and suggestions (Grade 2) based on high (A), moderate (B), and low (C) quality evidence. Results In patients with acute ischemic stroke, we recommend IV recombinant tissue plasminogen activator (r-tPA) if treatment can be initiated within 3 h (Grade 1A) or 4.5 h (Grade 2C) of symptom onset; we suggest intraarterial r-tPA in patients ineligible for IV tPA if treatment can be initiated within 6 h (Grade 2C); we suggest against the use of mechanical thrombectomy (Grade 2C) although carefully selected patients may choose this intervention; and we recommend early aspirin Therapy at a dose of 160 to 325 mg (Grade 1A). In patients with acute stroke and restricted mobility, we suggest the use of prophylactic-dose heparin or intermittent pneumatic compression devices (Grade 2B) and suggest against the use of elastic compression stockings (Grade 2B). In patients with a history of noncardioembolic ischemic stroke or TIA, we recommend long-term treatment with aspirin (75-100 mg once daily), clopidogrel (75 mg once daily), aspirin/extended release dipyridamole (25 mg/200 mg bid), or cilostazol (100 mg bid) over no antiplatelet Therapy (Grade 1A), oral anticoagulants (Grade 1B), the combination of clopidogrel plus aspirin (Grade 1B), or triflusal (Grade 2B). Of the recommended antiplatelet regimens, we suggest clopidogrel or aspirin/extended-release dipyridamole over aspirin (Grade 2B) or cilostazol (Grade 2C). In patients with a history of stroke or TIA and atrial fibrillation we recommend oral anticoagulation over no Antithrombotic Therapy, aspirin, and combination Therapy with aspirin and clopidogrel (Grade 1B). Conclusions These recommendations can help clinicians make evidence-based treatment decisions with their patients who have had strokes.