Bleeding risk stratification in an era of aggressive management of acute coronary syndromes

Major bleeding is currently one of the most common non-cardiac complications observed in the treatment of patients with acute coronary syndrome (ACS). Hemorrhagic complications occur with a frequency of 1% to 10% during treatment for ACS. In fact, bleeding events are the most common extrinsic complication associated with ACS therapy. The identification of clinical characteristics and particularities of the antithrombin therapy associated with an increased risk of hemorrhagic complications would make it possible to adopt prevention strategies, especially among those exposed to greater risk. The international societies of cardiology renewed emphasis on bleeding risk stratification in order to decide strategy and therapy for patients with ACS. With this review, we performed an update about the ACS bleeding risk scores most frequently used in daily clinical practice.     

Why do mortality rates for nonvariceal upper gastrointestinal bleeding differ around the world? A systematic review of cohort studies

BACKGROUND:

Discrepancies exist in reported mortality rates of nonvariceal upper gastrointestinal bleeding (NVUGIB).

OBJECTIVE:

To perform a systematic review assessing possible reasons for these disparate findings and to more reliably compare them.

METHODS:

The MEDLINE, EMBASE and ISI Web of Knowledge databases were searched for studies reporting mortality rates in NVUGIB involving adults and published in English. To ensure robust and contemporary estimates, studies spanning 1996 to January 2011 that included more than 1000 patients were selected.

RESULTS:

Eighteen of 3077 studies were selected. Ten studies used administrative databases and the remaining eight used registries. The mortality rates reported in these studies ranged from 1.1% in Japan to 11% in Denmark. There were variations in reported mortality rates among countries and also within countries. Reasons for these disparities included a spectrum of quality in reporting as well as heterogeneous definitions of case ascertainment, differing patient populations with regard to severity of presentation and associated comorbidities, varying durations of follow-up and different health care system-related practices.

CONCLUSIONS:

Wide differences in reported NVUGIB mortality rates are attributable to differences in adopted methodologies and populations studied. More uniform standards in reporting are needed; only then can true observed variations enable a better understanding of causes of death and pave the way to improved patient outcomes.     

结肠镜下结肠息肉摘除术后延迟出血18例

为探讨结肠息肉摘除术后延迟出血在结肠镜下治疗的价值,对18例行结肠息肉摘除术后24-72h肠道出血的患者,行结肠镜检查和内镜下治疗。结果显示,对结肠镜检查发现的出血部位,立即于结肠镜下行注射治疗和电凝治疗可使出血停止。18例全部治愈,未发生任何并发症。结果发明,结肠镜下治疗结肠息肉摘除术后延迟出血,是可行、有效和安全的方法。     

医源性动脉出血的介入栓塞治疗

目的探讨介入栓塞治疗医源性动脉出血的临床应用价值。方法回顾性分析我科35例医源性动脉出血、接受介入栓塞治疗患者的临床及影像资料,观察介入栓塞治疗医源性动脉出血的疗效。结果对35例外科术后动脉出血患者均成功进行介入栓塞治疗。5例肠道术后出血DSA示局部血管紊乱,其中3例见少量对比剂外漏进入肠管,给予适量明胶海绵颗粒进行栓塞;余30例DSA均可见对比剂外漏,其中17例伴假性动脉瘤形成,均采用微弹簧圈予以栓塞。随访10～15天,33例出血停止,2例肠道术后出血患者仍有持续性少量便血,进行再次手术止血治疗。所有患者均未发生器官缺血坏死等严重并发症。结论介入栓塞治疗医源性动脉出血具有一定优势;对于外科术后导致动脉出血、尤其是病情危重的患者,采取介入栓塞治疗具有较好的临床应用价值。     

In vitro effects of recombinant activated factor VII on thrombin generation and coagulation following inhibition of platelet procoagulant activity by prasugrel

Introduction

Prasugrel is a thienopyridyl P2Y₁₂ antagonist with potent antiplatelet effects. At present, little is known about its effects on thrombin generation or what strategies may emergently reverse its anticoagulant effects. In the current study we evaluated whether recombinant activated factor VII may reverse prasugrel induced effects and increase thrombin generation in an in vitro model.

Methods

The effect of prasugrel active metabolite, PAM (R-138727), was evaluated on platelet aggregation, thrombin generation, and rotational thromboelastometry parameters using blood from 20 healthy volunteers. Additionally, we evaluated the effects of adenosine diphosphate (ADP) and recombinant activated factor VII on restoring these parameters towards baseline values.

Results

PAM reduced maximum platelet aggregation and led to platelet disaggregation. It also decreased peak thrombin, increased lag time, and increased time to peak thrombin. Treatment with recombinant activated factor VII restored all three parameters of thrombin generation towards baseline. ADP decreased lag time and time to peak thrombin, but had no effect on peak thrombin. When recombinant activated factor VII and ADP were combined they had a greater effect on thrombin parameters than either drug alone. PAM also increased thromboelastometric clotting time and clot formation time, but had no effect on maximum clot firmness. Treatment with either recombinant activated factor VII or ADP restored these values towards baseline.

Conclusions

Recombinant activated factor VII restores thrombin generation in the presence of PAM. In patients taking prasugrel with life-threatening refractory bleeding it has the potential to be a useful therapeutic approach. Additional clinical studies are needed to validate our findings.