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The Severity of Bleeding and Mortality in Trauma Patients Taking Dabigatran
Dabigatran, a direct thrombin inhibitor, has been shown to be more effective than warfarin in the prevention of stroke in patients with atrial fibrillation. Until recently, it lacked a reversal agent, and its contribution to the risk of transfusion in injured patients is unknown.
Source: The Journal of Emergency Medicine - June 26, 2016 Category: Emergency Medicine Authors: Zachary D.W. Dezman, Angela C. Comer, Gordon S. Smith, Mayur Narayan, John R. Hess, Jon Mark Hirshon Tags: Brief Report Source Type: research

Coagulation assessment with the new generation of oral anticoagulants
Long-term oral anticoagulant (OAC) therapy is used for the treatment and prevention of thrombosis and thromboembolism. As OAC use is so widespread, emergency physicians are likely to encounter patients on anticoagulant therapy in the emergency department (ED) on a regular basis, either for the same reasons as the population in general or as a result of the increased bleeding risk that OAC use entails. The vitamin K antagonist warfarin has been the standard OAC for several decades, but recently, the newer agents dabigatran etexilate, rivaroxaban and apixaban (collectively, novel OACs, non-vitamin K OACs, or simply ‘NO...
Source: Emergency Medicine Journal - May 18, 2016 Category: Emergency Medicine Authors: Pollack, C. V. Tags: Open access, Drugs: cardiovascular system, Stroke, Venous thromboembolism Review Source Type: research

Should we be looking for and treating isolated calf vein thrombosis?
Management of isolated calf deep vein thrombosis is an area of significant international debate and variable clinical practice. Both therapeutic anticoagulation and conservative management carry risk. As clinical care of suspected and confirmed venous thromboembolic disease increasingly becomes the remit of emergency medicine, complex decisions are left to practising clinicians at the front door. We aim to provide a contemporary overview of recent evidence on this topic and associated challenges facing clinicians. Given the lack of high-level evidence, we present this work as a narrative review, based on structured literat...
Source: Emergency Medicine Journal - May 18, 2016 Category: Emergency Medicine Authors: Horner, D., Hogg, K., Body, R. Tags: Drugs: cardiovascular system, Stroke, Pregnancy, Venous thromboembolism, Pulmonary embolism Review Source Type: research

Stroke prevention for patients with atrial fibrillation: values and preferences of Canadian emergency medicine trainees
Atrial fibrillation (AF) is the most common serious cardiac arrhythmia, and it is associated with a 5-fold increase in the risk of ischemic stroke [1 –3] . This risk can be reduced by up to 64% with oral anticoagulation (OAC) [4] . Many patients are first diagnosed with AF in the context of visit to the emergency department (ED), and AF can account for 1% or more of ED visits [5–7] . Clinical risk stratification for stroke and bleeding and subsequent prescription of OAC are the cornerstones of management of AF.
Source: The American Journal of Emergency Medicine - May 12, 2016 Category: Emergency Medicine Authors: William F. McIntyre, Zardasht Oqab, Payam Yazdan-Ashoori, Kieran L. Quinn, Erik M. van Oosten, Wilma M. Hopman, Adrian Baranchuk Tags: Correspondence Source Type: research

Stroke Prevention for Patients with Atrial Fibrillation: Values and Preferences of Canadian Emergency Medicine Trainees
Atrial Fibrillation (AF) is the most common serious cardiac arrhythmia and it is associated with a five-fold increase in the risk of ischemic stroke[1–3]. This risk can be reduced by up to 64% with oral anticoagulation (OAC)[4]. Many patients are first diagnosed with atrial fibrillation (AF) in the context of visit to the emergency department (ED) and AF can account for 1% or more of ED visits[5–7]. Clinical risk stratification for stroke and bleeding and subsequent prescription of OAC are the cornerstones of management of AF.
Source: The American Journal of Emergency Medicine - May 12, 2016 Category: Emergency Medicine Authors: William F. McIntyre, Zardasht Oqab, Payam Yazdan-Ashoori, Kieran L. Quinn, Erik M. van Oosten, Wilma M. Hopman, Adrian Baranchuk Tags: Correspondence Source Type: research

Treatment With Prothrombin Complex Concentrate to Enable Emergency Lumbar Puncture in Patients Receiving Vitamin K Antagonists
Conclusion Reversing the effect of vitamin K antagonist with prothrombin complex concentrates to enable emergency lumbar puncture appears effective and safe, particularly in regard to bleeding events.
Source: Annals of Emergency Medicine - April 14, 2016 Category: Emergency Medicine Source Type: research

Why switch from warfarin to NOACs?
Abstract Several patients with non-valvular atrial fibrillation treated with warfarin or other vitamin-K antagonists (VKA) might benefit from switching to an oral non vitamin-K antagonist anticoagulant (NOAC). In the absence of randomised comparative trials of switching to NOACs versus maintaining VKA treatment, several considerations argue in favour of a switching strategy. First, there is conclusive evidence that haemorrhagic strokes and intracranial bleedings are much fewer in number with NOACs than with warfarin. The risk of intracranial bleeding is 52 % lower with NOACS than with warfarin, with extremes rang...
Source: Internal and Emergency Medicine - March 14, 2016 Category: Emergency Medicine Source Type: research

Comparison of Four Bleeding Risk Scores to Identify Rivaroxaban‐treated Patients With Venous Thromboembolism at Low Risk for Major Bleeding
ConclusionsFour scoring systems that use criteria obtained in routine clinical practice, derived to predict low bleeding risk with VKA treatment for VTE, identified patients with less than a 1% risk of major bleeding during full‐course treatment with rivaroxaban.
Source: Academic Emergency Medicine - January 14, 2016 Category: Emergency Medicine Authors: Jeffrey A. Kline, David Jimenez, D. Mark Courtney, Juliana Ianus, Lynn Cao, Anthonie W.A. Lensing, Martin H. Prins, Philip S. Wells Tags: Original Contribution Source Type: research

Comparison of Four Bleeding Risk Scores to Identify Rivaroxaban-treated Patients With Venous Thromboembolism at Low Risk for Major Bleeding.
CONCLUSIONS: Four scoring systems that use criteria obtained in routine clinical practice, derived to predict low bleeding risk with VKA treatment for VTE, identified patients with less than a 1% risk of major bleeding during full-course treatment with rivaroxaban. PMID: 26765080 [PubMed - as supplied by publisher]
Source: Accident and Emergency Nursing - January 14, 2016 Category: Emergency Medicine Authors: Kline JA, Jimenez D, Courtney DM, Ianus J, Cao L, Lensing AW, Prins MH, Wells PS Tags: Acad Emerg Med Source Type: research

Initial results of the re-verse ad trial: idarucizumab reverses the anticoagulant effects of dabigatran in patients in an emergency setting of major bleeding, urgent surgery or interventions
Conclusion Idarucizumab is a promising specific reversal agent that rapidly and safely reverses dabigatran's anticoagulant effects within minutes in emergency situations that reflect real world clinical practice.
Source: Emergency Medicine Journal - November 23, 2015 Category: Emergency Medicine Authors: Pollack, C., Eikelboom, J., Weitz, J., Reilly, P., Glund, S., Dubiel, R., Kreuzer, J., Stangier, J., Wang, B., Gagg, J., Verhamme, P., Bernstein, R., Huisman, M., Hylek, E., Kamphuisen, P., Levy, J., Selke, F., Steiner, T., Kam, C. Tags: Drugs: cardiovascular system, Stroke TOP SCORING NON TRAINEES Source Type: research

Time trends in intracranial bleeding and new oral anticoagulant prescription
Conclusion We found an increasing number of patients treated for intracranial bleeding over time. Warfarin accounted for a disproportionate number of intracranial bleeds and the new oral anticoagulants, fewer than expected.
Source: Emergency Medicine Journal - November 23, 2015 Category: Emergency Medicine Authors: Hogg, K., Stiell, I., Bahl, B. Tags: Drugs: cardiovascular system, Stroke RCEM FREE PAPERS Source Type: research

Direct oral anticoagulants in atrial fibrillation: can data from randomized clinical trials be safely transferred to the general population? Yes
Abstract Atrial fibrillation is the most common arrhythmia and is associated with significant morbidity and mortality. The current therapeutic options for patients at high thromboembolic risk include the vitamin K antagonists and the direct oral anticoagulants. These novel agents have been evaluated in more than 40,000 patients enrolled in four large randomized controlled trials for stroke prevention in non-valvular atrial fibrillation. When these results were pooled together, a greater efficacy profile, as well as a consistent reduction in life-threatening bleeding was shown in comparison to vitamin K antagonists...
Source: Internal and Emergency Medicine - July 7, 2015 Category: Emergency Medicine Source Type: research

Management of Bleeding Complications in Patients Taking Direct Oral Anticoagulants at a Large Tertiary Academic Medical Center
Abstract Direct oral anticoagulants (DOACs) offer a fixed-dose alternative to warfarin for stroke prevention in patients with atrial fibrillation. However, there is minimal evidence to guide the management of bleeding in patients taking a DOAC. We retrospectively evaluated the acute management of major bleeding in this patient population at a large, tertiary academic medical center. We evaluated various strategies of management including dialysis, transfusions, pharmacologic agents, surgical intervention, and reinitiation of anticoagulation. We also assessed length of intensive care unit and hospital stay, mor...
Source: Current Emergency and Hospital Medicine Reports - June 13, 2015 Category: Emergency Medicine Source Type: research

Management of Apixaban-Associated Subdural Hematoma: A Case Report on the Use of Factor Eight Inhibitor Bypassing Activity
Conclusions: Factor VIII inhibitor bypassing activity may be a viable, nonspecific reversal agent for life-threatening bleeding associated with apixaban.
Source: Critical Care Medicine - May 16, 2015 Category: Emergency Medicine Tags: Online Case Report Source Type: research

To treat or not to treat very elderly naïve patients with atrial fibrillation with vitamin K antagonists (VKA): results from the VENPAF cohort
Abstract Despite the recommendations in the guidelines, physicians still underuse warfarin in very elderly patients with non-valvular atrial fibrillation (NVAF). The risks of stroke and major bleeding both increase with age, but it is still not clear whether the beneficial effects of vitamin K antagonists (VKA) in preventing stroke outweigh the related bleeding risks in fragile, very elderly patients. The bleeding rates reported in real-world observational studies differ considerably. The aim of this study was to retrospectively assess the incidence of major bleeding in VKA-naïve patients over 80 years old w...
Source: Internal and Emergency Medicine - April 21, 2015 Category: Emergency Medicine Source Type: research

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