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Evidence-Based Minireview: Should warfarin or a direct oral anticoagulant be used in patients presenting with thrombosis in the splanchnic or cerebral veins?

ABSTRACT: Case 1: A 23-year-old female third-year medical student who has no medical history seeks treatment for abdominal distention. She takes an estrogen-containing birth control pill and does not smoke or consume alcohol. Family history is unremarkable. Physical examination is significant for abdominal distention, and an abdominal fluid wave is detected. Complete blood count is normal. Imaging confirms occlusive thrombosis of the main portal vein. On endoscopy, grade 1 to 2 esophageal varices are noted and banded. Unfractionated heparin is begun. Subsequent workup reveals a homozygous factor V Leiden mutation. Long-term anticoagulation is planned, and she asks if warfarin can be avoided given her hectic ward rotations, erratic diet, and need for monitoring. Case 2: A 35-year-old woman who has no medical history seeks treatment for progressively worsening posterior headaches for 1 week. Magnetic resonance imaging of the brain shows dural sinus thrombosis with associated small areas of petechial cerebral hemorrhage. She is started on a continuous unfractionated heparin infusion and admitted to the hospital for further observation. Her grandmother is on warfarin for atrial fibrillation, and the patient would prefer to avoid warfarin because she does not think she can comply with the frequent monitoring that will be required. She inquires about other oral anticoagulant options for her condition.

SUBMITTER: Mathew C

PROVIDER: S-EPMC8791162 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Equivalent inpatient mortality among direct-acting oral anticoagulant and warfarin users presenting with major hemorrhage.

Project description:BackgroundExtrapolation of clinical trial results comparing warfarin and direct-acting oral anticoagulant (DOAC) users experiencing major hemorrhage to clinical care is challenging due to differences seen among non-randomized oral anticoagulant users, bleed location, and etiology. We hypothesized that inpatient all-cause-mortality among patients presenting with major hemorrhage differed based on the home-administered anticoagulant medication class, DOAC versus warfarin.MethodsMore than 1.5 million hospitalizations were screened and 3731 patients with major hemorrhage were identified in the REDS-III Recipient Database. Propensity score matching and stratification were used to account for potentially confounding factors.ResultsInpatient all-cause-mortality was lower for DOAC (HR = 0.60, 95%CI 0.45-0.80, p = 0.0005) before accounting for confounding and competing events. Inpatient all-cause-mortality for 1266 propensity-score-matched patients compared using proportional hazards regression did not differ (HR = 0.84, 95%CI 0.58-1.22, p = 0.36). Inpatient all-cause-mortality in stratified analyses (warfarin as reference) produced: HR = 0.69 (95%CI 0.31-1.55) for traumatic head injuries; HR = 1.10 (95%CI 0.62-1.95) for non-traumatic head injuries; HR = 0.62 (95%CI 0.20-1.94) for traumatic, non-head injuries; and HR = 0.69 (95%CI 0.29-1.63) for non-traumatic, non-head injuries. Mean time to discharge was shorter for DOAC (HR = 1.17, 95%CI 1.05-1.30, p = 0.0034) in the propensity score matched analysis. Plasma transfusion occurred in 42% of warfarin hospitalizations and 11% of DOAC hospitalizations. Vitamin K was administered in 63% of warfarin hospitalizations.ConclusionsAfter accounting for differences in patient characteristics, location of bleed, and traumatic injury, inpatient survival was no different in patients presenting with major hemorrhage while on DOAC or warfarin.

| S-EPMC7035631 | biostudies-literature

Anticoagulation in splanchnic and cerebral vein thrombosis: An international vignette-based survey.

Project description:BackgroundAnticoagulant treatment of splanchnic (SVT) and cerebral vein thrombosis (CVT) can be challenging due to the rarity of these conditions, the concomitantly high thrombotic and bleeding risks, and the available low-quality evidence.ObjectivesTo explore the current therapeutic approaches to SVT and CVT, and the rationale behind the anticoagulant treatment choice.MethodsA cross-sectional survey was conducted (October 2018-April 2019) among members of three thrombosis and hemostasis societies. The survey consisted of four vignette cases: (i) SVT secondary to transient risk factor; (ii) cirrhotic SVT with esophageal varices; (iii) CVT secondary to transient risk factor; and (iv) unprovoked CVT with intracranial hemorrhage.ResultsA total of 397 physicians responded to the survey. There was wide variability in anticoagulant treatment options, starting time, and duration. Vitamin K antagonists were the commonest choice across the four vignette cases (44.2%-63.0%). The direct oral anticoagulants (DOACs) were the second commonest choice in low-bleeding-risk scenarios (27.7% in case 1, 22.9% in case 3), while parenteral anticoagulation alone was the second commonest choice in high-bleeding-risk scenarios (39.9% in case 2, 39.8% in case 4). The most frequent reasons for selecting DOACs were oral route of administration (50.6%), lack of need for laboratory monitoring (48.1%), and favorable safety profile of these drugs (43.4%).ConclusionsThe results of our study showed that, despite being off-label, the DOACs were considered for the treatment of unusual-site venous thromboembolism. The wide variability among different physicians reflected the clinical difficulties and raised the need for more collaborative trials on these disorders.

| S-EPMC7590282 | biostudies-literature

Anticoagulant treatment satisfaction with warfarin and direct oral anticoagulants for venous thromboembolism.

Project description:Treatment options for patients with venous thromboembolism (VTE) include warfarin and direct oral anticoagulants (DOACs). Although DOACs are easier to administer than warfarin and do not require routine laboratory monitoring, few studies have directly assessed whether patients are more satisfied with DOACs. We surveyed adults from two large integrated health systems taking DOACs or warfarin for incident VTE occurring between January 1, 2015 and June 30, 2018. Treatment satisfaction was assessed using the validated Anti-Clot Treatment Scale (ACTS), divided into the ACTS Burdens and ACTS Benefits scores; higher scores indicate greater satisfaction. Mean treatment satisfaction was compared using multivariable linear regression, adjusting for patient demographic and clinical characteristics. The effect size of the difference in means was calculated using a Cohen's d (0.20 is considered a small effect and ≥ 0.80 is considered large). We surveyed 2217 patients, 969 taking DOACs and 1248 taking warfarin at the time of survey. Thirty-one point five percent of the cohort was aged ≥ 75 years and 43.1% were women. DOAC users were on average more satisfied with anticoagulant treatment, with higher adjusted mean ACTS Burdens (50.18 v. 48.01, p < 0.0001) and ACTS Benefits scores (10.21 v. 9.84, p = 0.046) for DOACs vs. warfarin, respectively. The magnitude of the difference was small (Cohen's d of 0.29 for ACTS Burdens and 0.12 for ACTS Benefits). Patients taking DOACs for venous thromboembolism were on average more satisfied with anticoagulant treatment than were warfarin users, although the magnitude of the difference was small.

| S-EPMC8605968 | biostudies-literature

Trends in direct oral anticoagulant use in patients presenting with acute stroke.

Project description:Acute ischaemic strokes occur despite the use of direct oral anticoagulants (DOACs). A retrospective review was conducted at a high-volume primary stroke centre over a 3-year period to assess the acute management of stroke presentations in patients prescribed DOACs. During the time period of the study, 103 of 195 anticoagulated stroke patients presented within the timeframe for thrombolysis and only 15 patients had DOAC plasma level assays performed. Of these 103, 5 received thrombolysis; however, DOAC level was not a factor in these cases.

| S-EPMC9546077 | biostudies-literature

Venous thrombosis recurrence risk according to warfarin versus direct oral anticoagulants for the secondary prevention of venous thrombosis.

Project description:BackgroundVenous thromboembolism (VTE) affects nearly 1 million Americans annually, and many benefit from continued anticoagulation after the initial 3- to 6-month treatment period (secondary prevention).ObjectivesTo determine whether warfarin, apixaban, or rivaroxaban is associated with reduced recurrent VTE hospitalization in the secondary prevention of VTE.Patients/methodsWe performed a retrospective cohort study of participants enrolled in the MarketScan Insurance Database between 2013 and 2017 in those with an incident VTE. In those individuals who continued oral anticoagulation (warfarin, apixaban, or rivaroxaban) beyond 6 months, we determined the relative rate of recurrent VTE hospitalization.ResultsAmong 119 964 individuals with VTE, 25 419 remained on anticoagulation after 6 months and were matched successfully by age, sex, and date. After adjusting for a propensity score, apixaban versus rivaroxaban (hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.45-0.94) and apixaban versus warfarin (HR, 0.68; 95% CI, 0.47-1.00) had a reduced risk of recurrent VTE hospitalization, and rivaroxaban versus warfarin (HR, 1.12; 95% CI, 0.94-1.33) had equivalent rates. For the rivaroxaban versus warfarin comparison there was a significant interaction by renal function (P < .01) where rivaroxaban was associated with a lower risk of recurrent VTE hospitalization (HR, 0.65; 95% CI, 0.41-1.03) in those with kidney disease and increased risk in those without kidney disease (HR, 1.24; 95% CI, 1.02-1.50).ConclusionsThese data suggest that apixaban has a lower recurrent VTE hospitalization rate than rivaroxaban during the secondary prevention of VTE, and further study of diverse patient populations, especially by kidney function, is warranted.

| S-EPMC8371351 | biostudies-literature

Cerebral venous thrombosis presenting as vision loss & multiple cranial palsy - A rarity.

Project description: Not available

| S-EPMC8257208 | biostudies-literature

Long-Term Outcome of Splanchnic Vein Thrombosis in Cirrhosis.

Project description:INTRODUCTION:Little is known about the long-term outcome of cirrhotic patients with splanchnic vein thrombosis (SVT). This prospective cohort study aimed to describe the clinical presentation, bleeding incidence, thrombotic events, and mortality in patients with SVT associated with cirrhosis. METHODS:Among 604 consecutive patients with SVT enrolled over 2 years, 149 had cirrhosis. Major bleeding, thrombotic events, and all-cause mortality were recorded during a 2-year follow-up. In a subgroup, the degree of recanalization with or without anticoagulation therapy, and the correlation between clinical events and liver disease severity were also investigated. RESULTS:The most common thrombosis sites were the portal (88%) and mesenteric veins (34%). At presentation, 50% of patients were asymptomatic. Anticoagulation was administered to 92/149 patients for a median of 6.5 months. Vessel recanalization was documented in 47/98 patients with a radiological follow-up. Anticoagulation was associated with a 3.33-fold higher of recanalization rate, and a lower recurrent thrombosis rate, while patients with and without anticoagulation experienced a similar rate of major bleeding episodes. Mortality rates were 6.8 per 100 patient-years for patients with thrombosis completely or partially resolving during the follow-up, and 15.4 per 100 patient-years for those with stable or progressing thrombosis. An impact of SVT on survival was only apparent in patients with more advanced liver disease (Child-Pugh B-C). CONCLUSIONS:Patients with SVT and cirrhosis have a substantial long-term risk of recurrent thrombotic events, which is reduced by anticoagulation therapy without any increase in bleeding risk. Anticoagulation can improve the likelihood of vessel recanalization, and is associated with a lower risk of death for decompensated patients.

| S-EPMC6092393 | biostudies-literature

The outcomes of pregnant and postpartum patients with cerebral venous sinus thrombosis after anticoagulant therapy.

Project description:BackgroundTo describe the outcome of the patients with cerebral venous sinus thrombosis (CVST) during pregnancy and postpartum treated with anticoagulant therapy.MethodsThis is a retrospective cohort study and patients with CVST were collected from October 2009 to March 2018. Patients were divided into pregnancy-related (occurred during pregnancy and postpartum) group and non-pregnancy-related. Recovery rate at 12 months after anticoagulant therapy, adverse events, characteristics of patients with poor outcomes were statistically analyzed.ResultsFifty-eight pregnancy-related CVST patients (17 pregnancy and 41 postpartum) as study group and 76 non-pregnancy-related CVST women as control group were enrolled. Study group was statistically different to control group in several baseline variables. More pregnancy-related patients had modified rankin scale (mRS) = 5 (15.5% vs 11.8%, P = 8.1×10-3) before anticoagulant therapy. At 12 months heparinization, difference in recovery rate was not statistically significant (80% vs 87.5%, P = .29) between 2 groups. No differences were found of adverse events between 2 groups. Patients with poor outcomes had less sigmoid sinus thrombosis (16.7% vs 61.5%, P = .14), more coma (41.2% vs 17.2%, P = 5.2×10-7), more mRS = 4 (33.3% vs 19.2%, P = 1.63 × 10-4), more mRS = 5 (66.7% vs 9.6%, P = 1.63 × 10-4) before treatment.ConclusionPregnancy-related CVST patients had severer condition before treatment, but can achieve comparable recovery rate at 12 months after anticoagulant therapy with non-pregnancy-related women. Pregnancy-related patients with poor prognosis had less sinus sigmoid occlusion, more coma, high mRS at admission.

| S-EPMC8257884 | biostudies-literature

Occipital Lobe Epilepsy Presenting with Eyelid Blinking Following Cerebral Venous Sinus Stenotic Thrombosis.

Project description: Not available

| S-EPMC8490913 | biostudies-literature

Recurrent thrombosis of splanchnic and lower extremity arteries with essential thrombocythemia.

Project description:Essential thrombocythemia is a myeloproliferative neoplasm characterized by platelet aggregation and thrombosis. Clinically, essential thrombocythemia increases the risk of both thrombosis and bleeding. Essential thrombocythemia is more involved in micro- and small-sized arteries than in large arteries. Many essential thrombocythemia patients exhibit various symptoms, including microvascular thrombosis with acute coronary disease, digital ischemia, and transient ischemic attack. This study reports a rare case of recurrent thrombosis in relatively large vessels including splanchnic, lower extremity arteries, and aorta in essential thrombocythemia. A 70-year-old woman was admitted to the emergency room with abdominal pain and fever for a day. The patient underwent three operations due to recurrent arterial thrombosis of superior mesenteric, splenic, aorta, and lower extremities. She had recurrent diarrhea and acute kidney injury because of short bowel syndrome after extensive bowel resection. In conclusion, essential thrombocythemia patients aged >60 years and who have risk factors such as history of major ischemic events or severe leukocytosis must be careful of thrombosis of the medium- and large-sized arteries, including splanchnic and lower extremity arteries.

| S-EPMC6767714 | biostudies-literature

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