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[Appropriateness criteria for the management of anticoagulant therapy in complex patients with atrial fibrillation. The opinion of a group of expert Italian cardiologists].
Botto, GL, Padeletti, L, Ammirati, F, Calò, L, Calvi, V, Cappato, R, Capucci, A, D'Onofrio, A, Grimaldi, M, Lombardi, F, et al
Giornale italiano di cardiologia (2006). 2018;(10):591-600
Abstract
Atrial fibrillation (AF) is a common arrhythmia often associated with high thromboembolic risk. The purpose of this position paper is to provide clinicians with recommendations useful in managing some important issues regarding the use of anticoagulant therapy in patients with AF in particularly complex clinical situations.The RAND/UCLA appropriateness method, validated to combine the best available scientific evidence with the collective judgment of experts, was used to assess the judgment of an expert panel of cardiologists. To this purpose, the benefit-to-harm ratio of 37 clinical scenarios was rated. Each indication was classified as "appropriate", "uncertain", or "inappropriate" in accordance with the panelists' median score.The present document reports the results of this consensus process, which led to the development of recommendations for clinical practice on how to use anticoagulant therapy in patients with AF in complex clinical settings, including the presence of comorbidities, cardioversion, or ablation. Non-vitamin K oral anticoagulants are a valid alternative to vitamin K antagonists in preventing embolic events in patients with non-valvular AF, particularly in case of clinical complexity.
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2.
2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation: A Report of the American College of Cardiology Clinical Expert Consensus Document Task Force.
Doherty, JU, Gluckman, TJ, Hucker, WJ, Januzzi, JL, Ortel, TL, Saxonhouse, SJ, Spinler, SA
Journal of the American College of Cardiology. 2017;(7):871-898
Abstract
Periprocedural management of anticoagulation is a common clinical conundrum that involves a multidisciplinary team, cuts across many specialties, and varies greatly between institutions in the way it is practiced. Nowhere is this more evident than in the management of patients with nonvalvular atrial fibrillation. Although they have been found to improve patient outcomes, standardized evidence-based protocols are infrequently in place. The frequency of anticoagulant interruption in preparation for a procedure is high, with an estimated 250,000 patients undergoing temporary interruption annually in North America alone. Knowledge about risk of bleeding and short-term thrombotic risk resides in many specialties, further complicating the issue. Our goal in creating this pathway is to help guide clinicians in the complex decision making in this area. In this document, we aim to: 1) validate the appropriateness of the decision to chronically anticoagulate; 2) guide clinicians in the decision of whether to interrupt anticoagulation; 3) provide direction on how to interrupt anticoagulation with specific guidance for vitamin K antagonists and direct-acting oral anticoagulants; 4) evaluate whether to bridge with a parenteral agent periprocedurally; 5) offer advice on how to bridge; and 6) outline the process of restarting anticoagulation post-procedure.
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3.
Consensus on Management of Deep Vein Thrombosis with Emphasis on NOACs (Non-Vitamin K Antagonist Oral Anticoagulants): Recommendations from Inter-Disciplinary Group of Indian Experts.
Parakh, R, Krishna, PR, Amin, P, Bedi, VS, Desai, S, Dumra, HS, Gupta, PC, Gupta, V, Hydrabadi, R, Kamerkar, D, et al
The Journal of the Association of Physicians of India. 2016;(9 Suppl):7-26
Abstract
It is estimated that around 2.5 lac patients are identified as having an acute venous thrombo-embolic event in India annually. This includes patients with deep vein thrombosis and pulmonary embolism, and is estimated to result in more than 3.7 lacs deaths each year in European countries. The 'Consensus on Management of Deep Vein Thrombosis with Emphasis on NOACs (Non-Vitamin K Antagonist Oral Anticoagulants): Recommendations from Inter-Disciplinary Group of Indian Experts' position paper was developed to assist clinicians and institutions with an evidence-based approach to the diagnosis and treatment of acute deep vein thrombosis patients. Key to the evaluation of patients with suspected deep vein thrombosis is the use of the clinician's clinical evaluation with the help of pre-test probability tools as well as judicious use of objective diagnostic tests. Our hope is that we have supplemented clinicians' clinical acumen, and assisted them and their health systems in developing best practice approaches to this ever-interesting population of patients. The Deep Vein Thrombosis Consensus Working Group welcomes your inputs on how improvements might be made on this paper in the future.
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4.
[ANMCO/AIAC/SICI-GISE/SIC/SICCH Consensus document: Percutaneous left atrial appendage occlusion in patients with nonvalvular atrial fibrillation: indications, patient selection, competences, organization, and operator training].
Casu, G, Gulizia, MM, Molon, G, Mazzone, P, Audo, A, Casolo, G, Di Lorenzo, E, Portoghese, M, Pristipino, C, Ricci, RP, et al
Giornale italiano di cardiologia (2006). 2016;(7-8):594-613
Abstract
Atrial fibrillation (AF) is the most common arrhythmia and its prevalence is increasing due to the progressive aging of the population. About 20% of strokes are attributable to AF and AF patients are at 5-fold increased risk of stroke. The mainstay of treatment of AF is the prevention of thromboembolic complications with oral anticoagulation therapy. Drug treatment for many years has been based on the use of vitamin K antagonists, but recently newer and safer molecules have been introduced (dabigatran etexilate, rivaroxaban, apixaban and edoxaban). Despite these advances, many patients still do not receive adequate anticoagulation therapy because of contraindications (relative and absolute) to this treatment. Over the last decade, percutaneous closure of left atrial appendage, main site of thrombus formation during AF, proved effective in reducing thromboembolic complications, thus offering a valid medical treatment especially in patients at increased bleeding risk. The aim of this consensus document is to review the main aspects of left atrial appendage occlusion (selection and multidisciplinary assessment of patients, currently available methods and devices, requirements for centers and operators, associated therapies and follow-up modalities) having as a ground the significant evolution of techniques and the available relevant clinical data.
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5.
Prophylaxis of the antiphospholipid syndrome: a consensus report.
Alarcón-Segovia, D, Boffa, MC, Branch, W, Cervera, R, Gharavi, A, Khamashta, M, Shoenfeld, Y, Wilson, W, Roubey, R
Lupus. 2003;(7):499-503
Abstract
Hypothetical circumstances that may require prophylaxis for a potential antiphospholipid syndrome (primary prophylaxis), or in some instances when there already had been some manifestations ofthe syndrome (secondary prophylaxis), were presented to a panel of experts for their consideration on potential prophylactic intervention. These were subsequently presented to the participants in the First International Consensus on Treatment of the Antiphospholipid Syndrome. In most instances there was consensus in adding low dose aspirin, an exception being aspirin allergy when other antiaggregants could be used in nonpregnant subjects. General measures to prevent thrombosis and other vasoprotective actions should also be provided. Higher risk of fetal loss or thrombosis called for anticoagulation with coumadin in nonpregnant subjects or subcutaneous low molecular weight heparin in pregnant ones. When indicated, prophylaxis of the antiphospholipid syndrome should be provided in systemic lupus erythematosus patients who are being treated for their disease. In no instance should corticosteroids or immunosuppresants be given as prophylactic of an antiphospholipid syndrome.
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6.
Acute coronary syndrome: pharmacotherapy.
O'Connor, R, Persse, D, Zachariah, B, Ornato, JP, Swor, RA, Falk, J, Slovis, CM, Storrow, AB, Griswell, JK, ,
Prehospital emergency care. 2001;(1):58-64
Abstract
Acute coronary syndrome (ACS) refers to the spectrum of cardiac disease, from unstable angina to ST-segment-elevation myocardial infarction. In the emergency medical services (EMS) setting, ACS may be more broadly thought to include patients with chest pain or other symptoms believed to have a cardiac origin who have evidence of ischemia or acute myocardial infarction on a 12-lead electrocardiogram, or symptomatic patients with a previous cardiac event or known cardiac disease. Pharmacologic management of these patients is based on the use of three primary classes of drugs: those that affect clotting, those that establish and maintain hemodynamic control, and those that relieve pain. Many of these agents have been evaluated in large clinical trials for in-hospital use, and a number of ongoing studies are assessing their efficacy in the prehospital setting. The appropriateness of prehospital use of specific agents within each class depends on proper patient selection, the necessity of immediate intervention, ease of use in the field, expertise of EMS personnel, and cost-effectiveness of therapy. This consensus group reviewed agents from all three classes (including aspirin, GPIIb/IIIa inhibitors, unfractionated and low-molecular-weight heparins, fibrinolytics, beta-adrenergic blockers, calcium antagonists, nitrates, and morphine) for their overall indication, applicability to the prehospital setting, and current prehospital use.