73 results on '"Michela Giustozzi"'
Search Results
2. Rates and Determinants for the Use of Anticoagulation Treatment before Stroke in Patients with Known Atrial Fibrillation
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Michela Giustozzi, Giancarlo Agnelli, Silvia Quattrocchi, Monica Acciarresi, Andrea Alberti, Valeria Caso, Maria Cristina Vedovati, Michele Venti, and Maurizio Paciaroni
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atrial fibrillation ,antithrombotic treatment ,stroke ,oral anticoagulants ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
Introduction and Objective: Even though the introduction of less cumbersome anticoagulant agents has improved, the rates ofoverall anticoagulant treatment in eligible patients with atrial fibrillation (AF) remain to be defined. We aimed to assess the rates of and determinants for the use of anticoagulation treatment before stroke in patients with known AF since the introduction of direct oral anticoagulants (DOAC) in clinical practice. Methods: Consecutive patients admitted to an individual stroke unit, from September 2013 through July 2019, for acute ischemic stroke or transient ischemic attack (TIA) with known AF before the event were included in the study. Logistic regression analysis was used to identify independent predictors of the use of anticoagulant treatment. Results: Overall, 155 patients with ischemic stroke/TIA and known AF were included in this study. Among 152 patients with a CHA2DS2-VASc score >1, 43 patients were not receiving any treatment, 47 patients were receiving antiplatelet agents, and the remaining 62 patients were on oral anticoagulants. Among 34 patients on DOAC, 13 were receiving a nonlabeled reduced dose and 18 out of 34 patients on vitamin K antagonists had an INR value
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- 2020
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3. Stand on the Same Side Against Covid – 19 Clinical Management of Covid-19
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Lorenzo Corbetta, Leonardo M. Fabbri, Shiyue Li, Jing Li, Bin Cao, Jin Yang, Giancarlo Agnelli, Michela Giustozzi, Alberto Mantovani, Luigi Camporota, Semra Bilaçeroğlu, and Adrian Rendon
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Covid-19 ,Clinical Management ,LOTUS China Trial ,Lopinavir ,Ritonavir ,Wuhan ,History (General) and history of Europe ,Chemistry ,QD1-999 - Abstract
This document is the direct transcription of a Webinar organized by Prof. L. Corbetta of the University of Florence on May 29th, 2020.
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- 2020
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4. Data on the use of oral anticoagulants in nonagenarians with atrial fibrillation
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Michela Giustozzi, Maria Cristina Vedovati, Melina Verso, Luca Scrucca, Serenella Conti, Paolo Verdecchia, Giulio Bogliari, Lucia Pierpaoli, Giancarlo Agnelli, and Cecilia Becattini
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Computer applications to medicine. Medical informatics ,R858-859.7 ,Science (General) ,Q1-390 - Abstract
The data presented in this article are related to the research article entitled “Patients aged 90 years or older with atrial fibrillation treated with oral anticoagulants: A multicentre observational study” [1]. This article unveils original data of a cohort of 546 patients aged 90 years or older with non-valvular atrial fibrillation treated with oral anticoagulants. Here, we describe the time course of ischemic stroke and systemic embolism and of major bleeding according to the presence of outcome predictors and report the causes of permanent discontinuation and of death. Furthermore, we report data on the incidence of ischemic stroke and systemic embolism, of major bleeding, of permanent discontinuation and of all-cause death comparing i) oral anticoagulant naïve users vs. long-term oral anticoagulant users, ii) patients on anticoagulant therapy for less than 2 years (new users) vs. patients on anticoagulant therapy for more than 2 years. The material of this data article provides a better understanding on the use of oral anticoagulants in this fragile population and facilitates further critical analysis. Moreover, it aims at highlighting the importance of increasing knowledge in patients aged 90 years or older. These patients are often excluded from or under-represented in clinical trials and cohort studies.
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- 2019
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5. Thromboembolic Complications in Covid-19: From Clinical Scenario to Laboratory Evidence
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Alberto Palazzuoli, Michela Giustozzi, Gaetano Ruocco, Francesco Tramonte, Edoardo Gronda, and Giancarlo Agnelli
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coagulation ,thrombosis ,COVID-19 infection ,antithrombotic therapy ,Science - Abstract
SARS-Cov-2 infection, a pandemic disease since March 2020, is associated with a high percentage of cardiovascular complications mainly of a thromboembolic (TE) nature. Although clinical patterns have been described for the assessment of patients with increased risk, many TE complications occur in patients with apparently moderate risk. Notably, a recent statement from the European Society of Cardiology (ESC) atherosclerosis and vascular biology working group pointed out the key role of vascular endothelium for the recruitment of inflammatory and thrombotic pathways responsible for both disseminated intravascular coagulation and cardiovascular complications. Therefore, a better understanding of the pathophysiological process linking infection to increased TE risk is needed in order to understand the pathways of this dangerous liaison and possibly interrupt it with appropriate treatment. In this review, we describe the histological lesions and the related blood coagulation mechanisms involved in COVID-19, we define the laboratory parameters and clinical risk factors associated with TE events, and propose a prophylactic anticoagulation treatment in relation to the risk category. Finally, we highlight the concept that a solid risk assessment based on prospective multi-center data would be the challenge for a more precise risk stratification and more appropriate treatment.
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- 2021
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6. Perirectal Hematoma and Intra-Abdominal Bleeding after Stapled Hemorrhoidopexy and STARR—A Proposal for a Decision-Making Algorithm
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Georgi Popivanov, Piergiorgio Fedeli, Roberto Cirocchi, Massimo Lancia, Domenico Mascagni, Michela Giustozzi, Ivan Teodosiev, Kirien Kjossev, and Marina Konaktchieva
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stapled hemorrhoidopexy ,stapled transanal rectal resection ,perirectal hematoma ,Medicine (General) ,R5-920 - Abstract
Background and Objectives: The present study aims to assess the effectiveness and current evidence of the treatment of perirectal bleeding after stapled haemorrhoidopexy. Materials and methods: A systematic literature review was performed that combined the published and the obtained original data after a search of PubMed, Web of Science, and SCOPUS. Results: The present systematic review includes 16 articles with 37 patients. Twelve papers report perirectal and six report intra-abdominal bleeding. Stapled hemorrhoidopexy (SH) was performed in 57% of cases (3 PPH 01 and 15 PPH 03), stapled transanal rectal resection (STARR) in 13%, and for 30% information was not available. The median age was 49 years (±11.43). The sign and symptoms of perirectal bleeding were abdominal pain (43%), pelvic discomfort without rectal bleeding (36%), urinary retention (14%), and external rectal bleeding (21%). The median time to bleeding was 1 day (±1.53 postoperative days), with median hemoglobin at diagnosis 8.8 ± 1.04 g/dL. Unstable hemodynamic was reported in 19%. Computed tomography scan (CT) was the first examination in 77%. Only two cases underwent the abdominal US, but subsequently, a CT scan was also conducted. Non-operative management was performed in 38% (n = 14) with selective arteriography and percutaneous angioembolization in two cases. A surgical treatment was performed in 23 cases—transabdominal surgery (3 colostomies, 1 Hartmann’ procedure, 1 low anterior resection of the rectum, 1 bilateral ligation of internal iliac artery and 1 ligation of vessels located at the rectal wall), transanal surgery (n = 13), a perineal incision in one, and CT-guided paracoccygeal drainage in one. Conclusions: Because of the rarity and lack of experience, no uniform tactic for the treatment of perirectal hematomas exists in the literature. We propose an algorithm similar to the approach in pelvic trauma, based on two main pillars—hemodynamic stability and the finding of contrast CT.
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- 2020
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7. Incidence and risk factors for venous thromboembolism after laparoscopic surgery for colorectal cancer
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Cecilia Becattini, Fabio Rondelli, Maria C. Vedovati, Giuseppe Camporese, Michela Giustozzi, Michela Boncompagni, Salvatore Pucciarelli, Ruben Balzarotti, Enrico Mariani, Esmeralda Filippucci, Annibale Donini, and Giancarlo Agnelli
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Diseases of the blood and blood-forming organs ,RC633-647.5 - Published
- 2015
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8. Risk factors for recurrence and major bleeding in patients with cancer-associated venous thromboembolism
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Maria Cristina Vedovati, Michela Giustozzi, Andrés Munoz, Laurent Bertoletti, Alexander T. Cohen, Frederikus A. Klok, Jean M. Connors, Rupert Bauersachs, Benjamin Brenner, Mauro Campanini, Cecilia Becattini, and Giancarlo Agnelli
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Risk factors ,Internal Medicine ,Anticoagulants ,Major bleeding ,Recurrent venous thromboembolism ,Cancer - Published
- 2023
9. Practical '1-2-3-4-Day' Rule for Starting Direct Oral Anticoagulants After Ischemic Stroke With Atrial Fibrillation: Combined Hospital-Based Cohort Study
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Shunsuke Kimura, Kazunori Toyoda, Sohei Yoshimura, Kazuo Minematsu, Masahiro Yasaka, Maurizio Paciaroni, David J. Werring, Hiroshi Yamagami, Takehiko Nagao, Shinichi Yoshimura, Alexandros Polymeris, Annaelle Zietz, Stefan T. Engelter, Bernd Kallmünzer, Manuel Cappellari, Tetsuya Chiba, Takeshi Yoshimoto, Masayuki Shiozawa, Takanari Kitazono, Masatoshi Koga, Kenichi Todo, Kazumi Kimura, Yoshiki Yagita, Eisuke Furui, Ryo Itabashi, Tadashi Terasaki, Yoshiaki Shiokawa, Teruyuki Hirano, Kenji Kamiyama, Jyoji Nakagawara, Shunya Takizawa, Kazunari Homma, Satoshi Okuda, Yasushi Okada, Keisuke Tokunaga, Tomoaki Kameda, Kazuomi Kario, Yoshinari Nagakane, Yasuhiro Hasegawa, Hisanao Akiyama, Satoshi Shibuya, Hiroshi Mochizuki, Yasuhiro Ito, Takahiro Nakashima, Hideki Matsuoka, Kazuhiro Takamatsu, Kazutoshi Nishiyama, Shoichiro Sato, Shoji Arihiro, Manabu Inoue, Masahito Takagi, Kanta Tanaka, Kazuyuki Nagatsuka, Takenori Yamaguchi, Yoichiro Hashimoto, Kiyohiro Houkin, Kazuo Kitagawa, Masayasu Matsumoto, Norio Tanahashi, Yasuo Terayama, Shinichiro Uchiyama, Etsuro Mori, Yutaka Furukawa, Takeshi Kimura, Yoshiaki Kumon, Ken Nagata, Shigeru Nogawa, Tomohiro Sakamoto, Toshinori Hirai, Kohsuke Kudo, Makoto Sasaki, Shotai Kobayashi, Toshimitsu Hamasaki, Michela Giustozzi, Monica Acciarresi, Giancarlo Agnelli, Valeria Caso, Fabio Bandini, Georgios Tsivgoulis, Shadi Yaghi, Karen L. Furie, Prasanna Tadi, Cecilia Becattini, Marialuisa Zedde, Azmil H Abdul-Rahim, Kennedy R Lees, Andrea Alberti, Michele Venti, Cataldo D’Amore, Maria Giulia Mosconi, Ludovica Anna Cimini, Paolo Bovi, Monica Carletti, Alberto Rigatelli, Jukka Putaala, Liisa Tomppo, Turgut Tatlisumak, Simona Marcheselli, Alessandro Pezzini, Loris Poli, Alessandro Padovani, Vieri Vannucchi, Sung-Il Sohn, Gianni Lorenzini, Rossana Tassi, Francesca Guideri, Maurizio Acampa, Giuseppe Martini, George Ntaios, George Athanasakis, Konstantinos Makaritsis, Efstathia Karagkiozi, Konstantinos Vadikolias, Chrissoula Liantinioti, Maria Chondrogianni, Nicola Mumoli, Franco Galati, Simona Sacco, Cindy Tiseo, Francesco Corea, Walter Ageno, Marta Bellesini, Giovanna Colombo, Giorgio Silvestrelli, Alfonso Ciccone, Alessia Lanari, Umberto Scoditti, Licia Denti, Michelangelo Mancuso, Miriam Maccarrone, Leonardo Ulivi, Giovanni Orlandi, Nicola Giannini, Tiziana Tassinari, Maria Luisa De Lodovici, Christina Rueckert, Antonio Baldi, Danilo Toni, Federica Letteri, Martina Giuntini, Enrico Maria Lotti, Yuriy Flomin, Alessio Pieroni, Odysseas Kargiotis, Theodore Karapanayiotides, Serena Monaco, Mario Maimone Baronello, Laszló Csiba, Lilla Szabó, Alberto Chiti, Elisa Giorli, Massimo Del Sette, Davide Imberti, Dorjan Zabzuni, Boris Doronin, Vera Volodina, Patrik Michel, Peter Vanacker, Kristian Barlinn, Lars-Peder Pallesen, Jessica Barlinn, Dirk Deleu, Gayane Melikyan, Faisal Ibrahim, Naveed Akhtar, Vanessa Gourbali, Luca Masotti, Adrian Parry-Jones, Chris Patterson, Christopher Price, Abduelbaset Elmarimi, Anthea Parry, Arumug Nallasivam, Azlisham Mohd Nor, Bernard Esis, David Bruce, Christine Roffe, Clare Holmes, David Cohen, David Hargroves, David Mangion, Dinesh Chadha, Djamil Vahidassr, Dulka Manawadu, Elio Giallombardo, Elizabeth Warburton, Enrico Flossman, Gunaratam Gunathilagan, Harald Proschel, Hedley Emsley, Ijaz Anwar, James Okwera, Janet Putterill, Janice O’Connell, John Bamford, John Corrigan, Jon Scott, Jonathan Birns, Karen Kee, Kari Saastamoinen, Kath Pasco, Krishna Dani, Lakshmanan Sekaran, Lillian Choy, Liz Iveson, Maam Mamun, Mahmud Sajid, Martin Cooper, Matthew Burn, Matthew Smith, Michael Power, Michelle Davis, Nigel Smyth, Roland Veltkamp, Pankaj Sharma, Paul Guyler, Paul O’Mahony, Peter Wilkinson, Prabel Datta, Prasanna Aghoram, Rachel Marsh, Robert Luder, Sanjeevikumar Meenakishundaram, Santhosh Subramonian, Simon Leach, Sissi Ispoglou, Sreeman Andole, Timothy England, Aravindakshan Manoj, Frances Harrington, Habib Rehman, Jane Sword, Julie Staals, Karim Mahawish, Kirsty Harkness, Louise Shaw, Michael McCormich, Nikola Sprigg, Syed Mansoor, Vinodh Krishnamurthy, Philippe A Lyrer, Leo H Bonati, David J Seiffge, Christopher Traenka, Nils Peters, Gian Marco De Marchis, Sebastian Thilemann, Nikolaos S Avramiotis, Henrik Gensicke, Lisa Hert, Benjamin Wagner, Fabian Schaub, Louisa Meya, Joachim Fladt, Tolga Dittrich, Urs Fisch, Bruno Bonetti, Giampaolo Tomelleri, Nicola Micheletti, Cecilia Zivelonghi, Andrea Emiliani, Kosmas Macha, Gabriela Siedler, Svenja Stoll, Ruihao Wang, Bastian Volbers, Stefan Schwab, David Haupenthal, and Luise Gaßmann
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Advanced and Specialized Nursing ,acute ischemic stroke ,Time Factors ,Administration, Oral ,Anticoagulants ,Hemorrhage ,cardioembolism ,Hospitals ,United States ,Brain Ischemia ,anticoagulation ,atrial fibrillation ,stroke prevention ,Cohort Studies ,Stroke ,Treatment Outcome ,Ischemic Attack, Transient ,Atrial Fibrillation ,Humans ,Prospective Studies ,Neurology (clinical) ,Cardiology and Cardiovascular Medicine ,Ischemic Stroke - Abstract
Background: The “1-3-6-12-day rule” for starting direct oral anticoagulants (DOACs) in patients with nonvalvular atrial fibrillation after acute ischemic stroke or transient ischemic attack recommends timings that may be later than used in clinical practice. We investigated more practical optimal timing of DOAC initiation according to stroke severity. Methods: The combined data of prospective registries in Japan, Stroke Acute Management with Urgent Risk-factor Assessment and Improvement-nonvalvular atrial fibrillation (September 2011 to March 2014) and RELAXED (February 2014 to April 2016) were used. Patients were divided into transient ischemic attack and 3 stroke subgroups by the National Institutes of Health Stroke Scale score: mild (0–7), moderate (8–15), and severe (≥16). The early treatment group was defined as patients starting DOACs earlier than the median initiation day in each subgroup. Outcomes included a composite of recurrent stroke or systemic embolism, ischemic stroke, and severe bleeding within 90 days. Six European prospective registries were used for validation. Results: In the 1797 derivation cohort patients, DOACs were started at median 2 days after transient ischemic attack and 3, 4, and 5 days after mild, moderate, and severe strokes, respectively. Stroke or systemic embolism was less common in Early Group (n=785)—initiating DOACS within 1, 2, 3, and 4 days, respectively—than Late Group (n=1012) (1.9% versus 3.9%; adjusted hazard ratio, 0.50 [95% CI, 0.27–0.89]), as was ischemic stroke (1.7% versus 3.2%, 0.54 [0.27–0.999]). Major bleeding was similarly common in the 2 groups (0.8% versus 1.0%). On validation, both ischemic stroke (2.4% versus 2.2%) and intracranial hemorrhage (0.2% versus 0.6%) were similarly common in Early (n=547) and Late (n=1483) Groups defined using derivation data. Conclusions: In Japanese and European populations, early DOAC initiation within 1, 2, 3, or 4 days according to stroke severity seemed to be feasible to decrease the risk of recurrent stroke or systemic embolism and no increase in major bleeding. These findings support ongoing randomized trials to better establish the optimal timing of DOAC initiation.
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- 2022
10. Effects of Direct Oral Anticoagulants' Nonrecommended Dose in Atrial Fibrillation: A Meta-Analysis
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Maria Giulia Mosconi, Giorgio Maraziti, Maurizio Paciaroni, Michela Giustozzi, Maria Cristina Vedovati, Giulio Bogliari, Chiara Urbini, Laura Traballi, and Valeria Caso
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Direct oral anticoagulants ,Stroke ,Neurology ,Cardioembolism ,Nonvalvular atrial fibrillation ,Hemorrhage ,Neurology (clinical) ,Nonrecommended dose - Abstract
Background: The efficacy and safety profiles of nonrecommended direct oral anticoagulant (DOAC) doses in patients with nonvalvular atrial fibrillation (NVAF) are still undefined. Summary: We searched for randomized controlled trials and observational studies that compared nonrecommended versus recommended doses of DOACs, published up to December 2021. Primary study outcomes were ischemic stroke/transient ischemic attack/systemic embolism (IS/TIA/SE) and major bleeding (MB). All-cause mortality was a secondary outcome. We determined pooled odds ratios (ORs) between groups of patients with a random-effect model. Twenty-three studies with 175,801 patients were included. Nonrecommended doses were associated with a higher risk of IS/TIA/SE and all-cause mortality, but not of MB as compared to recommended doses of DOACs (OR 1.25 [95% CI: 1.14–1.38], OR 1.69 [95% CI: 1.31–2.18] and OR 1.10 [95% CI: 0.93–1.31], respectively). The nonrecommended low dose was associated with an increased risk of IS/TIA/SE and all-cause death (OR 1.21 [95% CI: 1.05–1.39] and OR 1.66 [95% CI: 1.18–2.35], respectively) but not of MB (OR 1.01 [95% CI: 0.83–1.22] as compared to recommended doses. Subgroup analysis of nonrecommended low doses of DOACs showed a nonsignificant increase in IS/TIA/SE in Asians (OR 1.17 [95% CI: 0.89–1.54] vs. non-Asian (OR 1.21 [95% CI: 1.07–1.36]). Key Messages: Compared with recommended doses, nonrecommended low doses of DOACs increase the risk of ischemic events without decreasing the risk of bleeding. For Asians, the efficacy of DOACs seemed preserved despite the nonrecommended low-dose prescription. Clinicians should carefully adhere to recommended DOAC prescription advice in managing NVAF patients.
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- 2023
11. Blood coagulation disorders in heart failure: from basic science to clinical perspectives
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ALEKSANDER SINIARSKI, ALEKSANDRA GĄSECKA, JOSIP ANDELO BOROVAC, PANTELEIMON E. PAPAKONSTANTINOU, DARIO BONGIOVANNI, HANNE EHRLINDER, MICHELA GIUSTOZZI, RUI AZEVEDO GUERREIRO, and WILLIAM A.E. PARKER
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anticoagulation ,antiplatelet ,thrombosis ,coagulation ,heart failure ,thrombus ,tailored therapy ,antithrombotic ,ddc:610 ,Cardiology and Cardiovascular Medicine - Abstract
Heart failure (HF) is a clinical syndrome divided into three subtypes, based on the left ventricular ejection fraction. Every subtype has specific clinical characteristics and concomitant diseases, substantially increasing risk of thromboembolic complications such as stroke, peripheral embolism and pulmonary embolism. Despite the annual prevalence of 1% and devastating clinical consequences, thromboembolic complications are not typically recognised as the leading problem in HF patients, representing an underappreciated clinical challenge. Although the currently available data do not support routine anticoagulation in patients with HF and sinus rhythm, initial reports suggest that such strategy might be beneficial in a subset of patients at especially high thromboembolic risk. Considering the existing evidence gap, we aimed to review the currently available data regarding coagulation disorders in acute and chronic HF based on the insight from preclinical and clinical studies, summarize the evidence regarding anticoagulation in HF in special case scenarios and outline future research directions to establish the optimal patient-tailored strategies for antiplatelet and anticoagulant therapy in HF. In summary, we highlight the top 10 pearls in the management of patients with HF and no other specific indications for oral anticoagulation therapy. Further studies are urgently needed to shed light on the pathophysiological role of platelet activation in HF and to evaluate whether antiplatelet or antithrombotic therapy could be beneficial in HF patients.
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- 2023
12. DOACs in patients with brain cancers: promising but still a long way to go
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Michela Giustozzi, Cecilia Becattini, Fausto Roila, Giancarlo Agnelli, and Mario Mandalà
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Hematology - Published
- 2023
13. ICH in primary or metastatic brain cancer patients with or without anticoagulant treatment: a systematic review and meta-analysis
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Michela Giustozzi, Giulia Proietti, Cecilia Becattini, Fausto Roila, Giancarlo Agnelli, and Mario Mandalà
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Brain Neoplasms ,Administration, Oral ,Anticoagulants ,Humans ,Hematology ,Heparin, Low-Molecular-Weight ,Intracranial Hemorrhages - Abstract
Anticoagulant treatment in patients with primary and metastatic brain cancer is a concern due to risk of intracranial hemorrhage (ICH). We performed a systematic review and meta-analysis to evaluate the risk of ICH in patients with primary or metastatic brain cancer treated with or without anticoagulants. Articles on ICH in patients with primary or metastatic brain cancer treated with or without anticoagulants published up to September 2021 were identified by searching PubMed, EMBASE, and Cochrane Library databases. The primary outcome of this analysis was ICH. Thirty studies were included. Rate of ICH was 13.0% in 1009 patients with metastatic brain cancer and 6.4% in 2353 patients with primary brain cancer (relative risk [RR], 3.26; 95% confidence interval [CI], 2.69-3.94; I2 = 92.8%). In patients with primary brain cancer, ICH occurred in 12.5% and 4.4% of patients treated with or without anticoagulants, respectively (11 studies, 659 treated and 1346 not treated patients; RR, 2.63; 95% CI, 1.48-4.67; I2 = 49.6%). In patients with metastatic brain cancer, ICH occurred in 14.7% and 15.4% (5 studies, 265 treated and 301 not treated patients; RR, 0.92; 95% CI, 0.43-1.93; I2 = 0%). ICH occurred in 8.3% of 172 treated with direct oral anticoagulants (DOACs) and in 11.7% of 278 treated with low-molecular weight heparin (LMWH) (5 studies; RR, 0.44; 95% CI, 0.25-0.79; I2 = 0%). Patients with metastatic brain cancer have a particularly high risk of ICH. Patients with primary brain cancer have an increased risk of ICH during anticoagulation. DOACs are associated with a lower risk of ICH than LMWH.
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- 2022
14. Recurrent Ischemic Stroke and Bleeding in Patients With Atrial Fibrillation Who Suffered an Acute Stroke While on Treatment With Nonvitamin K Antagonist Oral Anticoagulants: The RENO-EXTEND Study
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Maurizio Paciaroni, Valeria Caso, Giancarlo Agnelli, Maria Giulia Mosconi, Michela Giustozzi, David Julian Seiffge, Stefan T. Engelter, Philippe Lyrer, Alexandros A. Polymeris, Lilian Kriemler, Annaelle Zietz, Jukka Putaala, Daniel Strbian, Liisa Tomppo, Patrik Michel, Davide Strambo, Alexander Salerno, Suzette Remillard, Manuela Buehrer, Odessa Bavaud, Peter Vanacker, Susanna Zuurbier, Laetitia Yperzeele, Caroline M.J. Loos, Manuel Cappellari, Andrea Emiliani, Marialuisa Zedde, Azmil Abdul-Rahim, Jesse Dawson, Robert Cronshaw, Erika Schirinzi, Massimo Del Sette, Christoph Stretz, Narendra Kala, Michael Reznik, Ashley Schomer, Brian Mac Grory, Mahesh Jayaraman, Ryan McTaggart, Shadi Yaghi, Karen L. Furie, Luca Masotti, Elisa Grifoni, Danilo Toni, Angela Risitano, Anne Falcou, Luca Petraglia, Enrico Maria Lotti, Marina Padroni, Lucia Pavolucci, Piergiorgio Lochner, Giorgio Silvestrelli, Alfonso Ciccone, Andrea Alberti, Michele Venti, Laura Traballi, Chiara Urbini, Odysseas Kargiotis, Alessandro Rocco, Marina Diomedi, Simona Marcheselli, Pietro Caliandro, Aurelia Zauli, Giuseppe Reale, Kateryna Antonenko, Eugenia Rota, Tiziana Tassinari, Valentina Saia, Francesco Palmerini, Paolo Aridon, Valentina Arnao, Serena Monaco, Salvatore Cottone, Antonio Baldi, Cataldo D’Amore, Walter Ageno, Samuela Pegoraro, George Ntaios, Dimitrios Sagris, Sotirios Giannopoulos, Maria Kosmidou, Evangelos Ntais, Michele Romoli, Leonardo Pantoni, Silvia Rosa, Pierluigi Bertora, Alberto Chiti, Isabella Canavero, Carlo Emanuele Saggese, Maurizio Plocco, Elisa Giorli, Lina Palaiodimou, Eleni Bakola, Georgios Tsivgoulis, Fabio Bandini, Antonio Gasparro, Valeria Terruso, Marina Mannino, Alessandro Pezzini, Raffaele Ornello, Simona Sacco, Nemanja Popovic, Umberto Scoditti, Antonio Genovese, Licia Denti, Yuriy Flomin, Michelangelo Mancuso, Elena Ferrari, Maria Chiara Caselli, Leonardo Ulivi, Nicola Giannini, Gian Marco De Marchis, Paciaroni, Maurizio, Caso, Valeria, Agnelli, Giancarlo, Mosconi, Maria Giulia, Giustozzi, Michela, Seiffge, David Julian, Engelter, Stefan T, Lyrer, Philippe, Polymeris, Alexandros A, Kriemler, Lilian, Zietz, Annaelle, Putaala, Jukka, Strbian, Daniel, Tomppo, Liisa, Michel, Patrik, Strambo, Davide, Salerno, Alexander, Remillard, Suzette, Buehrer, Manuela, Bavaud, Odessa, Vanacker, Peter, Zuurbier, Susanna, Yperzeele, Laetitia, Loos, Caroline M J, Cappellari, Manuel, Emiliani, Andrea, Zedde, Marialuisa, Abdul-Rahim, Azmil, Dawson, Jesse, Cronshaw, Robert, Schirinzi, Erika, Del Sette, Massimo, Stretz, Christoph, Kala, Narendra, Reznik, Michael, Schomer, Ashley, Grory, Brian Mac, Jayaraman, Mahesh, McTaggart, Ryan, Yaghi, Shadi, Furie, Karen L, Masotti, Luca, Grifoni, Elisa, Toni, Danilo, Risitano, Angela, Falcou, Anne, Petraglia, Luca, Lotti, Enrico Maria, Padroni, Marina, Pavolucci, Lucia, Lochner, Piergiorgio, Silvestrelli, Giorgio, Ciccone, Alfonso, Alberti, Andrea, Venti, Michele, Traballi, Laura, Urbini, Chiara, Kargiotis, Odyssea, Rocco, Alessandro, Diomedi, Marina, Marcheselli, Simona, Caliandro, Pietro, Zauli, Aurelia, Reale, Giuseppe, Antonenko, Kateryna, Rota, Eugenia, Tassinari, Tiziana, Saia, Valentina, Palmerini, Francesco, Aridon, Paolo, Arnao, Valentina, Monaco, Serena, Cottone, Salvatore, Baldi, Antonio, D'Amore, Cataldo, Ageno, Walter, Pegoraro, Samuela, Ntaios, George, Sagris, Dimitrio, Giannopoulos, Sotirio, Kosmidou, Maria, Ntais, Evangelo, Romoli, Michele, Pantoni, Leonardo, Rosa, Silvia, Bertora, Pierluigi, Chiti, Alberto, Canavero, Isabella, Saggese, Carlo Emanuele, Plocco, Maurizio, Giorli, Elisa, Palaiodimou, Lina, Bakola, Eleni, Tsivgoulis, Georgio, Bandini, Fabio, Gasparro, Antonio, Terruso, Valeria, Mannino, Marina, Pezzini, Alessandro, Ornello, Raffaele, Sacco, Simona, Popovic, Nemanja, Scoditti, Umberto, Genovese, Antonio, Denti, Licia, Flomin, Yuriy, Mancuso, Michelangelo, Ferrari, Elena, Caselli, Maria Chiara, Ulivi, Leonardo, Giannini, Nicola, De Marchis, Gian Marco, and Neurology
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Oral ,Advanced and Specialized Nursing ,hypertension ,recurrence ,anticoagulant ,Administration, Oral ,Anticoagulants ,Hemorrhage ,Settore MED/26 ,Brain Ischemia ,Stroke ,Risk Factors ,Administration ,Atrial Fibrillation ,Humans ,Settore MED/26 - Neurologia ,Human medicine ,Neurology (clinical) ,Prospective Studies ,Cardiology and Cardiovascular Medicine ,atrial fibrillation ,ischemic stroke ,Ischemic Stroke - Abstract
Background: In patients with atrial fibrillation who suffered an ischemic stroke while on treatment with nonvitamin K antagonist oral anticoagulants, rates and determinants of recurrent ischemic events and major bleedings remain uncertain. Methods: This prospective multicenter observational study aimed to estimate the rates of ischemic and bleeding events and their determinants in the follow-up of consecutive patients with atrial fibrillation who suffered an acute cerebrovascular ischemic event while on nonvitamin K antagonist oral anticoagulant treatment. Afterwards, we compared the estimated risks of ischemic and bleeding events between the patients in whom anticoagulant therapy was changed to those who continued the original treatment. Results: After a mean follow-up time of 15.0±10.9 months, 192 out of 1240 patients (15.5%) had 207 ischemic or bleeding events corresponding to an annual rate of 13.4%. Among the events, 111 were ischemic strokes, 15 systemic embolisms, 24 intracranial bleedings, and 57 major extracranial bleedings. Predictive factors of recurrent ischemic events (strokes and systemic embolisms) included CHA 2 DS 2 -VASc score after the index event (odds ratio [OR], 1.2 [95% CI, 1.0–1.3] for each point increase; P =0.05) and hypertension (OR, 2.3 [95% CI, 1.0–5.1]; P =0.04). Predictive factors of bleeding events (intracranial and major extracranial bleedings) included age (OR, 1.1 [95% CI, 1.0–1.2] for each year increase; P =0.002), history of major bleeding (OR, 6.9 [95% CI, 3.4–14.2]; P =0.0001) and the concomitant administration of an antiplatelet agent (OR, 2.8 [95% CI, 1.4–5.5]; P =0.003). Rates of ischemic and bleeding events were no different in patients who changed or not changed the original nonvitamin K antagonist oral anticoagulants treatment (OR, 1.2 [95% CI, 0.8–1.7]). Conclusions: Patients suffering a stroke despite being on nonvitamin K antagonist oral anticoagulant therapy are at high risk of recurrent ischemic stroke and bleeding. In these patients, further research is needed to improve secondary prevention by investigating the mechanisms of recurrent ischemic stroke and bleeding.
- Published
- 2022
15. Risk Factors for Intracerebral Hemorrhage in Patients With Atrial Fibrillation on Non–Vitamin K Antagonist Oral Anticoagulants for Stroke Prevention
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Panagiotis Halvatsiotis, Giuseppe Reale, Jennifer A. Frontera, Giuseppe Martini, S. Pegoraro, Leonardo Pantoni, Aristeidis H. Katsanos, Piergiorgio Lochner, Daniel Strbian, Giorgia Zepponi, Valentina Saia, Karen L. Furie, Giancarlo Agnelli, Elisa Giorli, Erica Scher, Lina Palaiodimou, Valentina Arnao, Giorgio Silvestrelli, Simona Marcheselli, Letizia Riva, Andrea Zini, Angela Risitano, Tiziana Tassinari, Carlo Emanuele Saggese, Francesco Palmerini, Erika Schirinzi, Michael E. Reznik, Marina Mannino, Jukka Putaala, Maria Kosmidou, Michela Giustozzi, Cesare Porta, Maurizio Paciaroni, Marina Padroni, Loris Poli, Maria Cristina Vedovati, Danilo Toni, Manuel Cappellari, Alessandro Rocco, Alessandro Pezzini, Ashkan Shoamanesh, Stefano Forlivesi, Serena Monaco, Raffaele Ornello, Simona Sacco, Silvia Rosa, Shadi Yaghi, Valeria Terruso, Andrea Alberti, Francesco Corea, Elena Ferrari, Christoph Stretz, Marialuisa Zedde, Monica Acciarresi, Cataldo D'Amore, Kateryna Antonenko, Nemanja Popovic, Francesca Guideri, Evangelos Ntais, Boris Doronin, Luca Masotti, Filippo Angelini, Giovanni Orlandi, Licia Denti, Nicola Mumoli, Sotirios Giannopoulos, Elisabetta Toso, Maria Giulia Mosconi, Paolo Aridon, Aurelia Zauli, Giuseppe Micieli, Azmil H. Abdul-Rahim, Laura Brancaleoni, Marina Diomedi, Elisa Grifoni, Georgios Tsivgoulis, Maurizio Acampa, Michele Venti, Walter Ageno, Pietro Caliandro, Alfonso Ciccone, Isabella Canavero, Laura Franco, George Ntaios, Fabio Bandini, Vera Volodina, Pierluigi Bertora, Dimitrios Sagris, Antonio Baldi, Michele Romoli, Hanne Sallinen, Michelangelo Mancuso, Yuriy Flomin, Rossana Tassi, Valeria Caso, Massimo Del Sette, Enrico Maria Lotti, Antonio Gasparro, Alberto Chiti, Jesse Dawson, Brian Mac Grory, Alberto Rigatelli, Paciaroni, Maurizio, Agnelli, Giancarlo, Giustozzi, Michela, Caso, Valeria, Toso, Elisabetta, Angelini, Filippo, Canavero, Isabella, Micieli, Giuseppe, Antonenko, Kateryna, Rocco, Alessandro, Diomedi, Marina, Katsanos, Aristeidis H, Shoamanesh, Ashkan, Giannopoulos, Sotirio, Ageno, Walter, Pegoraro, Samuela, Putaala, Jukka, Strbian, Daniel, Sallinen, Hanne, Mac Grory, Brian C, Furie, Karen L, Stretz, Christoph, Reznik, Michael E, Alberti, Andrea, Venti, Michele, Mosconi, Maria Giulia, Vedovati, Maria Cristina, Franco, Laura, Zepponi, Giorgia, Romoli, Michele, Zini, Andrea, Brancaleoni, Laura, Riva, Letizia, Silvestrelli, Giorgio, Ciccone, Alfonso, Zedde, Maria Luisa, Giorli, Elisa, Kosmidou, Maria, Ntais, Evangelo, Palaiodimou, Lina, Halvatsiotis, Panagioti, Tassinari, Tiziana, Saia, Valentina, Ornello, Raffaele, Sacco, Simona, Bandini, Fabio, Mancuso, Michelangelo, Orlandi, Giovanni, Ferrari, Elena, Pezzini, Alessandro, Poli, Lori, Cappellari, Manuel, Forlivesi, Stefano, Rigatelli, Alberto, Yaghi, Shadi, Scher, Erica, Frontera, Jennifer A, Masotti, Luca, Grifoni, Elisa, Caliandro, Pietro, Zauli, Aurelia, Reale, Giuseppe, Marcheselli, Simona, Gasparro, Antonio, Terruso, Valeria, Arnao, Valentina, Aridon, Paolo, Abdul-Rahim, Azmil H, Dawson, Jesse, Saggese, Carlo Emanuele, Palmerini, Francesco, Doronin, Bori, Volodina, Vera, Toni, Danilo, Risitano, Angela, Schirinzi, Erika, Del Sette, Massimo, Lochner, Piergiorgio, Monaco, Serena, Mannino, Marina, Tassi, Rossana, Guideri, Francesca, Acampa, Maurizio, Martini, Giuseppe, Lotti, Enrico Maria, Padroni, Marina, Pantoni, Leonardo, Rosa, Silvia, Bertora, Pierluigi, Ntaios, George, Sagris, Dimitrio, Baldi, Antonio, D'Amore, Cataldo, Mumoli, Nicola, Porta, Cesare, Denti, Licia, Chiti, Alberto, Corea, Francesco, Acciarresi, Monica, Flomin, Yuriy, Popovic, Nemanja, and Tsivgoulis, Georgios
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Male ,Administration, Oral ,030204 cardiovascular system & hematology ,Settore MED/11 ,0302 clinical medicine ,80 and over ,risk factors ,Medicine ,atrial fibrillation ,Prospective Studies ,Aged, 80 and over ,cerebral hemorrhage ,logistic models ,white matter ,Aged ,Antithrombins ,Atrial Fibrillation ,Case-Control Studies ,Cerebral Hemorrhage ,Female ,Humans ,Middle Aged ,Risk Factors ,Stroke ,Atrial fibrillation ,Vitamin K antagonist ,3. Good health ,Administration ,Settore MED/26 - Neurologia ,Cardiology and Cardiovascular Medicine ,medicine.drug ,Oral ,medicine.medical_specialty ,medicine.drug_class ,Settore MED/26 ,Lower risk ,03 medical and health sciences ,Internal medicine ,cardiovascular diseases ,logistic model ,Advanced and Specialized Nursing ,Intracerebral hemorrhage ,business.industry ,Warfarin ,medicine.disease ,Clinical trial ,Concomitant ,Heart failure ,Neurology (clinical) ,business ,030217 neurology & neurosurgery - Abstract
Background and Purpose: Clinical trials on stroke prevention in patients with atrial fibrillation have consistently shown clinical benefit from either warfarin or non–vitamin K antagonist oral anticoagulants (NOACs). NOAC-treated patients have consistently reported to be at lower risk for intracerebral hemorrhage (ICH) than warfarin-treated patients. The aims of this prospective, multicenter, multinational, unmatched, case-control study were (1) to investigate for risk factors that could predict ICH occurring in patients with atrial fibrillation during NOAC treatment and (2) to evaluate the role of CHA 2 DS 2 -VASc and HAS-BLED scores in the same setting. Methods: Cases were consecutive patients with atrial fibrillation who had ICH during NOAC treatment. Controls were consecutive patients with atrial fibrillation who did not have ICH during NOAC treatment. As within the CHA 2 DS 2 -VASc and HAS-BLED scores there are some risk factors in common, several multivariable logistic regression models were performed to identify independent prespecified predictors for ICH events. Results: Four hundred nineteen cases (mean age, 78.8±8.1 years) and 1526 controls (mean age, 76.0±10.3 years) were included in the study. From the different models performed, independent predictors of ICH were increasing age, concomitant use of antiplatelet agents, active malignancy, high risk of fall, hyperlipidemia, low clearance of creatinine, peripheral artery disease, and white matter changes. Low doses of NOACs (given according to label or not) and congestive heart failure were inversely associated with the risk of ICH. HAS-BLED and CHA 2 DS 2 -VASc scores performed poorly in predicting ICH with areas under the curves of 0.496 (95% CI, 0.468–0.525) and 0.530 (95% CI, 0.500–0.560), respectively. Conclusions: Several risk factors were associated to ICH in patients treated with NOACs for stroke prevention but not HAS-BLED and CHA 2 DS 2 -VASc scores.
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- 2021
16. Lower dose direct oral anticoagulants and improved survival: A combined analysis in patients with established atherosclerosis
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Martina Briani, Pierpaolo Lupo, Gianluca Bonitta, Hussam Ali, Cristina Balla, Francesco Furlanello, Riccardo Cappato, Mauro Chiarito, Michela Giustozzi, Giulio G. Stefanini, Letizia Riva, Corrado Lodigiani, and Riccardo Cappato
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medicine.medical_specialty ,Acute coronary syndrome ,Administration, Oral ,Hemorrhage ,030204 cardiovascular system & hematology ,Gastroenterology ,Dabigatran ,Coronary artery disease ,03 medical and health sciences ,chemistry.chemical_compound ,0302 clinical medicine ,Edoxaban ,Internal medicine ,Atrial Fibrillation ,Antithrombotic ,Internal Medicine ,medicine ,Humans ,030212 general & internal medicine ,Direct oral anticoagulantsAtherosclerosisCoronary artery diseaseAtrial fibrillation ,Rivaroxaban ,business.industry ,Warfarin ,Anticoagulants ,Atrial fibrillation ,Atherosclerosis ,medicine.disease ,Stroke ,chemistry ,business ,medicine.drug - Abstract
Background: Antithrombotic/anticoagulation effects of direct oral anticoagulants (DOACs) are dose-dependent. However, recent observations suggest that administering lower dose DOACs may better protect against all-cause mortality. We investigated whether, in patients with established atherosclerosis, DOAC dose selection would affect the risk of all-cause mortality. Methods: We performed a structured literature research for controlled trials allowing random assignment to a lower dose DOAC, a higher dose DOAC, or control therapy in patients with established atherosclerosis. Pooled risk ratios (RRs) of all-cause mortality in lower and higher dose DOACs versus control therapy were estimated using a random-effect model. Results: Atherosclerosis manifested as acute coronary syndrome (n=17,220), stable coronary (CAD) and/or peripheral artery disease (PAD) (n=27,395) or CAD associated with atrial fibrillation (n=4,510). Antithrombotic doses of rivaroxaban (2.5 mg or 5.0 mg BID) or dabigatran (50 mg, 75 mg, 110 mg, or 150 mg, BID) were tested in three trials versus single or dual antiplatelet control therapy, whereas anticoagulation doses of edoxaban (30 mg or 60 OD) were tested versus warfarin in one trial. Compared to control, patients receiving lower dose (RR 0.80, 95% CI 0.73-0.89, pI²=0%), but not those receiving higher dose DOACs (RR 0.95, 95% CI 0.87-1.05, p=0.3074, I²=0%), had a significant reduction of all-cause mortality. Benefit from lower dose DOACs remained after sensitivity analysis or direct comparison with higher dose DOACs (RR 0.84, 95% CI 0.76-0.93, p=0.0009, I²=0%). Conclusions: Within antithrombotic/anticoagulation regimens of DOAC administration, selection of lower dose appears to protect from all-cause mortality in patients with established atherosclerosis.
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- 2021
17. Shock and Diffuse ST-elevation in a Patient with Coronavirus Disease-2019 Disease
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Maria Cristina Vedovati, Cecilia Becattini, Michela Giustozzi, and Serenella Conti
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medicine.medical_specialty ,medicine.medical_treatment ,030204 cardiovascular system & hematology ,Pericardial effusion ,030218 nuclear medicine & medical imaging ,Coronary artery disease ,Sepsis ,03 medical and health sciences ,0302 clinical medicine ,Internal medicine ,medicine ,case report ,Radiology, Nuclear Medicine and imaging ,Myocardial infarction ,Cardiac catheterization ,Lung ,business.industry ,coronavirus disease-19 ,medicine.disease ,Cardiovascular disease ,medicine.anatomical_structure ,Respiratory failure ,Pericardiocentesis ,Cardiology ,Cardiology and Cardiovascular Medicine ,business ,severe acute respiratory syndrome coronavirus 2 - Abstract
The infection by the novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is associated with significant cardiovascular morbidity and mortality. Cardiac events require prompt diagnosis and management, also in the SARS-CoV-2 era. A 58-year-old male, heavy smoker and with known SARS-CoV-2 infection, abruptly developed severe hypotension and asthenia. At patients' home, emergency physicians found hemodynamic compromise with diffuse ST-elevation at electrocardiography. The patient was rapidly moved to the cardiac catheterization laboratory, and any contact with other health-care workers was avoided. Coronary angiography excluded coronary artery disease. At admission to the coronavirus disease-2019 unit, an increase in inflammatory markers and liver enzymes with normal troponin levels were observed. Bedside lung ultrasonography showed interstitial syndrome and bilateral pleural effusion, whereas echocardiography showed large and diffuse pericardial effusion with a swinging heart. The hemodynamic status improved after gentle fluid therapy such suggesting potential concomitant sepsis and pericardiocentesis was not performed. At this time, a computed tomography scan showed a widespread neoplasm in the right lung involving the subclavian artery and vein and the thoracic lymph nodes. The histology confirmed the diagnosis of a locally advanced pulmonary adenocarcinoma. One week after admission, the patient died for worsening respiratory failure. Not delayed primary PCI remains the standard of care for patients with suspected ST-elevation myocardial infarction (STEMI) in the SARS-CoV-2 era. A diagnostic deepening for potential STEMI-mimicker (known to be associated with SARS-CoV-2 infection and to patients' comorbidities) should be considered, and a multidisciplinary approach is needed in these patients.
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- 2021
18. Concomitant Use of Direct Oral Anticoagulants and Antiepileptic Drugs: A Prospective Cohort Study in Patients with Atrial Fibrillation
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Maria Cristina Vedovati, Giancarlo Agnelli, Cecilia Becattini, Matteo Mazzetti, Maurizio Paciaroni, and Michela Giustozzi
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Topiramate ,Oral ,Male ,medicine.medical_specialty ,Administration, Oral ,Hemorrhage ,030204 cardiovascular system & hematology ,030226 pharmacology & pharmacy ,Brain Ischemia ,Cohort Studies ,03 medical and health sciences ,0302 clinical medicine ,Internal medicine ,Thromboembolism ,Atrial Fibrillation ,medicine ,80 and over ,Humans ,Pharmacology (medical) ,Original Research Article ,Prospective Studies ,Prospective cohort study ,Stroke ,Aged ,Aged, 80 and over ,business.industry ,Ischemic Attack ,Transient ,Incidence ,Anticoagulants ,Atrial fibrillation ,General Medicine ,Carbamazepine ,Middle Aged ,medicine.disease ,Ischemic Attack, Transient ,Cohort ,Administration ,Anticonvulsants ,Female ,Levetiracetam ,business ,medicine.drug ,Cohort study - Abstract
Background European guidelines do not recommend the use of carbamazepine, levetiracetam, phenobarbital, phenytoin, topiramate and valproic acid in patients taking direct oral anticoagulants (DOACs). Little is known regarding the clinical relevance of the interaction between DOACs and antiepileptic drugs. Objectives To evaluate the incidence of thromboembolic and bleeding events in patients with non-valvular atrial fibrillation (AF) concurrently treated with DOACs and antiepileptic drugs. Methods This is a prospective multicentre cohort study of patients with non-valvular AF concurrently treated with DOACs and antiepileptic drugs. The primary outcome was ischaemic stroke/transient ischaemic attack (TIA)/systemic embolism (SE). Secondary outcome was major bleeding (MB). Incidence rates (% patient-year) were evaluated for the study outcomes. Results Overall, 91 patients were included. Mean age was 78 ± 9.5 years, 49.5% were female. Mean CHA2DS2-VASc score was 4.76 ± 1.59 and mean HAS-BLED was 2.67 ± 1.26. Overall, 41, 20, 11, 10 and 9 out of 91 patients were treated with levetiracetam, valproic acid, phenobarbital, carbamazepine and other antiepileptic drugs, respectively. During a median follow-up of 17.5 ± 14.5 months, stroke/TIA/SE occurred in 9 patients (5.7% patient-year) and MB in 3 patients (1.9% patient-year). Ischaemic stroke was fatal in 3 patients (1.9% patient-year) and MB in one patient (0.6% patient-year). Conclusion In this cohort, patients with non-valvular AF treated with DOACs and antiepileptic drugs appear to have a relatively high rate of thromboembolic events.
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- 2020
19. The Effects of Leukocyte-Poor Platelet Rich Plasma for the Symptomatic Knee Osteoarthritis: A Single Centre Experience
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Andrea Farneti, Michela Giustozzi, Marta Micheli, Enrico Sebastiani, Michele Berloco, Luca Pennacchi, Carlo Farneti, and Fabio Perrone
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General Medicine - Published
- 2020
20. Unmet clinical needs in the prevention and treatment of cancer-associated venous thromboembolism
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Michela Giustozzi, Laura Franco, Giancarlo Agnelli, and Melina Verso
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Treatment ,Anticoagulation ,New oral anticoagulants ,Prophylaxis ,Cancer ,Venous thromboembolism ,Cardiology and Cardiovascular Medicine - Abstract
Venous thromboembolism (VTE), which includes pulmonary embolism and deep vein thrombosis, is a leading cause of morbidity and mortality in patients with cancer. Based on accumulating evidence, the prophylaxis and treatment of cancer-associated VTE have been changed over the years. Recently, the introduction in clinical practice of the direct oral anticoagulants has radically changed the management of cancer-associated VTE for their easier use and non-inferior efficacy-safety profile compared to low-molecular-weight heparins. However, the heterogeneity of the cancer population in terms of site, type and stage of the malignancy, the presence of comorbidities, and the variability in cancer treatment and prognosis represent major challenges in the management of VTE in patients with cancer. In the present review, we will discuss clinical questions that represent unsolved issues in the setting of cancer-associated VTE and provide an overview on recent evidence on this topic: primary prophylaxis in ambulatory cancer patients treated with chemotherapy and in cancer surgical patients, need of long-term anticoagulation in cancer patients, treatment of VTE in cancer patients at increased bleeding risk and in special categories such as incidental VTE, splanchnic vein thrombosis or catheter-related thrombosis.
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- 2022
21. Management of Anticoagulant Treatment and Anticoagulation-Related Complications in Nonagenarians
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Michela Giustozzi, Lana A Castellucci, and Geoffrey D. Barnes
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Male ,anticoagulants ,medicine.medical_specialty ,medicine.drug_class ,Clinical Decision-Making ,venous thromboembolism ,Population ,Hemorrhage ,oldest age ,Risk Assessment ,Cost of Illness ,Antithrombotic ,medicine ,Humans ,atrial fibrillation ,Intensive care medicine ,education ,Blood Coagulation ,Aged ,Aged, 80 and over ,education.field_of_study ,business.industry ,Incidence ,Anticoagulant ,Atrial fibrillation ,Hematology ,medicine.disease ,Clinical trial ,Anticoagulant therapy ,nonagenarians ,Female ,Anticoagulant Agent ,business ,Intracranial Hemorrhages ,Venous thromboembolism ,Factor Xa Inhibitors - Abstract
Given the aging population, the burden of age-dependent diseases is growing. Despite this, elderly patients are often underrepresented in clinical trials and little data are available on current anticoagulant management and outcomes in this unique population, especially those aged 90 years or older. There is uncertainty, and a fear of “doing harm,” that often leads to de-prescription of antithrombotic agents in nonagenarian patients. Decision-making concerning the use of anticoagulant treatment needs to balance the risk of thrombotic events against the risk of major bleeding, especially intracranial hemorrhage. In this perspective, the development of direct oral anticoagulants (DOACs), acting as direct and selective inhibitors of a specific step or enzyme of the coagulation cascade, has dramatically changed oral anticoagulant treatment. In fact, given the lower incidence of intracranial hemorrhage, the favorable overall efficacy and safety, and the lack of routine monitoring, DOACs are the currently recommended anticoagulant agents for the treatment of both atrial fibrillation and venous thromboembolism even in very elderly patients. However, given the limited data available on the management of anticoagulation in nonagenarians, a few unanswered questions remain. In this review, we focused on recent evidence for anticoagulant treatment in atrial fibrillation and venous thromboembolism along with management of anticoagulation-related bleeding in nonagenarians.
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- 2020
22. Timing of initiation of oral anticoagulants in patients with acute ischemic stroke and atrial fibrillation comparing posterior and anterior circulation strokes
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Michele Venti, Walter Ageno, Alfonso Ciccone, Luana Gentile, Vanessa Gourbali, Antonio Baldi, Elisa Grifoni, László Csiba, Cataldo D'Amore, Prasanna Tadi, Yuriy Flomin, Rossana Tassi, Sung Il Sohn, Bruno Bonetti, Patrik Michel, Erika Schirinzi, Alessandro Padovani, Cindy Tiseo, Maria Luisa De Lodovici, Odysseas Kargiotis, Konstantinos Vadikolias, Shadi Yaghi, Maurizio Paciaroni, Georgios Tsivgoulis, Enrico Maria Lotti, Manuel Cappellari, Lilla Szabó, Ashraf Eskandari, Federica Letteri, Leonardo Ulivi, Chrissoula Liantinioti, Valeria Caso, Lina Palaiodimou, Dirk Deleu, Jesse Dawson, Licia Denti, Konstantinos Makaritsis, Gianni Lorenzini, Marina Mannino, Monica Acciarresi, Miriam Maccarrone, Nicola Mumoli, Marta Bellesini, Simona Sacco, George Athanasakis, Umberto Scoditti, Maurizio Acampa, Giuseppe Martini, Brian Mac Grory, Alberto Rigatelli, Kristian Barlinn, Vieri Vannucchi, Serena Monaco, Efstathia Karagkiozi, Elisa Giorli, Francesca Guideri, Martina Giuntini, Dorjan Zabzuni, Davide Imberti, Giorgio Silvestrelli, Luca Masotti, Loris Poli, Karen L. Furie, Alessio Pieroni, Marialuisa Zedde, Franco Galati, Andrea Alberti, Giancarlo Agnelli, Jessica Barlinn, Turgut Tatlisumak, Maria Chiara Caselli, Boris Doronin, Liisa Tomppo, Kennedy R. Lees, Mario Maimone Baronello, Maria Giulia Mosconi, Jukka Putaala, Tiziana Tassinari, Azmil H. Abdul-Rahim, Peter Vanacker, Christina Rueckert, Valentina Bogini, Alessandro Pezzini, Francesco Corea, Giovanni Orlandi, Simona Marcheselli, Michela Giustozzi, Theodore Karapanayiotides, Michelangelo Mancuso, George Ntaios, Fabio Bandini, Vera Volodina, Nicola Giannini, Cesare Porta, Danilo Toni, Alberto Chiti, and Massimo Del Sette
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Severe bleeding ,medicine.medical_specialty ,Stroke recurrence ,Infarction ,stroke recurrence ,030204 cardiovascular system & hematology ,03 medical and health sciences ,0302 clinical medicine ,Original Research Articles ,Internal medicine ,Ischaemic stroke ,Acute stroke ,Medicine ,atrial fibrillation ,In patient ,Acute ischemic stroke ,business.industry ,Atrial fibrillation ,medicine.disease ,Cardiology ,Human medicine ,Neurology (clinical) ,Cardiology and Cardiovascular Medicine ,business ,030217 neurology & neurosurgery - Abstract
Introduction The aim of this study in patients with acute posterior ischaemic stroke (PS) and atrial fibrillation (AF) was to evaluate (1) the risks of recurrent ischaemic event and severe bleeding and (2) these risks in relation with oral anticoagulant therapy (OAT) and its timing. Materials and Methods Patients with PS were prospectively included; the outcome events of these patients were compared with those of patients with anterior stroke (AS) which were taken from previous registries. The primary outcome was the composite of stroke recurrence, transient ischaemic attack, symptomatic systemic embolism, symptomatic cerebral bleeding and major extracranial bleeding occurring within 90 days from acute stroke. Results A total of 2470 patients were available for the analysis: 473 (19.1%) with PS and 1997 (80.9%) with AS. Over 90 days, 213 (8.6%) primary outcome events were recorded: 175 (8.7%) in patients with AS and 38 (8.0%) in those with PS. In patients who initiated OAT within 2 days, the primary outcome occurred in 5 out of 95 patients (5.3%) with PS compared to 21 out of 373 patients (4.3%) with AS (OR 1.07; 95% CI 0.39–2.94). In patients who initiated OAT between days 3 and 7, the primary outcome occurred in 3 out of 103 patients (2.9%) with PS compared to 26 out of 490 patients (5.3%) with AS (OR 0.54; 95% CI 0.16–1.80). Discussion our findings suggest that, when deciding the time to initiate oral anticoagulation, the location of stroke, either anterior or posterior, does not predict the risk of outcome events. Conclusions Patients with PS or AS and AF appear to have similar risks of ischaemic or haemorrhagic events at 90 days with no difference concerning the timing of initiation of OAT.
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- 2020
23. Total parenteral nutrition-induced Wernicke’s encephalopathy after oncologic gastrointestinal surgery
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Georgi Popivanov, Michela Giustozzi, Richard Justin Davies, Roberto Cirocchi, Piergiorgio Fedeli, and Paolo Bruzzone
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Vitamin ,medicine.medical_specialty ,Ataxia ,Encephalopathy ,Case Report ,parenteral nutrition ,Disease ,Wernicke's encephalopathy ,03 medical and health sciences ,chemistry.chemical_compound ,0302 clinical medicine ,medicine ,business.industry ,malpractice ,General Medicine ,medicine.disease ,Colorectal surgery ,Surgery ,Parenteral nutrition ,wernicke’s encephalopathy ,chemistry ,030220 oncology & carcinogenesis ,Inadequate vitamin intake ,Medicine ,030211 gastroenterology & hepatology ,medicine.symptom ,business - Abstract
Carl Wernicke described the disease bearing his name in 1881 and reported three cases characterized by the presence of mental confusion, ataxia, and ophthalmoplegia. Wernicke’s disease is mainly observed in alcoholic patients, due to decreased vitamin intake as a consequence of an unbalanced diet, and a reduction of absorption due to the effects of alcohol. Likewise, inadequate vitamin intake is prevalent in older patients. Wernicke’s encephalopathy due to inappropriate total parenteral nutrition (TPN) occurs infrequently; recently, there is an increase in the literature concerning Wernicke’s encephalopathy in patients after general and bariatric surgeries. We present two cases of Wernicke’s encephalopathy after oncologic gastrointestinal surgery by failure to administer vitamin B1 during TPN; to our knowledge, these are the first two cases of Wernicke’s encephalopathy after colorectal surgery for cancer. In our opinion, timely diagnosis and treatment are mandatory to avoid nonfunctional recovery and consequent malpractice legal actions as well as an increase in the health-care costs correlated with the prolonged hospital stay and with the nonfunctional recovery.
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- 2020
24. Safety of catheter ablation of atrial fibrillation in cancer survivors
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Guido De Ambroggi, Gianpaolo Reboldi, Giancarlo Agnelli, Cristina Balla, Hussam Ali, Sara Foresti, Michela Giustozzi, Pier Paolo Lupo, and Riccardo Cappato
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medicine.medical_specialty ,medicine.medical_treatment ,Population ,Catheter ablation ,030204 cardiovascular system & hematology ,NO ,Anticoagulation ,03 medical and health sciences ,0302 clinical medicine ,Primary outcome ,Cancer Survivors ,Neoplasms ,Physiology (medical) ,Internal medicine ,Atrial Fibrillation ,Humans ,Medicine ,In patient ,030212 general & internal medicine ,education ,Cancer ,education.field_of_study ,business.industry ,Genitourinary system ,Bleeding ,Anticoagulants ,Atrial fibrillation ,Odds ratio ,medicine.disease ,Treatment Outcome ,Catheter Ablation ,Cardiology and Cardiovascular Medicine ,business ,Af ablation - Abstract
In patients with cancer, the safety of catheter ablation for non-valvular atrial fibrillation (AF) has not been evaluated, yet. The aim of this study was to assess the safety of AF ablation in cancer survivors. Consecutively recruited patients undergoing catheter ablation of non-valvular AF at our center between March 2015 and March 2017 were evaluated. The primary outcome of the study was clinically relevant bleedings occurred within 30 ± 5 days after the procedure. Patients with cancer were propensity matched to patients without cancer in a 1:3 and 1:6 ratio after stratification by baseline clinical features. Overall, 184 patients were included in the study. Of them, 21 (11%) were cancer survivors. Cancer site was more frequently gastrointestinal (36%), breast (23%), and genitourinary (18%). At 30 ± 5 days, clinically relevant bleedings occurred in 14 patients. Crude odds ratio (OR) for clinically relevant bleedings was 3.60 (95% CI 1.02–12.7) higher in cancer than in non-cancer patients. This trend remained after propensity score–matched population (OR 3.48, 95% CI 0.76–15.90 for matched 1:3, OR 4.95, 95% CI 1.2–20.2 for matched 1:6). Type of anticoagulation was not associated with bleedings. Preliminary results suggest that clinically relevant bleeding after catheter ablation for AF is more frequent in cancer survivors than in patients without cancer. Further studies are required to confirm the present data.
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- 2020
25. Rates and Determinants for the Use of Anticoagulation Treatment before Stroke in Patients with Known Atrial Fibrillation
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Michele Venti, Giancarlo Agnelli, Maria Cristina Vedovati, Silvia Quattrocchi, Andrea Alberti, Michela Giustozzi, Maurizio Paciaroni, Monica Acciarresi, and Valeria Caso
- Subjects
Male ,lcsh:Diseases of the circulatory (Cardiovascular) system ,Time Factors ,Administration, Oral ,Practice Patterns ,030204 cardiovascular system & hematology ,Logistic regression ,0302 clinical medicine ,Patient Admission ,Risk Factors ,80 and over ,atrial fibrillation ,oral anticoagulants ,Practice Patterns, Physicians' ,Stroke ,Aged, 80 and over ,Ischemic Attack ,Transient ,Atrial fibrillation ,stroke ,Treatment Outcome ,Neurology ,Italy ,Ischemic Attack, Transient ,Administration ,Practice Guidelines as Topic ,Anticoagulant Agent ,Female ,Guideline Adherence ,Cardiology and Cardiovascular Medicine ,Risk assessment ,Oral ,medicine.medical_specialty ,antithrombotic treatment ,Risk Assessment ,Anticoagulation Treatment ,03 medical and health sciences ,Internal medicine ,medicine ,Humans ,In patient ,cardiovascular diseases ,Aged ,Original Paper ,Physicians' ,business.industry ,Anticoagulants ,medicine.disease ,Drug Utilization ,Anticoagulant therapy ,lcsh:RC666-701 ,Neurology (clinical) ,business ,030217 neurology & neurosurgery ,Factor Xa Inhibitors - Abstract
Introduction and Objective: Even though the introduction of less cumbersome anticoagulant agents has improved, the rates ofoverall anticoagulant treatment in eligible patients with atrial fibrillation (AF) remain to be defined. We aimed to assess the rates of and determinants for the use of anticoagulation treatment before stroke in patients with known AF since the introduction of direct oral anticoagulants (DOAC) in clinical practice. Methods: Consecutive patients admitted to an individual stroke unit, from September 2013 through July 2019, for acute ischemic stroke or transient ischemic attack (TIA) with known AF before the event were included in the study. Logistic regression analysis was used to identify independent predictors of the use of anticoagulant treatment. Results: Overall, 155 patients with ischemic stroke/TIA and known AF were included in this study. Among 152 patients with a CHA2DS2-VASc score >1, 43 patients were not receiving any treatment, 47 patients were receiving antiplatelet agents, and the remaining 62 patients were on oral anticoagulants. Among 34 patients on DOAC, 13 were receiving a nonlabeled reduced dose and 18 out of 34 patients on vitamin K antagonists had an INR value Conclusions: Only 21.9% of the patients hospitalized for a stroke or TIA with known AF before the event were adequately treated according to recent treatment guidelines. It is important to improve medical information about the risk of AF and the efficacy of anticoagulants in stroke prevention.
- Published
- 2020
26. Beyond the guidelines: Novelties, changes and unsolved issues from the 2019 ESC guidelines on pulmonary embolism
- Author
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Maria Cristina Vedovati, Michela Giustozzi, and Laura Franco
- Subjects
medicine.medical_specialty ,business.industry ,Acute Disease ,Internal Medicine ,medicine ,MEDLINE ,Humans ,Pulmonary Embolism ,medicine.disease ,Intensive care medicine ,business ,Pulmonary embolism - Published
- 2020
27. Coagulopathy and sepsis: Pathophysiology, clinical manifestations and treatment
- Author
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Josip Anđelo Borovac, P. Papakonstantinou, Aleksandra Gąsecka, Hanne Ehrlinder, Michela Giustozzi, Rui Azevedo Guerreiro, Dario Bongiovanni, and William A E Parker
- Subjects
medicine.medical_specialty ,Gastroenterology ,Fibrin ,Sepsis ,03 medical and health sciences ,DIC ,0302 clinical medicine ,Coagulopathy ,Internal medicine ,hemic and lymphatic diseases ,medicine ,Humans ,Platelet ,Prospective Studies ,Disseminated intravascular coagulation ,Disseminated intravascular coagulopathy ,biology ,business.industry ,Hematology ,Blood Coagulation Disorders ,Disseminated Intravascular Coagulation ,medicine.disease ,Thrombosis ,Thrombocytopenia ,Pathophysiology ,Antiplatelet drugs ,Disseminated Intravascular Coagulopathy ,Risk Scores ,Haemostasis ,Dacarbazine ,Oncology ,Coagulation ,030220 oncology & carcinogenesis ,biology.protein ,business ,030215 immunology - Abstract
Sepsis is a complex syndrome with a high incidence, increasing by 8.7% annually over the last 20 years. Coagulopathy is a leading factor associated with mortality in patients with sepsis and range from slight thrombocytopenia to fatal disorders, such as disseminated intravascular coagulation (DIC). Platelet reactivity increases during sepsis but prospective trials of antiplatelet therapy during sepsis have been disappointing. Thrombocytopenia is a known predictor of worse prognosis during sepsis. The mechanisms underlying thrombocytopenia in sepsis have yet to be fully understood but likely involves decreased platelet production, platelet sequestration and increased consumption. DIC is an acquired thrombohemorrhagic syndrome, resulting in intravascular fibrin formation, microangiopathic thrombosis, and subsequent depletion of coagulation factors and platelets. DIC can be resolved with treatment of the underlying disorder, which is considered the cornerstone in the management of this syndrome. This review presents the current knowledge on the pathophysiology, diagnosis, and treatment of sepsis-associated coagulopathies.
- Published
- 2021
28. Causes and Risk Factors of Cerebral Ischemic Events in Patients With Atrial Fibrillation Treated With Non–Vitamin K Antagonist Oral Anticoagulants for Stroke Prevention
- Author
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Panagiotis Papamichalis, Marina Padroni, Katiuscia Nardi, Maria Cristina Vedovati, Erika Schirinzi, Konstantinos Makaritsis, Serena Monaco, Valentina Saia, Karen L. Furie, Giancarlo Agnelli, Kennedy R. Lees, Dirk Deleu, Sotirios Giannopoulos, Azmil H. Abdul-Rahim, Miriam Maccarrone, Tiziana Tassinari, Jukka Putaala, Alexandros A Polymeris, Marina Diomedi, Elena Ferrari, Shadi Yaghi, Alexandra Rimoldi, Monica Acciarresi, Apostolos Komnos, Efstathia Karagkiozi, Elisabetta Toso, Gian Marco De Marchis, Maria Giulia Mosconi, Francesca Guideri, Aristeidis H. Katsanos, Luca Masotti, Piergiorgio Lochner, Angela Risitano, Danilo Toni, Elisa Giorli, Silvia Rosa, Alessandro Pezzini, Francesco Corea, Leonardo Pantoni, Boris Doronin, Filippo Angelini, Giovanni Orlandi, Simona Marcheselli, Chrysoula Liantinioti, Michela Giustozzi, Licia Denti, Manuel Cappellari, Marialuisa Zedde, Cataldo D'Amore, Patrizia Pierini, Elena Pinuccia Verrengia, Kateryna Antonenko, Stefan T. Engelter, Giorgio Silvestrelli, Patrik Michel, Bruno Bonetti, Leonardo Ulivi, Alessandro Rocco, Nicola Mumoli, Lina Palaiodimou, Andrea Alberti, Marina Mannino, Maurizio Paciaroni, Nemanja Popovic, Sung Il Sohn, Marija Zarkov, Odysseas Kargiotis, Ashraf Eskandari, Antonio Baldi, Massimo Del Sette, Michelangelo Mancuso, Michele Venti, Walter Ageno, Alfonso Ciccone, Alberto Chiti, Kalliopi Perlepe, George Ntaios, Silvia Galliazzo, Fabio Bandini, Vera Volodina, Pierluigi Bertora, Nicola Giannini, Georgios Tsivgoulis, Maurizio Acampa, David J. Seiffge, Elisa Grifoni, Brian Mac Grory, Paola Santalucia, Yuriy Flomin, Rossana Tassi, Valeria Caso, Enrico Maria Lotti, and Giuseppe Martini
- Subjects
Oral ,Male ,medicine.medical_specialty ,medicine.drug_class ,Administration, Oral ,030204 cardiovascular system & hematology ,Risk Assessment ,Brain Ischemia ,Settore MED/11 ,03 medical and health sciences ,0302 clinical medicine ,Risk Factors ,Internal medicine ,Atrial Fibrillation ,atrial fibrillation ,humans ,prevention and control ,risk factors ,stroke ,80 and over ,medicine ,Humans ,In patient ,Stroke ,Aged ,Aged, 80 and over ,Advanced and Specialized Nursing ,business.industry ,Age Factors ,Warfarin ,Anticoagulants ,Atrial fibrillation ,Middle Aged ,Vitamin K antagonist ,medicine.disease ,3. Good health ,Stroke prevention ,Administration ,Cardiology ,Settore MED/26 - Neurologia ,Female ,Neurology (clinical) ,Cardiology and Cardiovascular Medicine ,business ,030217 neurology & neurosurgery ,medicine.drug - Abstract
Background and Purpose— Despite treatment with oral anticoagulants, patients with nonvalvular atrial fibrillation (AF) may experience ischemic cerebrovascular events. The aims of this case-control study in patients with AF were to identify the pathogenesis of and the risk factors for cerebrovascular ischemic events occurring during non–vitamin K antagonist oral anticoagulants (NOACs) therapy for stroke prevention. Methods— Cases were consecutive patients with AF who had acute cerebrovascular ischemic events during NOAC treatment. Controls were consecutive patients with AF who did not have cerebrovascular events during NOACs treatment. Results— Overall, 713 cases (641 ischemic strokes and 72 transient ischemic attacks; median age, 80.0 years; interquartile range, 12; median National Institutes of Health Stroke Scale on admission, 6.0; interquartile range, 10) and 700 controls (median age, 72.0 years; interquartile range, 8) were included in the study. Recurrent stroke was classified as cardioembolic in 455 cases (63.9%) according to the A-S-C-O-D (A, atherosclerosis; S, small vessel disease; C, cardiac pathology; O, other causes; D, dissection) classification. On multivariable analysis, off-label low dose of NOACs (odds ratio [OR], 3.18; 95% CI, 1.95–5.85), atrial enlargement (OR, 6.64; 95% CI, 4.63–9.52), hyperlipidemia (OR, 2.40; 95% CI, 1.83–3.16), and CHA 2 DS 2 -VASc score (OR, 1.72 for each point increase; 95% CI, 1.58–1.88) were associated with ischemic events. Among the CHA 2 DS 2 -VASc components, age was older and presence of diabetes mellitus, congestive heart failure, and history of stroke or transient ischemic attack more common in patients who had acute cerebrovascular ischemic events. Paroxysmal AF was inversely associated with ischemic events (OR, 0.45; 95% CI, 0.33–0.61). Conclusions— In patients with AF treated with NOACs who had a cerebrovascular event, mostly but not exclusively of cardioembolic pathogenesis, off-label low dose, atrial enlargement, hyperlipidemia, and high CHA 2 DS 2 -VASc score were associated with increased risk of cerebrovascular events.
- Published
- 2019
29. Venous thromboembolism and cancer: Current and future role of direct-acting oral anticoagulants
- Author
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Cecilia Becattini, Maria Cristina Vedovati, and Michela Giustozzi
- Subjects
medicine.medical_specialty ,Oral treatment ,Pyridines ,Population ,Direct-acting oral anticoagulants ,030204 cardiovascular system & hematology ,law.invention ,03 medical and health sciences ,Clinical trials ,0302 clinical medicine ,Rivaroxaban ,Randomized controlled trial ,law ,Neoplasms ,medicine ,Humans ,cardiovascular diseases ,Intensive care medicine ,education ,Cancer ,Clinical Trials as Topic ,education.field_of_study ,Venous thromboembolism ,Anticoagulants ,Factor Xa Inhibitors ,Heparin, Low-Molecular-Weight ,Thiazoles ,Venous Thromboembolism ,Heparin ,business.industry ,Low-Molecular-Weight ,Hematology ,equipment and supplies ,medicine.disease ,Clinical trial ,Regimen ,030220 oncology & carcinogenesis ,business ,Direct acting - Abstract
Approximately one-fifth of all cases of venous thromboembolism (VTE) are related to cancer and anticoagulant treatment in these patients has remained a challenge. Cancer patients with VTE are at increased risk of developing recurrent VTE compared to patients without cancer, but also have a higher risk of major bleeding. In these patients, low molecular weight heparins (LMWHs) have been shown to be more effective and as safe as vitamin K-antagonists (VKAs) for the treatment of VTE. Therefore, the majority of current clinical guidelines recommend LMWHs as the treatment of choice for cancer-associated VTE. However, several issues should be considered regarding the use of LMWHs as daily subcutaneous injections, the costs or risk of heparin-induced thrombocytopenia. In recent years, direct-acting oral anticoagulants (DOACs) have shown similar efficacy and better safety profile compared to VKAs and have become the standard of care for the treatment of VTE in the general population. Because DOACs offer a simple oral treatment regimen without the need for anticoagulation control, they could be an attractive alternative to LMWH. Before DOACs become an accepted treatment option for cancer associated VTE, they have to be evaluated in a head-to-head comparison with LMWH. Data from two randomized trials comparing DOACs vs. LMWH have recently been published. In the present review, we will provide three clinically relevant questions on the use of DOACs in patients with cancer and VTE and provide an overview on recent evidence on this topic: 1) are DOACs a treatment option for the prevention of VTE in cancer patients?; 2) what is the place for DOACs in patients with cancer-associated VTE?; 3) should I use DOACs for the extended treatment of cancer-related VTE?.
- Published
- 2019
30. The role of computed tomography angiography 3D imaging in postoperative hemorrhage after groin mesh hernioplasty during anticoagulation therapy
- Author
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Michela Giustozzi, Georgi Popivanov, Fabiano Bini, Massimo Lancia, Paolo Bruzzone, Franco Marinozzi, Vito D'Andrea, and Roberto Cirocchi
- Subjects
medicine.medical_specialty ,medicine.diagnostic_test ,Groin ,business.industry ,Computed Tomography Angiography ,hematoma ,Anticoagulants ,Postoperative Hemorrhage ,Surgical Mesh ,hernia, hematoma, Lichtenstein open hernia repair, 3D imaging ,hernia ,Text mining ,medicine.anatomical_structure ,Imaging, Three-Dimensional ,3D imaging ,Lichtenstein open hernia repair ,Medicine ,Humans ,Surgery ,Radiology ,Post operative ,business ,Herniorrhaphy ,Computed tomography angiography - Published
- 2021
31. Thromboembolic Complications in Covid-19: From Clinical Scenario to Laboratory Evidence
- Author
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Giancarlo Agnelli, Alberto Palazzuoli, Michela Giustozzi, Edoardo Gronda, Gaetano Ruocco, and Francesco Tramonte
- Subjects
medicine.medical_specialty ,Coronavirus disease 2019 (COVID-19) ,Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ,Science ,antithrombotic therapy ,Review ,030204 cardiovascular system & hematology ,General Biochemistry, Genetics and Molecular Biology ,03 medical and health sciences ,0302 clinical medicine ,medicine ,In patient ,030212 general & internal medicine ,coagulation ,Intensive care medicine ,Clinical scenario ,Ecology, Evolution, Behavior and Systematics ,thrombosis ,Disseminated intravascular coagulation ,business.industry ,Paleontology ,medicine.disease ,Thrombosis ,COVID-19 infection ,Increased risk ,Space and Planetary Science ,business ,Risk assessment - Abstract
SARS-Cov-2 infection, a pandemic disease since March 2020, is associated with a high percentage of cardiovascular complications mainly of a thromboembolic (TE) nature. Although clinical patterns have been described for the assessment of patients with increased risk, many TE complications occur in patients with apparently moderate risk. Notably, a recent statement from the European Society of Cardiology (ESC) atherosclerosis and vascular biology working group pointed out the key role of vascular endothelium for the recruitment of inflammatory and thrombotic pathways responsible for both disseminated intravascular coagulation and cardiovascular complications. Therefore, a better understanding of the pathophysiological process linking infection to increased TE risk is needed in order to understand the pathways of this dangerous liaison and possibly interrupt it with appropriate treatment. In this review, we describe the histological lesions and the related blood coagulation mechanisms involved in COVID-19, we define the laboratory parameters and clinical risk factors associated with TE events, and propose a prophylactic anticoagulation treatment in relation to the risk category. Finally, we highlight the concept that a solid risk assessment based on prospective multi-center data would be the challenge for a more precise risk stratification and more appropriate treatment.
- Published
- 2021
32. 1684P Cardiovascular events with immune checkpoint inhibitors in melanoma or NSCLC: A systematic review and meta-analysis
- Author
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Fausto Roila, Giancarlo Agnelli, Mario Mandalà, Cecilia Becattini, and Michela Giustozzi
- Subjects
Oncology ,medicine.medical_specialty ,business.industry ,Immune checkpoint inhibitors ,Meta-analysis ,Internal medicine ,Melanoma ,medicine ,Hematology ,medicine.disease ,business - Published
- 2021
33. Anticoagulation therapy in non-valvular atrial fibrillation in the COVID-19 era: is it time to reconsider our therapeutic strategy?
- Author
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Hanne Ehrlinder, William A E Parker, Aleksandra Gąsecka, Dario Bongiovanni, Rui Azevedo Guerreiro, Josip Anđelo Borovac, P. Papakonstantinou, Michela Giustozzi, Laboratory for Experimental Clinical Chemistry, and Laboratory for General Clinical Chemistry
- Subjects
medicine.medical_specialty ,2019-20 coronavirus outbreak ,Coronavirus disease 2019 (COVID-19) ,business.industry ,Epidemiology ,Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ,Non valvular atrial fibrillation ,MEDLINE ,COVID-19 ,Anticoagulants ,macromolecular substances ,Stroke ,atrial fibrillation ,anticoagulation ,NOAC ,DOAC ,novel oral anticoagulants ,interactions ,warfarin ,Atrial Fibrillation ,Commentary ,medicine ,cardiovascular system ,Humans ,AcademicSubjects/MED00200 ,Warfarin ,cardiovascular diseases ,Intensive care medicine ,business ,Cardiology and Cardiovascular Medicine ,Therapeutic strategy - Abstract
This article deals about initiation of NOAC therapy in COVID- 19 outpatients with non-valvular atrial fibrillation vs. vitamin K antagonists.
- Published
- 2021
34. Clinical characteristics and outcomes of incidental venous thromboembolism in cancer patients: Insights from the Caravaggio study
- Author
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Menno V. Huisman, Giancarlo Agnelli, Cecilia Becattini, Alexander T. Cohen, Francesco Dentali, Jean M. Connors, Ana Belen Ruperez Blanco, Nicolas Falvo, Michela Giustozzi, Sebastian Szmit, and Rupert Bauersachs
- Subjects
Dalteparin ,medicine.medical_specialty ,Colorectal cancer ,Deep vein ,venous thromboembolism ,apixaban ,incidental venous thromboembolism ,Hemorrhage ,Internal medicine ,Neoplasms ,medicine ,cancer ,Humans ,cardiovascular diseases ,business.industry ,Incidence (epidemiology) ,Hazard ratio ,Cancer ,symptomatic venous thromboembolism ,Anticoagulants ,Neoplasm Recurrence, Local ,Venous Thromboembolism ,Hematology ,medicine.disease ,equipment and supplies ,Thrombosis ,Pulmonary embolism ,medicine.anatomical_structure ,Neoplasm Recurrence ,Local ,Apixaban ,business ,medicine.drug - Abstract
Background Clinical guidelines advise similar anticoagulant treatment for symptomatic and incidental cancer-associated venous thromboembolism (VTE). We investigated clinical features and outcomes of cancer patients with incidental or symptomatic VTE randomized in the Caravaggio study. Objectives We performed a predefined sub-analysis of the Caravaggio study in order to investigate the clinical features and outcomes of incidental and symptomatic VTE in patients with cancer. The relative efficacy and safety of apixaban and dalteparin in patients with incidental and symptomatic VTE was also assessed. Methods The Caravaggio study compared apixaban to dalteparin for the 6-month treatment of cancer-associated VTE. The primary efficacy and safety outcomes were recurrent VTE and major bleeding. Results Two hundred thirty patients (20%) had incidental and 925 (80%) symptomatic VTE. Pulmonary embolism with or without deep vein thrombosis as index event, colorectal cancer, Eastern Cooperative Oncology Group (ECOG) score of 0, and locally advanced or metastatic cancer were more frequent in patients with incidental VTE. Deep vein thrombosis as index event, hematological cancer, and ECOG score of 2 were more frequent in patients with symptomatic VTE. Ten patients (4.3%) with incidental and 68 (7.4%) with symptomatic VTE had recurrent VTE (hazard ratio [HR] 0.57, 95% confidence interval [CI] 0.29-1.10). Major bleeding occurred in 12 (5.2%) patients with incidental VTE and in 33 (3.6%) patients with symptomatic VTE (HR 1.43, 95% CI 0.74-2.77). When comparing apixaban to dalteparin in patients with symptomatic and incidental VTE, the HR for recurrence was 0.73 (95% CI 0.45-1.19) and 0.41 (95% CI 0.11-1.56), respectively, and the HR for major bleeding 0.93 (95% CI 0.47-1.83) and 0.96 (95% CI 0.31-2.96), respectively. Conclusions Compared to cancer patients with symptomatic VTE, those with incidental VTE have different clinical features at presentation, with a numerically lower incidence of recurrent VTE and a numerically higher incidence of major bleeding.
- Published
- 2021
35. Risk factors and one-year mortality in patients with direct oral anticoagulant-associated gastrointestinal bleeding
- Author
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Cecilia Becattini, Laura Franco, Emanuela Marchesini, Michela Giustozzi, Maria Cristina Vedovati, Giancarlo Agnelli, Alessandra Vinci, and Melina Verso
- Subjects
Gastrointestinal bleeding ,medicine.medical_specialty ,Internal medicine ,Atrial Fibrillation ,medicine ,80 and over ,Humans ,In patient ,Mortality ,Aged ,Aged, 80 and over ,COPD ,business.industry ,Hazard ratio ,Cancer ,Anticoagulants ,Atrial fibrillation ,Hematology ,medicine.disease ,Confidence interval ,Oral anticoagulants ,Risk factors ,Case-Control Studies ,Ambulatory ,Bleeding complications ,business ,Gastrointestinal Hemorrhage - Abstract
Background and aim Risk factors and mortality in patients with DOACs-associated gastrointestinal bleeding (GIB) are not completely defined. Aims of this study were to identify risk factors for bleeding and evaluate one-year mortality in patients with DOACs-associated GIB. Methods We conducted a case-control study. Cases were patients with DOACs-associated GIB admitted to the Perugia Hospital, Italy between 2013 and 2019. Controls were derived from the prospective database of patients with DOACs referred to the ambulatory service. Cases and controls were matched by a 1:2 ratio for type and dose of DOAC, indication for anticoagulation and gender. Univariate and multivariable analyses were performed to identify risk factors. Hazard Ratio with 95% confidence interval was used to calculate mortality. Results We included 324 patients, of which 108 with DOACs-associated GIB. Mean age was 81.9 ± 7.2 years and 78.9 ± 8.7 years, respectively. The most frequent indication for anticoagulation was atrial fibrillation. Reduced doses of DOACs were prescribed in 186 patients (56.4%). At multivariable analysis, active cancer (OR:7.26; 95%CI 3.10–16.96), renal impairment (OR:4.26; 95%CI 1.98–9.17), bleeding predisposition (OR:3.66; 95%CI 2.00–6.68), COPD (OR:2.12; 95%CI 1.08–4.16) and uncontrolled hypertension (OR:1.86; 95%CI 1.07–3.23) were found to be predictors for DOACs-associated GIB. Adjusted one-year mortality was significantly higher in patients who experienced GIB compared with those who did not experience GIB (OR: 7.04; 95%CI 3.82–14.31). Conclusions Predictors of DOACs-associated GIB included active cancer, renal impairment, bleeding predisposition, COPD and uncontrolled hypertension. The adjusted one-year-mortality was significantly increased in patients with DOACs-associated GIB in comparison to DOACs patients without GIB.
- Published
- 2021
36. Patients with Atrial Fibrillation receiving NOACs: The boundary between appropriate and inappropriate dose
- Author
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Michela Giustozzi, Maria Cristina Vedovati, and Maurizio Paciaroni
- Subjects
Oral ,medicine.medical_specialty ,business.industry ,MEDLINE ,Boundary (topology) ,Administration, Oral ,Anticoagulants ,Atrial fibrillation ,Hemorrhage ,medicine.disease ,Text mining ,Rivaroxaban ,Internal medicine ,Atrial Fibrillation ,Administration ,Internal Medicine ,medicine ,Cardiology ,Humans ,business - Published
- 2021
37. Sex-specific differences in the presentation, clinical course, and quality of life of patients with acute venous thromboembolism according to baseline risk factors. Insights from the PREFER in VTE
- Author
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Cecilia Becattini, Alexander T. Cohen, Maria Cristina Vedovati, Eva-Maria Fronk, Giancarlo Agnelli, Michela Giustozzi, Luca Valerio, Stefano Barco, Frederikus A. Klok, Stavros Konstantinides, University of Zurich, and Giustozzi, Michela
- Subjects
Male ,medicine.medical_specialty ,Epidemiology ,610 Medicine & health ,030204 cardiovascular system & hematology ,03 medical and health sciences ,0302 clinical medicine ,Quality of life ,Recurrence ,Internal medicine ,Deep vein thrombosis ,Internal Medicine ,Medicine ,Humans ,cardiovascular diseases ,030212 general & internal medicine ,First episode ,Sex Characteristics ,business.industry ,10031 Clinic for Angiology ,Absolute risk reduction ,Cancer ,Anticoagulants ,Venous Thromboembolism ,equipment and supplies ,medicine.disease ,Sex specific ,Neoplasm Recurrence ,Risk factors ,Local ,2724 Internal Medicine ,Quality of Life ,Sex ,Female ,Presentation (obstetrics) ,Neoplasm Recurrence, Local ,business ,Venous thromboembolism - Abstract
Introduction Sex and the presence of specific provoking risk factors, along with age, influence the presentation and prognosis of venous thromboembolism (VTE). We investigated the presentation, course and quality of life in women and men with acute VTE classified according to their VTE provoking factors. Methods PREFER in VTE is an international, non-interventional registry of patients with a first episode of acute symptomatic VTE. Baseline provoking factors were classified as follows: major transient, minor transient, active cancer, and none identifiable. The primary outcome was recurrent VTE. Quality of life and treatment satisfaction were secondary outcomes. Results Of 3,455 patients with acute VTE, 1,623 (47%) were women. The mean age at the time of VTE was 61 (SD 18) in women, 60 (SD 15) in men. The distribution of provoking risk factors was similar between sexes, despite a tendency for higher frequency of minor and major transient risk factors in women, and cancer or unprovoked VTE in men. At 12-month follow-up, VTE recurrence was reported in 74 (6.5%) women and 80 (6.4%) men (absolute risk difference -0.1%, 95% CI -1.9%; +2.1%). In patients with unprovoked VTE, the VTE recurrence rate was 38/612 (6.2%) in women and 53/798 (6.6%) in men (absolute risk difference -0.4, 95% CI -3.0; +2.1%). Multivariable Cox regressions confirmed the absence of sex differences. Quality of life and treatment satisfaction scores one year after VTE were lower in women than in men irrespective of the provoking risk factors (p Conclusions Despite differences in the provoking risk factors for VTE, women and men had a similar rate VTE recurrence at one year. After acute VTE, women had lower quality of life and treatment satisfaction scores.
- Published
- 2021
38. Direct oral anticoagulants for the treatment of acute venous thromboembolism associated with cancer: a systematic review and meta-analysis
- Author
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Laurent Bertoletti, Inna Tzoran, Menno V. Huisman, Jorge del Toro-Cervera, Cecilia Becattini, Michela Giustozzi, Sebastian Szmit, Rachel P. Rosovsky, Frederikus A. Klok, Giancarlo Agnelli, Joerg Herold, and Anne-Céline Martin
- Subjects
0301 basic medicine ,Male ,Time Factors ,medicine.drug_mechanism_of_action ,Administration, Oral ,030204 cardiovascular system & hematology ,law.invention ,chemistry.chemical_compound ,0302 clinical medicine ,Randomized controlled trial ,Edoxaban ,law ,Recurrence ,Risk Factors ,Neoplasms ,Stroke ,Randomized Controlled Trials as Topic ,Hematology ,Middle Aged ,Treatment Outcome ,Meta-analysis ,Apixaban ,Female ,medicine.drug ,medicine.medical_specialty ,Factor Xa Inhibitor ,venous thromboembolism ,Hemorrhage ,Risk Assessment ,direct oral anticoagulants ,03 medical and health sciences ,dalteparin ,Internal medicine ,oral factor Xa inhibitors ,medicine ,Humans ,cancer ,Blood Coagulation ,Aged ,Rivaroxaban ,business.industry ,Anticoagulants ,Heparin, Low-Molecular-Weight ,medicine.disease ,meta-analysis ,030104 developmental biology ,chemistry ,Relative risk ,business ,Factor Xa Inhibitors - Abstract
Background International guidelines have endorsed the use of edoxaban or rivaroxaban as an alternative to low-molecular-weight heparin (LMWH) for the treatment of acute venous thromboembolism (VTE) in cancer patients. Recently, a large randomized controlled trial of apixaban versus dalteparin in patients with cancer was completed. We performed an updated meta-analysis to assess the efficacy and safety of direct oral anticoagulants (DOACs) versus LMWH in patients with cancer-associated VTE. Methods MEDLINE, EMBASE, and CENTRAL (Cochrane Controlled Trials Registry) were systematically searched up to March 30, 2020 for randomized controlled trials comparing DOACs versus LMWH for the treatment of VTE in patients with cancer. The two coprimary outcomes were recurrent VTE and major bleeding at 6 months. Data were pooled by the Mantel–Haenszel method and compared by relative risk ratios (RRs) and 95% confidence intervals (CIs). Results Four randomized controlled studies (2,894 patients) comparing apixaban, edoxaban, or rivaroxaban with dalteparin were included in the meta-analysis. Recurrent VTE occurred in 75 of 1,446 patients (5.2%) treated with oral factor Xa inhibitors and in 119 of 1,448 patients (8.2%) treated with LMWH (RR 0.62; 95% CI 0.43–0.91; I 2, 30%). Major bleeding occurred in 62 (4.3%) and 48 (3.3%) patients receiving oral factor Xa inhibitors or LMWH, respectively (RR 1.31; 95% CI 0.83–2.08; I 2, 23%). Conclusion In patients with cancer-associated VTE, oral factor Xa inhibitors reduced the risk of recurrent VTE without a significantly higher likelihood of major bleeding at 6 months compared with LMWH.
- Published
- 2020
39. The possible clinical impact of a threshold left atrial diameter associated with new AF in ESUS patients
- Author
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Michela Giustozzi and Maurizio Paciaroni
- Subjects
Stroke ,medicine.medical_specialty ,Text mining ,Left atrial ,business.industry ,Internal medicine ,Atrial Fibrillation ,Internal Medicine ,medicine ,Cardiology ,Humans ,Heart Atria ,business - Published
- 2020
40. [Grey zones on new oral anticoagulants in atrial fibrillation. Expert opinion]
- Author
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Giuseppe, Di Pasquale, Attilio, Iacovoni, Pasquale Perrone, Filardi, Michela, Giustozzi, Roberto, De Ponti, Anna, Falanga, Giovanni Luca, Botto, Paolo, De Filippo, Antonello, Gavazzi, Edoardo, Sciatti, Michele, Senni, and Maurizio, Porcu
- Subjects
Atrial Fibrillation ,Practice Guidelines as Topic ,Administration, Oral ,Anticoagulants ,Humans ,Stents ,Prostheses and Implants ,Randomized Controlled Trials as Topic - Abstract
Clinical guidelines, while representing an objective reference to perform appropriate treatment choices, contain grey zones, where recommendations are not supported by solid evidence. In a conference held in Bergamo in October 2018, an attempt was made to highlight some of the main grey zones in Cardiology and, through a comparison between experts, to draw shared conclusions that can illuminate our clinical practice. This manuscript contains the statements of the symposium concerning the controversies regarding new oral anticoagulants (NOACs) and atrial fibrillation (AF). The manuscript represents the organization of the meeting, with an initial review of current guidelines on this topic, followed by an expert presentation of pros (white) and cons (black) related to the identified "gaps of evidence". For every issue is then reported the response derived from the votes of the experts and the public, the discussion and, finally, the highlights, which are intended as practical "take home messages" to be used in everyday clinical practice. The first topic concerns the indication for anticoagulant therapy in patients with subclinical AF revealed by implanted devices. The second issue examines the opportunity to use NOACs in oncological patients with AF. The third gap evaluates the necessity of anticoagulating patients with AF and CHA2DS2-VASc 1 or CHA2DS2-VASc 2 if women. The last "gap in evidence" concerns the preference of triple or double therapy in patients with AF and acute coronary syndrome/coronary stenting. The work has also been implemented with evidences deriving from important randomized studies published after the date of the Conference.
- Published
- 2020
41. Variation in the Association between Antineoplastic Therapies and Venous Thromboembolism in Patients with Active Cancer
- Author
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Michela Giustozzi, Anja Katholing, Alexander T. Cohen, Christopher Wallenhorst, Jeffrey I. Weitz, Bob Weijs, Saulius Sudikas, Antonio Curcio, Thalia S. Field, Carlos Martinez, MUMC+: MA Med Staf Spec Cardiologie (9), and RS: Carim - H01 Clinical atrial fibrillation
- Subjects
0301 basic medicine ,Oncology ,Male ,Time Factors ,Databases, Factual ,medicine.medical_treatment ,Disease ,030204 cardiovascular system & hematology ,chemotherapy ,DISEASE ,0302 clinical medicine ,Risk Factors ,Neoplasms ,80 and over ,Cause of death ,Aged, 80 and over ,COMPLICATIONS ,Incidence (epidemiology) ,Incidence ,Hematology ,Middle Aged ,Treatment Outcome ,Hormonal therapy ,Female ,Immunotherapy ,BURDEN ,medicine.medical_specialty ,venous thromboembolism ,Antineoplastic Agents ,Risk Assessment ,03 medical and health sciences ,Databases ,Pancreatic cancer ,Internal medicine ,medicine ,Humans ,COHORT ,cardiovascular diseases ,radiotherapy ,Factual ,Aged ,Chemotherapy ,business.industry ,Cancer ,medicine.disease ,United Kingdom ,Radiation therapy ,THROMBOSIS ,030104 developmental biology ,RISK-FACTORS ,business - Abstract
Background Venous thromboembolism (VTE) is a major cause of death in cancer patients. Although patients with cancer have numerous risk factors for VTE, the relative contribution of cancer treatments is unclear. Objective The objective of this study is to evaluate the association between cancer therapies and the risk of VTE. Methods From UK Clinical Practice Research Datalink, data on patients with first cancer diagnosis between 2008 and 2016 were extracted along with information on hospitalization, treatments, and cause of death. Primary outcome was active cancer-associated VTE. To establish the independent effects of risk factors, adjusted subhazard ratios (adj-SHR) were calculated using Fine and Gray regression analysis accounting for death as competing risk. Results Among 67,801 patients with a first cancer diagnosis, active cancer-associated VTE occurred in 1,473 (2.2%). During a median observation time of 1.2 years, chemotherapy, surgery, hormonal therapy, radiation therapy, and immunotherapy were given to 71.1, 37.2, 17.2, 17.5, and 1.4% of patients with VTE, respectively. The active cancers associated with the highest risk of VTE—as assessed by incidence rates—included pancreatic cancer, brain cancer, and metastatic cancer. Chemotherapy was associated with an increased risk of VTE (adj-SHR: 3.17, 95% confidence interval [CI]: 2.76–3.65) while immunotherapy with a not significant reduced risk (adj-SHR: 0.67, 95% CI: 0.30–1.52). There was no association between VTE and radiation therapy (adj-SHR: 0.91, 95% CI: 0.65–1.27) and hormonal therapies. Conclusion VTE risk varies with cancer type. Chemotherapy was associated with an increased VTE risk, whereas with radiation and immunotherapy therapy, an association was not confirmed.
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- 2020
42. Venous thromboembolism and COVID-19: Mind the gap between clinical epidemiology and patient management
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Michela Giustozzi, Maria Cristina Vedovati, and Giancarlo Agnelli
- Subjects
medicine.medical_specialty ,Coronavirus disease 2019 (COVID-19) ,business.industry ,Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ,MEDLINE ,Anticoagulants ,COVID-19 ,Clinical epidemiology ,Venous Thromboembolism ,Patient management ,Observational Studies as Topic ,Review Literature as Topic ,Meta-Analysis as Topic ,Risk Factors ,medicine ,Internal Medicine ,Commentary ,Humans ,Intensive care medicine ,business ,Venous thromboembolism - Published
- 2020
43. Non-cirrhotic Extra-Hepatic Porto-Systemic Shunt Causing Adult-Onset Encephalopathy Treated with Endovascular Closure
- Author
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Giovanni Passalacqua, Benedetta Enrico, Emanuela Basile, Massimiliano Allegritti, Roberto Cirocchi, Michela Giustozzi, Lara de Vito, and Antonino Morabito
- Subjects
medicine.medical_specialty ,Cirrhosis ,Physiology ,Encephalopathy ,Congenital extra-hepatic porto-systemic shunt (CEPS) ,Hyperammonemia ,Rare malformation ,03 medical and health sciences ,0302 clinical medicine ,Internal medicine ,Humans ,Medicine ,business.industry ,Endovascular Procedures ,Vascular malformation ,Gastroenterology ,Emergency department ,Middle Aged ,Hepatology ,medicine.disease ,Shunt (medical) ,Surgery ,Portal System ,Treatment Outcome ,Splenic Vein ,Hepatic Encephalopathy ,030220 oncology & carcinogenesis ,Portal hypertension ,Female ,030211 gastroenterology & hepatology ,business - Abstract
Encephalopathy secondary to hyperammonemia due to Congenital Extra-hepatic Porto-systemic shunt (CEPS) in the absence of liver cirrhosis is an exceptionally unusual condition. We describe the case of a 54-year-old woman admitted to the Emergency Department complaining of recurrent episodes of confusion and worsening cognitive impairment. At admission, the patient displayed slowing cognitive-motor skills with marked static ataxia and impaired gait. Hyperammonemia was detected in the serum. An abdominal computed tomography (CT) excluded portal hypertension and liver cirrhosis, detecting a congenital extra-hepatic porto-systemic shunt which is a highly unusual vascular malformation. The patient was treated by interventional radiologists with a successful endovascular closure. We have performed a review of the last three decades of the literature, starting from the introduction of CT scanning in common clinical practice. Eighteen studies (case reports) described 29 patients with encephalopathy secondary to hyperammonemia due to CEPS in the absence of liver cirrhosis: They underwent treatment similar to our case report of CEPS. Encephalopathy secondary to hyperammonemia in the absence of hepatic dysfunction is an important diagnostic dilemma to many clinicians. An interventional radiologic approach is currently preferred.
- Published
- 2020
44. Perirectal Hematoma and Intra-Abdominal Bleeding after Stapled Hemorrhoidopexy and STARR—A Proposal for a Decision-Making Algorithm
- Author
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Massimo Lancia, Domenico Mascagni, Roberto Cirocchi, Piergiorgio Fedeli, Marina Konaktchieva, Georgi Popivanov, Kirien T. Kjossev, Michela Giustozzi, and Ivan Teodosiev
- Subjects
Adult ,Hemorrhoidectomy ,Male ,Abdominal pain ,Percutaneous ,medicine.medical_treatment ,Rectum ,Perirectal hematoma ,Stapled hemorrhoidopexy ,Stapled transanal rectal resection ,Review ,Decision Support Techniques ,Postoperative Complications ,Hematoma ,medicine.artery ,stapled hemorrhoidopexy ,Humans ,Medicine ,perirectal hematoma ,stapled transanal rectal resection ,lcsh:R5-920 ,business.industry ,Urinary retention ,General Medicine ,Middle Aged ,medicine.disease ,Internal iliac artery ,medicine.anatomical_structure ,Female ,medicine.symptom ,Gastrointestinal Hemorrhage ,lcsh:Medicine (General) ,business ,Ligation ,Algorithm ,Algorithms - Abstract
Background and Objectives: The present study aims to assess the effectiveness and current evidence of the treatment of perirectal bleeding after stapled haemorrhoidopexy. Materials and methods: A systematic literature review was performed that combined the published and the obtained original data after a search of PubMed, Web of Science, and SCOPUS. Results: The present systematic review includes 16 articles with 37 patients. Twelve papers report perirectal and six report intra-abdominal bleeding. Stapled hemorrhoidopexy (SH) was performed in 57% of cases (3 PPH 01 and 15 PPH 03), stapled transanal rectal resection (STARR) in 13%, and for 30% information was not available. The median age was 49 years (±11.43). The sign and symptoms of perirectal bleeding were abdominal pain (43%), pelvic discomfort without rectal bleeding (36%), urinary retention (14%), and external rectal bleeding (21%). The median time to bleeding was 1 day (±1.53 postoperative days), with median hemoglobin at diagnosis 8.8 ± 1.04 g/dL. Unstable hemodynamic was reported in 19%. Computed tomography scan (CT) was the first examination in 77%. Only two cases underwent the abdominal US, but subsequently, a CT scan was also conducted. Non-operative management was performed in 38% (n = 14) with selective arteriography and percutaneous angioembolization in two cases. A surgical treatment was performed in 23 cases — transabdominal surgery (3 colostomies, 1 Hartmann’ procedure, 1 low anterior resection of the rectum, 1 bilateral ligation of internal iliac artery and 1 ligation of vessels located at the rectal wall), transanal surgery (n = 13), a perineal incision in one, and CT-guided paracoccygeal drainage in one. Conclusions: Because of the rarity and lack of experience, no uniform tactic for the treatment of perirectal hematomas exists in the literature. We propose an algorithm similar to the approach in pelvic trauma, based on two main pillars —hemodynamic stability and the finding of contrast CT.
- Published
- 2020
45. Safety of anticoagulation in patients treated with urgent reperfusion for ischemic stroke related to atrial fibrillation
- Author
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Antonio Baldi, Licia Denti, Kennedy R. Lees, Nicola Mumoli, Panagiotis Halvatsiotis, Massimo Del Sette, Alberto Chiti, Peter Vanacker, Marta Bellesini, Tiziana Tassinari, Paolo Bovi, Alessandro Padovani, Christina Rueckert, Jessica Barlinn, Dorjan Zabzuni, Cataldo D'Amore, Loris Poli, Maria Luisa De Lodovici, Federica Letteri, Odysseas Kargiotis, Manuel Cappellari, Prasanna Tadi, Turgut Tatlisumak, Cecilia Becattini, Ludovica Anna Cimini, Liisa Tomppo, Yuriy Flomin, Giancarlo Agnelli, Aikaterini Theodorou, Serena Monaco, Elena Ferrari, Rossana Tassi, Monica Acciarresi, Patrik Michel, Alessio Pieroni, Enrico Maria Lotti, Michele Venti, Walter Ageno, Sung Il Sohn, Leonardo Ulivi, Maurizio Paciaroni, Konstantinos Vadikolias, Jukka Putaala, Cindy Tiseo, Valeria Caso, Alessandro Pezzini, Giorgio Silvestrelli, Alfonso Ciccone, Francesco Corea, Lilla Szabó, Francesca Guideri, Martina Giuntini, Gianni Lorenzini, Efstathia Karagkiozi, Davide Imberti, Luca Masotti, Azmil H. Abdul-Rahim, Theodore Karapanayiotides, Alessia Lanari, Andrea Alberti, Simona Marcheselli, Vieri Vannucchi, Giuseppe Martini, Shadi Yaghi, Marialuisa Zedde, Michela Giustozzi, Karen L. Furie, Danilo Toni, Chrissoula Liantinioti, Dirk Deleu, Franco Galati, Elisa Giorli, Monica Carletti, Vanessa Gourbali, Michelangelo Mancuso, George Ntaios, George Athanasakis, Fabio Bandini, Vera Volodina, Nicola Giannini, Umberto Scoditti, Mario Maimone Baronello, Boris Doronin, Simona Sacco, Maria Giulia Mosconi, Georgios Tsivgoulis, László Csiba, Alberto Rigatelli, Kristian Barlinn, Konstantinos Makaritsis, Maurizio Acampa, and Giovanni Orlandi
- Subjects
Male ,anticoagulants ,medicine.medical_specialty ,medicine.medical_treatment ,Hemorrhage ,Brain Ischemia ,Dabigatran ,Brain ischemia ,Internal medicine ,80 and over ,medicine ,Humans ,atrial fibrillation ,Prospective Studies ,Prospective cohort study ,Blood Coagulation ,Stroke ,Aged ,thrombolytic therapy ,Aged, 80 and over ,Advanced and Specialized Nursing ,Rivaroxaban ,business.industry ,Warfarin ,Atrial fibrillation ,Thrombolysis ,Middle Aged ,medicine.disease ,secondary prevention ,thrombectomy ,Anticoagulants ,Atrial Fibrillation ,Female ,Reperfusion ,Thrombectomy ,Thrombolytic Therapy ,Treatment Outcome ,Cardiology ,Neurology (clinical) ,Human medicine ,Cardiology and Cardiovascular Medicine ,business ,medicine.drug - Abstract
Background and Purpose: The optimal timing for starting oral anticoagulant after an ischemic stroke related to atrial fibrillation remains a challenge, mainly in patients treated with systemic thrombolysis or mechanical thrombectomy. We aimed at assessing the incidence of early recurrence and major bleeding in patients with acute ischemic stroke and atrial fibrillation treated with thrombolytic therapy and/or thrombectomy, who then received oral anticoagulants for secondary prevention. Methods: We combined the dataset of the RAF and the RAF-NOACs (Early Recurrence and Major Bleeding in Patients With Acute Ischemic Stroke and Atrial Fibrillation Treated With Non–Vitamin K Oral Anticoagulants) studies, which were prospective observational studies carried out from January 2012 to March 2014 and April 2014 to June 2016, respectively. We included consecutive patients with acute ischemic stroke and atrial fibrillation treated with either vitamin K antagonists or nonvitamin K oral anticoagulants. Primary outcome was the composite of stroke, transient ischemic attack, symptomatic systemic embolism, symptomatic cerebral bleeding, and major extracerebral bleeding within 90 days from the inclusion. Treated-patients were propensity matched to untreated-patients in a 1:1 ratio after stratification by baseline clinical features. Results: A total of 2159 patients were included, 564 (26%) patients received acute reperfusion therapies. After the index event, 505 (90%) patients treated with acute reperfusion therapies and 1287 of 1595 (81%) patients untreated started oral anticoagulation. Timing of starting oral anticoagulant was similar in reperfusion-treated and untreated patients (median 7.5 versus 7.0 days, respectively). At 90 days, the primary study outcome occurred in 37 (7%) patients treated with reperfusion and in 146 (9%) untreated patients (odds ratio, 0.74 [95% CI, 0.50–1.07]). After propensity score matching, risk of primary outcome was comparable between the 2 groups (odds ratio, 1.06 [95% CI, 0.53–2.02]). Conclusions: Acute reperfusion treatment did not influence the risk of early recurrence and major bleeding in patients with atrial fibrillation–related acute ischemic stroke, who started on oral anticoagulant.
- Published
- 2020
46. Vascular events with immune checkpoint inhibitors in melanoma or non-small cell lung cancer: A systematic review and meta-analysis
- Author
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Fausto Roila, Cecilia Becattini, Mario Mandalà, Michela Giustozzi, and Giancarlo Agnelli
- Subjects
medicine.medical_specialty ,Lung Neoplasms ,Myocardial Infarction ,Immune checkpoint inhibitor ,Gastroenterology ,Carcinoma, Non-Small-Cell Lung ,Internal medicine ,medicine ,Humans ,Radiology, Nuclear Medicine and imaging ,Myocardial infarction ,Lung cancer ,Prospective cohort study ,Immune Checkpoint Inhibitors ,Melanoma ,Stroke ,Cancer ,Randomized Controlled Trials as Topic ,business.industry ,Incidence ,Incidence (epidemiology) ,Venous Thromboembolism ,General Medicine ,medicine.disease ,Oncology ,Meta-analysis ,Immunotherapy ,business - Abstract
The incidence of venous and arterial thromboembolic events in advanced cancer patients treated with immune checkpoint inhibitors (ICIs) has been sporadically reported. We performed a systematic review and meta-analysis to assess the rate of vascular events in patients with melanoma and non-small cell lung cancer (NSCLC) treated with ICIs. A systematic search of MEDLINE and EMBASE was performed to identify randomized clinical trials and prospective studies. The main outcomes were venous thromboembolism (VTE), stroke or systemic embolism (SE) and myocardial infarction (MI). Secondary outcomes were fatal VTE, fatal stroke or SE and fatal MI. Pooled proportions with 95% confidence intervals (CI) were calculated using random-effects models. A total of 59 trials, 25 in 5,578 patients with melanoma and 34 in 6,543 patients with NSCLC were included. In patients with melanoma, rates of VTE, stroke or SE and MI were 1.5% (95% CI 0.8–2.8), 1.7% (95% CI 0.8–3.7) and 0.4% (95% CI 0.2–0.9), respectively. In patients with NSCLC, corresponding rates were 1.9% (95% CI 1.2–3.2), 1.2% (95% CI 0.6–2.5), and 1.1% (95% CI 0.5–2.1), respectively. Rates of fatal VTE and MI were similar in melanoma and NSCLC patients. Rates of fatal stroke or SE were 1.9% (95% CI 0.4–9.5) and 0.7% (95% CI 0.2–2.3) in melanoma and NSCLC patients, respectively. Rates of VTE (3.1% vs. 1.1%) and myocardial infarction (3.4% Vs. 0.5%) were numerically higher in NSCLC patients treated with combined-ICIs vs mono-ICIs. Our study shows a not negligible rate of vascular events in patients with melanoma or NSCLC treated with ICIs.
- Published
- 2021
47. Anticoagulation in patients with isolated distal deep vein thrombosis: a meta‐analysis
- Author
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Michela Giustozzi, Cecilia Becattini, Laura Franco, and Giancarlo Agnelli
- Subjects
anticoagulants ,calf vein thrombosis ,distal deep vein thrombosis ,pulmonary embolism ,venous thromboembolism ,Aged ,Anticoagulants ,Blood Coagulation ,Female ,Hemorrhage ,Humans ,Incidence ,Male ,Middle Aged ,Odds Ratio ,Outcome Assessment (Health Care) ,Pulmonary Embolism ,Recurrence ,Risk Factors ,Thrombolytic Therapy ,Treatment Outcome ,Venous Thromboembolism ,Venous Thrombosis ,Hematology ,medicine.medical_specialty ,Deep vein ,030204 cardiovascular system & hematology ,03 medical and health sciences ,0302 clinical medicine ,Outcome Assessment, Health Care ,Recurrent thromboembolism ,medicine ,030212 general & internal medicine ,business.industry ,Incidence (epidemiology) ,Odds ratio ,medicine.disease ,Thrombosis ,Confidence interval ,Pulmonary embolism ,Surgery ,medicine.anatomical_structure ,business ,Cohort study - Abstract
Essentials The optimal management of isolated distal deep vein thrombosis (IDDVT) is undefined. This meta-analysis aimed to assess the clinical benefit of anticoagulation for IDDVT. Anticoagulation reduced the rate of pulmonary embolism without increasing major bleeding risk. Recurrent thromboembolism was less common with more than 6 weeks vs. 6 weeks of anticoagulation. SummaryBackground The optimal management of patients with isolated distal deep vein thrombosis (IDDVT), concerning both the need for anticoagulation and its duration, is undefined. Objectives We performed a meta-analysis of randomized and cohort studies in patients with IDDVT to assess the clinical benefit of: (i) anticoagulation versus no anticoagulation; and (ii) anticoagulant treatment for 6 weeks versus for > 6 weeks. Methods The primary outcome of this analysis was recurrent venous thromboembolism (proximal propagation, recurrence of deep vein thrombosis, and pulmonary embolism). Data were pooled and compared by the use of odds ratio (OR) and 95% confidence interval (CI). Results A reduction in the rate of recurrent venous thromboembolism was observed in patients who received anticoagulation relative to those who did not receive anticoagulation (either therapeutic or prophylactic) (20 studies, 2936 patients; OR 0.50, 95% CI 0.31–0.79), without an increase in the risk of major bleeding (OR 0.64, 95% CI 0.15–2.73). The rate of pulmonary embolism was lower in anticoagulant-treated patients than in controls (15 studies, 1997 patients; OR 0.48, 95% CI 0.25–0.91). A lower rate of recurrent venous thromboembolism was observed in patients who received > 6 weeks of anticoagulant therapy than in those who received 6 weeks of anticoagulant therapy (four studies, 1136 patients; OR 0.39, 95% CI 0.17–0.90). Conclusions In patients with IDDVT, anticoagulation (both therapeutic and prophylactic) reduces the rate of recurrent venous thromboembolism and the incidence of pulmonary embolism as compared with no anticoagulation, without an increased risk of major bleeding. Anticoagulation for > 6 weeks should be preferred over shorter durations.
- Published
- 2017
48. P3850Impact of sex and risk factors for venous thromboembolism on the clinical course of first acute venous thromboembolism. Insights from the PREFER in VTE
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Cecilia Becattini, Stefano Barco, F.A. Klok, Stavros Konstantinides, Giancarlo Agnelli, Maria Cristina Vedovati, Luca Valerio, and Michela Giustozzi
- Subjects
medicine.medical_specialty ,business.industry ,medicine ,Clinical course ,Cardiology and Cardiovascular Medicine ,Intensive care medicine ,business ,Venous thromboembolism - Abstract
Introduction The interaction between sex and specific provoking risk factors for venous thromboembolism (VTE) may influence initial presentation and prognosis. Purpose We investigated the impact of sex on the risk of recurrence across subgroups of patients with first VTE classified according to baseline risk factors. Methods PREFER in VTE was an international, non-interventional registry (2013–2015) including patients with a first episode of acute symptomatic objectively diagnosed VTE. We studied the risk of recurrence in patients classified according to baseline provoking risk factors for VTE consisted of i) major transient (major surgery/trauma, >5 days in bed), ii) minor transient (pregnancy or puerperium, estroprogestinic therapy, prolonged immobilization, current infection or bone fracture/soft tissue trauma); iii) unprovoked events, iv) active cancer-associated VTE. Results A total of 3,455 patients diagnosed with first acute VTE were identified, of whom 1,623 (47%) were women. The percentage of patients with a major transient risk factor was 22.2% among women and 19.7% among men. Minor transient risk factors were present in 21.3% and 12.4%, unprovoked VTE in 51.6% and 61.6%, cancer-associated VTE in 4.9% of women and 6.3% of men, respectively. The proportions of cases treated with Vitamin-K antagonists (VKAs) and direct oral anticoagulants (DOACs) were similar between sexes. Median length of treatment of VKAs was 181.5 and 182.0 days and of DOACs was 113.0 and 155.0 days in women and men, respectively. At 12-months of follow-up, VTE recurrence was reported in 74 (4.8%) women and 80 (4.5%) men. Table 1 shows the sex-specific proportion of recurrences by VTE risk factor categories. Table 1 Major Transient (n=722) Minor transient (n=573) Cancer-associated (n=195) Unprovoked (1965) Women (361) Men (361) OR (95% CI) Women (346) Men (227) OR (95% CI) Women (79) Men (116) OR (95% CI) Women (837) Men (1128) OR (95% CI) One-year follow-up, n (N%) Recurrent VTE, 21 (6.2) 10 (2.9) 0.46 (0.2; 0.9) 9 (2.7) 12 (5.4) 2.09 (0.9; 5.0) 6 (8.0) 5 (4.5) 0.54 (0.2; 1.9) 38 (4.7) 53 (4.7) 1.03 (0.7; 1.6) Major bleeding, 6 (1.8) 5 (1.5) 0.83 (0.3; 2.7) 5 (1.5) 1 (0.5) 0.30 (0.1; 2.6) 1 (1.3) 3 (2.7) 2.07 (0.2; 20) 10 (1.2) 15 (1.4) 1.11 (0.6; 2.4) All-cause death, 37 (10.2) 31 (8.5) 0.82 (0.5; 1.4) 10 (2.9) 14 (6.2) 2.21 (0.9; 5.1) 26 (32.9) 49 (42.2) 1.49 (0.8; 2.7) 33 (3.9) 30 (2.7) 0.66 (0.4; 1.1) Conclusions The proportion of patients with recurrent VTE events after first acute symptomatic VTE provoked by transient risk factors was not negligible during the first year of follow-up during in both women and men. These results may have implications on the decision whether to consider extended anticoagulant therapy in selected patients with provoked events. Acknowledgement/Funding This study was funded by Daiichi Sankyo.
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- 2019
49. Incident Atrial Fibrillation, Dementia and the Role of Anticoagulation: A Population-Based Cohort Study
- Author
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Alexander T. Cohen, Thalia S. Field, Bob Weijs, Saulius Sudikas, Anja Katholing, Michela Giustozzi, Christopher Wallenhorst, Antonio Curcio, Jeffrey I. Weitz, Carlos Martinez, RS: Carim - H01 Clinical atrial fibrillation, RS: CARIM - R2.01 - Clinical atrial fibrillation, and MUMC+: MA Med Staf Spec Cardiologie (9)
- Subjects
Male ,0301 basic medicine ,030204 cardiovascular system & hematology ,Cohort Studies ,0302 clinical medicine ,80 and over ,risk factors ,ORAL ANTICOAGULATION ,atrial fibrillation ,Cognitive decline ,anticoagulation ,Stroke ,Aged, 80 and over ,OUTCOMES ,population study ,Ischemic Attack ,Transient ,Hazard ratio ,Atrial fibrillation ,Hematology ,ASSOCIATION ,Middle Aged ,stroke ,Ischemic Attack, Transient ,Cohort ,Female ,MENTAL-HEALTH ,Risk ,medicine.medical_specialty ,03 medical and health sciences ,Internal medicine ,medicine ,Humans ,Dementia ,Risk factor ,Blood Coagulation ,Aged ,Proportional Hazards Models ,Retrospective Studies ,DECLINE ,business.industry ,MORTALITY ,TIA ,Anticoagulants ,Retrospective cohort study ,medicine.disease ,COGNITIVE IMPAIRMENT ,United Kingdom ,TRANSIENT ISCHEMIC ATTACK ,030104 developmental biology ,LONG-TERM RISK ,business ,Follow-Up Studies ,dementia - Abstract
Introduction Atrial fibrillation (AF) is associated with dementia. Anticoagulation may modify this relationship, but it is unclear if this is due to stroke reduction alone. Methods Age- and sex-matched individuals from the U.K. Clinical Practice Research Datalink (2008–2016) with and without an incident diagnosis of AF were followed for a new dementia diagnosis. We estimated adjusted hazard ratios (aHRs) for incident dementia diagnosis in the AF cohort, overall and stratified by anticoagulation status, using the matched non-AF cohorts as reference. We performed a sensitivity analysis excluding individuals with stroke/transient ischaemic attack (TIA) before the observation period. Results Over 193,082 person-years (mean follow-up 25.7 ± 0.1 months), 347/15,276 AF (2.3%) and 1,085/76,096 non-AF (1.4%) were newly diagnosed with dementia (aHR, 1.31, 95% confidence interval, 1.15–1.49). The AF group had more co-morbidity and higher rates of dementia, both with and without anticoagulation, than non-AF. When those with history of stroke/ TIA before the observation period were excluded and those with incident stroke/TIA during the observation period were censored, AF individuals not on anticoagulation had significantly higher rates of dementia compared with non-AF, aHR 1.30 (1.06–1.58). Conclusion Our findings support the hypothesis that AF is a distinct risk factor for dementia, independent of stroke/TIA and other vascular risk factors. In those without stroke/TIA, risk of dementia is increased only in those who are not on anticoagulation, suggesting anticoagulation is protective presumably through reduction of sub-clinical embolic events. Further prospective research is needed to better ascertain the role of anticoagulation amongst targeted therapeutic strategies to reduce cognitive decline in AF.
- Published
- 2019
50. Risk of recurrent venous thromboembolism after acute pulmonary embolism: Role of residual pulmonary obstruction and persistent right ventricular dysfunction. A meta-analysis
- Author
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Giancarlo Agnelli, Cecilia Becattini, Michela Giustozzi, Pau Cerdà, Antoni Riera-Mestre, and Ludovica Anna Cimini
- Subjects
Male ,medicine.medical_specialty ,Perfusion Imaging ,Ventricular Dysfunction, Right ,computed tomography angiography ,meta-analysis ,pulmonary embolism ,right ventricular dysfunction ,venous thromboembolism ,ventilation-perfusion scan ,030204 cardiovascular system & hematology ,Risk Assessment ,03 medical and health sciences ,0302 clinical medicine ,Recurrence ,Risk Factors ,Internal medicine ,medicine ,Prevalence ,Humans ,Computed tomography angiography ,Aged ,Venous Thrombosis ,Lung ,medicine.diagnostic_test ,Ventilation/perfusion scan ,business.industry ,Anticoagulants ,Hematology ,Odds ratio ,Venous Thromboembolism ,Middle Aged ,medicine.disease ,Pulmonary embolism ,medicine.anatomical_structure ,Treatment Outcome ,Meta-analysis ,Angiography ,Cardiology ,Ventricular Function, Right ,Female ,business ,Pulmonary Embolism ,Perfusion - Abstract
Essentials Debated is the role of residual pulmonary obstruction (RPO) in predicting venous thromboembolism. Whether right ventricular dysfunction (RVD) predicts recurrent venous thromboembolism is unknown. 15 studies on RPO and 4 on RVD and venous thromboembolism were included in this meta-analysis. RPO is a predictor of recurrent venous thromboembolism when assessed by perfusion lung scan. RVD after acute pulmonary embolism is not associated with recurrent venous thromboembolism. Background There is conflicting evidence regarding the role of residual pulmonary obstruction (RPO) or persistent right ventricular dysfunction (RVD) after pulmonary embolism (PE) as a predictor of recurrent venous thromboembolism (VTE). The aim of this study was to assess whether RPO or persistent RVD after PE is associated with recurrent VTE. Methods MEDLINE and EMBASE were searched through December 2018. Studies reporting on (a) RPO either on computed tomography (CT) angiography or perfusion lung scan, or RVD on echocardiography or CT angiography, after therapeutic anticoagulation for the acute PE, and (b) recurrent VTE, were included in this meta-analysis. Results RPO was associated with an increased risk of recurrent VTE (16 studies; 3472 patients; odds ratio [OR] 2.22; 95% confidence interval [CI] 1.61-3.05; I2 = 26%); the association was statistically significant for lung scan-detected RPO (11 studies; 2916 patients; OR 2.21; 95% CI 1.63-3.01) but not for CT angiography-detected RPO (five studies; 556 patients; OR 2.56; 95% CI 0.82-7.94). No significant association was found between persistent RVD and recurrent VTE (four studies; 852 patients; OR 1.62; 95% CI 0.63-4.17). Conclusions RPO is a predictor of recurrent VTE after a first acute PE, mainly when assessed by perfusion lung scan.
- Published
- 2019
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