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Dental Surgery and Antiplatelet Agents: Bleed or Die

Dental Surgery and Antiplatelet Agents: Bleed or Die | Heart and Vascular Health | Scoop.it

In patients taking antiplatelet medications who are undergoing dental surgery, physicians and dentists must weigh the bleeding risks in continuing antiplatelet medications versus the thrombotic risks in interrupting antiplatelet medications. Bleeding complications requiring more than local measures for hemostasis are rare after dental surgery in patients taking antiplatelet medications. Conversely, the risk for thrombotic complications after interruption of antiplatelet therapy for dental procedures apparently is significant, although small. When a clinician is faced with a decision to continue or interrupt antiplatelet therapy for a dental surgical patient, the decision comes down to “bleed or die.” That is, there is a remote chance that continuing antiplatelet therapy will result in a (nonfatal) bleeding problem requiring more than local measures for hemostasis versus a small but significant chance that interrupting antiplatelet therapy will result in a (possibly fatal) thromboembolic complication. The decision is simple: It is time to stop interrupting antiplatelet therapy for dental surgery.

Seth Bilazarian, MD's insight:

From the paper's conclusion:

When a clinician is faced with a decision to continue or interrupt antiplatelet therapy for a dental surgical patient, the decision comes down to “bleed or die.” That is, there is a remote (∼0.2%) chance that continuing antiplatelet therapy will result in a (nonfatal) bleeding problem requiring more than local measures for hemostasis versus an unknown but significant chance that interrupting antiplatelet therapy will result in a (possibly fatal) thromboembolic complication. The decision is fairly simple: It is time to stop interrupting antiplatelet therapy for dental surger

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Pradaxa (dabigatran) Safety Review of Serious Bleeding Events by FDA

UPDATED 11/02/2012. Results of FDAs Mini-Sentinel assessment indicate that bleeding rates associated with new use of Pradaxa do not appear to be higher than bleeding rates associated with new use of warfarin.
My comment -= I hope this review by the FDA reassures patients that the use of Pradaxa is safe as an alternative to warfarin,. This adds to the randomized trial RE-L. Patients are being unnecessarily frightened by TV ads by malpractice attorneys and decisions about options fro treatment are being complicated without reason.,
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Association of Aspirin With Major Bleeding

Association of Aspirin  With Major Bleeding | Heart and Vascular Health | Scoop.it

KEY TAKE AWAY: This trial looked at PRIMARY prevention.  The use of a drug to prevent a first event such as heart attack.  This study has no bearing on SECONDARY prevention.  Drug use to prevent a second event (after a heart attack).  The net benefit of aspirin for secondary prevention would substantially exceed the bleeding risk. =>  DON'T STOP if you are in this group.

There is a debate about aspirin in primary prevention.  Is the bleeding too high compared with reduced heart attack benefit?  Because risk factors for bleeding overlap with cardiovascular risk  factors, "guidelines advocating the routine use of aspirin for primary prevention for individuals above moderate risk of coronary heart disease should be carefully considered as this approach may not be advisable for all patients."

In this study18.5% of patients were younger than 50 - a low risk group.  The annual aspirin bleeding rate is about 0.6%.

I will continue to recommend aspirin for high risk men with multiple coronary risk factors including diabetes after age 50, who do not have a history of GI bleeding, consistent with guidelines from AHA and ADA.

 

The editorial by Jolanta M. Siller-Matula, MD, PhD accompanying the paper does a great job reviewing these issues.

http://goo.gl/82iPr ;

 

From the JAMA article:

The benefit of aspirin for primary prevention of cardiovascular events is relatively small for individuals with and without diabetes. This benefit could easily be offset by the risk of hemorrhage.

In 186,425 individuals treated with low-dose aspirin and matched controls without aspirin.  During 5.7 years follow-up, the bleeding rate was 5.58 for aspirin users and 3.60 (per 1000 person-years) for those without aspirin.  Aspirin was associated with a greater risk of major bleeding.  In a population-based cohort, aspirin use was significantly associated with an increased risk of major gastrointestinal or cerebral bleeding episodes. Patients with diabetes had a high rate of bleeding that was not independently associated with aspirin use.

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Caution on initial bleeding risk with warfarin

Caution on initial bleeding risk with warfarin | Heart and Vascular Health | Scoop.it

My comment: We have new options for patients with atrial fibrillation.  These new drugs Pradaxa and Xarelto are under scrutiny because they are new nadn bleeding hazard has been reprted.  This study helps us understand that warfarin (coumadin) also has significcant risk and the risk is high in the first week of starting thsi medicine.  This early hazard but be an advatage for the newer options.

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Rates of serious bleeding among patients taking warfarin are much higher than those found in clinical trials of the drug and are even greater during the first month of use, according to a five-year study of 125,195 seniors with atrial fibrillation.

The findings complicate an already difficult decision-making process for patients with atrial fibrillation (AF) and highlight the importance of careful management of warfarin, especially during the first month of use, experts said. Warfarin is a generic anticoagulant that is marketed under brand names such as Coumadin and Jantoven.

Compared with clinical trials for warfarin that found serious hemorrhaging rates of between 1% and 3% per year, bleeding problems are more common in real-life clinical practice, said the study, published Nov. 26 in the Canadian Medical Assn. Journal. In the study, the overall rate of hemorrhaging — bleeds serious enough to send patients to the hospital — was 3.8% per person, per year.

However, during the first month of treatment, the annualized hemorrhage rates were 11.8% in all patients and 16.7% among patients with higher risk of stroke. 

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HAS-BLED Bleeding Risk Score in Atrial Fibrillation treated with Warfarin

HAS-BLED Bleeding Risk Score in Atrial Fibrillation treated with Warfarin | Heart and Vascular Health | Scoop.it

Take Home Message:  In cardiovascular medicine there are several circumstances when it is valuable to give anticoagulant medications (blood thinners). These medicines reduce the chance of clot formation and lower the risk of strokes and heart attacks.  Because it is harder to form clots patient will have a higher risk of bleeding.  In atrial fibrillation, we have good criteria for evaluating the risk of clotting and stroke (CHADS2 and CHADS-VASC) but are in search of a good score to help doctors and patients predict bleeding risk when on the blood thinner coumadin  (warfarin).  The HAS-BLED score http://www.mdcalc.com/has-bled-score-for-major-bleeding-risk/ ;  performed best, but not very well in this analysis except for its ability to predict the most serious type of bleeding called intracranial hemmorhage.

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