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Antithrombotic Therapy after Bleeding in Elderly Polimorbid Patient: Our Time Challenge

https://doi.org/10.20996/1819-6446-2018-14-4-524-528

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Abstract

In recent years, there has been a clear trend towards an increase in the number of elderly patients suffering from several polymorbid diseases, which considerably complicates the forecast and tactics of management. A clinical case of an elderly patient, suffering for a long time from type 2 diabetes mellitus, receiving insulin and treated with programmed hemodialysis due to terminal chronic renal failure, and suffering from atrial fibrillation in permanent form, is presented. The patient was hospitalized in theCityClinicalHospital№1 named after N.I. Pirogov due to acute repeated myocardial infarction. An emergency percutaneous coronary intervention was performed, the infarct-dependent artery was stented with a drug-eluted stent. The postoperative period complicated by the development of acute blood loss associated with bleeding from the upper sections of the gastrointestinal tract, and severe anemia of the combined genesis (posthemorrhagic, renal). This situation required doctors to make non-standard decisions in the choice of antithrombotic therapy. This clinical case illustrates the difficulties in elderly polymorbid patient management in real clinical practice and the controversial issues arising in the prescribing the antithrombotic therapy, especially after bleeding had developed. The supporting guidelines cannot answer all the questions which the daily practice poses to the doctor. In each case, the resumption of antithrombotic therapy and its optimal choice for an elderly polymorbid patient with developed bleeding is the subject of discussion and presented a real challenge for the treating physician.

About the Authors

M. R. Atabegashvili
City Clinical Hospital №1 named after N.I. Pirogov
Russian Federation

Maria R. Atabegashvili – MD, Doctor, Department of Cardiology

Leninsky Prospect 8, Moscow, 119049 



M. Yu. Gilyarov
City Clinical Hospital №1 named after N.I. Pirogov; I.M. Sechenov First Moscow State Medical University (Sechenov University)
Russian Federation

Mikhail Yu. Gilyarov – MD, PhD, Deputy Chief Physician for Therapeutic Care, City Clinical Hospital №1 named after N.I. Pirogov; Professor, Chair of Preventive and Emergency Cardiology, Sechenov University 

Trubetskaya ul. 8-2, Moscow, 119991



E. V. Konstantinova
City Clinical Hospital №1 named after N.I. Pirogov; Pirogov Russian National Research Medical University
Russian Federation

Ekaterina V. Konstantinova – MD, PhD, Associate Professor, Chair of Faculty Therapy named after A.I. Nesterov, Pirogov Russian National Research Medical University; Doctor, Department of Cardiology, City Clinical Hospital №1 named after N.I. Pirogov

Ostrovitianova ul. 1, Moscow, 117997 



A. N. Kostina
I.M. Sechenov First Moscow State Medical University (Sechenov University)
Russian Federation

Anna N. Kostina – 6th Year Student 

Trubetskaya ul. 8-2, Moscow, 119991



A. P. Nesterov
City Clinical Hospital №1 named after N.I. Pirogov
Russian Federation

Alexey P. Nesterov – MD, PhD, Head of Intensive Care Unit for Patients with Myocardial Infarction 

Leninsky Prospect 8, Moscow, 119049 



T. D. Pakharkova
I.M. Sechenov First Moscow State Medical University (Sechenov University)
Russian Federation

Tatyana D. Pakharkova – 5th Year Student 

Trubetskaya ul. 8-2, Moscow, 119991



A. E. Udovichenko
City Clinical Hospital №1 named after N.I. Pirogov; I.M. Sechenov First Moscow State Medical University (Sechenov University)
Russian Federation

Anna E. Udovichenko – MD, PhD, Head of Department of Interventional Radiology, City ClinicalHospital №1 named after N.I. Pirogov; Associate Professor, Chair of Preventive and Emergency Cardiology, SechenovUniversity

Trubetskaya ul. 8-2, Moscow, 119991



References

1. Wan H., Goodkind D., Kowal P. International Population Reports. P95/16-1, An Aging World: 2015. Washington, DC: U.S. Government Publishing Office; 2016.

2. Lee P.Y., Alexander K.P., Hammill B.G., et al. Representation of elderly persons and women in published randomized trials of acute coronary syndromes. JAMA. 2001;286:708-13.

3. Kandzari D.E., Roe M.T., Chen A..Y, et al. Influence of clinical trial enrollment on the quality of care and outcomes for patients with non-ST-segment elevation acute coronary syndromes. Am Heart J. 2005;149:474-81. doi: 10.1016/j.ahj.2004.11.014.

4. Alexander K.P., Roe M.T., Chen A.Y. et al. Evolution of care for older adults with AMI. J Am Coll Cardiol. 2005;46:1479-97. doi: 10.11909/j.issn.1671-5411.2016.02.012.

5. Schmidt M., Jacobsen J.B., Lash T.L., Toft H. 25 year trends in first time hospitalisation for acute myocardial infarction, subsequent short and long term mortality, and the prognostic impact of sex and comorbidity: a Danish nationwide cohort study. BMJ. 2012;344:e356-64. doi: 10.1136/bmj.e356.

6. Suaya J.A., Stason W.B., Ades P.A., et al. Cardiac rehabilitation and survival in older coronary patients. J Am Coll Cardiol. 2009;54(1):25-33. doi: 10.1016/j.jacc.2009.01.078.

7. Kirchhof P., Benussi S., Kotecha D., et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016;37:2893-962. doi: 10.1093/eurheartj/ ehw210.

8. Ibanez B., James S., Agewall S., et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018;39(2):119-77. doi: 10.1093/eurheartj/ehx393.

9. Roffi M., Patrono C., Collet JP, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST segment elevation: Task Force for the Management of acute coronary syndromes in patients presenting without persistent ST-segment elevation of European Society of Cardiology (ESC). Eur Heart J. 2016;37:267-315. doi: 10.1093/eurheartj/ehv320.

10. Connolly S., Pogue J., Hart R., et al. Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial. Lancet. 2006;367:1903-12. doi: 10.1016/S01406736(06)68845-4.

11. Lopes R.D., Rao M., Simon D.N., et al. Triple vs dual antithrombotic therapy in patients with atrial fibrillation and coronary artery disease. Am J Med. 2016:;129:592-9. doi: 10.1016/j.amjmed. 2015.12.026.

12. Hicks K.A., Stockbridge N.L., Targum S.L., Temple R.J. Bleeding Academic Research Consortium Consensus Report. The Food and Drug Administration Perspective. Circulation. 2011;123:2664-5. doi: 10.1161/CIRCULATIONAHA.111.032433.

13. Halvorsen S., Storey R.F., Rocca B., et al. Management of antithrombotic therapy after bleeding in patients with coronary artery disease and/or atrial fibrillation: expert consensus paper of the European Society of Cardiology Working Group on Thrombosis. Eur Heart J. 2017;38(19):1455-62. doi: 10.1093/eurheartj/ehw454.

14. Valgimigli M., Bueno H., Byrne RA., et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2017;39(3):213-60. doi: 10.1093/eurheartj/ehx419.

15. Mehran R., Baber U., Steg P.G., et al. Cessation of dual antiplatelet treatment and cardiac events after percutaneous coronary intervention (PARIS): 2 year results from a prospective observational study. Lancet. 2013;382:1714-22. doi: 10.1016/S0140-6736(13)61720-1.

16. Steffel J, Verhamme P, Potpara T.S. et al. The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J. 2018;39:1330-93. doi:10.1093/eurheartj/ehy136.

17. Mavrakanas Th.A., Samer C.F., Nessim S.J. et al. Apixaban pharmacokinetics at steady state in hemodialysis patients. J Am Soc Nephrol. 2017;28:2241-8. doi: 10.1681/ASN.2016090980.

18. Hao P.P., Zhang M.X., Li R.J., et al. Clopidogrel 150 vs. 75 mg day in patients undergoing percutaneous coronary intervention: a meta-analysis. Journal of Thrombosis and Haemostasis. 2011;9:62737. doi: 10.1111/j.1538-7836.2011.04216.x.


For citation:


Atabegashvili M.R., Gilyarov M.Y., Konstantinova E.V., Kostina A.N., Nesterov A.P., Pakharkova T.D., Udovichenko A.E. Antithrombotic Therapy after Bleeding in Elderly Polimorbid Patient: Our Time Challenge. Rational Pharmacotherapy in Cardiology. 2018;14(4):524-528. (In Russ.) https://doi.org/10.20996/1819-6446-2018-14-4-524-528

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ISSN 1819-6446 (Print)
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