Two Ways to Reduce Blood Thinner Risks That Lead to GI Bleeding

For some patients on blood thinners, gastrointestinal bleeding caused by those medications is an adverse event that can be disabling or even fatal.

New research highlights two strategies to potentially reduce the risk.

Some patients are simply taking too many blood-thinning drugs that increase their bleeding risk, while others could start another medication to reduce the risk of gastrointestinal bleeding, Michigan Medicine investigators say.

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And those takeaways build on previous research that shows the use of just one low-dose anticoagulant already nearly doubles the risk of upper gastrointestinal bleeding.

“Anticoagulation strategy is all about the balance between preventing blood clots and reducing the risk of bleeding complications,” says senior author Geoffrey Barnes, M.D., M.Sc., a vascular cardiologist at the University of Michigan Frankel Cardiovascular Center and an assistant professor of internal medicine at the U-M Medical School.

SEE ALSO: More Than One-Third of Patients Risk Major Bleeding By Doubling Up on Blood Thinners

Barnes and other researchers studied 6,907 patients who started using the popular anticoagulant warfarin (also known as Coumadin or Jantoven), between 2011 and 2018, and went to a clinic as part of the Michigan Anticoagulation Quality Improvement Initiative — a multicenter quality improvement collaborative of anticoagulation clinics across the state sponsored by Blue Cross Blue Shield of Michigan.

Nearly half faced an avoidable danger: Forty-five percent of the patients on warfarin were also using anti-platelet therapy such as aspirin, which increases the risk of bleeding.

“Overall, 36 percent of the patients in our study could benefit from one or both of the strategies we present to reduce the risk of GI bleeding,” Barnes says.

The research was published in Vascular Medicine.

Doubling up on blood thinners

Patients in this study were most likely to take blood thinners for venous thromboembolism, which is a blood clot in a vein, or to prevent a stroke due to existing atrial fibrillation.

But the use of two blood antithrombotics might be increasing some patients’ risks of GI hemorrhage without further reducing their risk of having a stroke, researchers say.

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“Many patients may not need to take a medication like aspirin if they’re already taking warfarin,” Barnes says. “We couldn’t find a reason for the second anticoagulant for about 30 percent of the high-risk patients who were on multiple blood thinners. These patients may be able to reduce their risk of GI bleeding simply by stopping one of their blood thinners.”

Some appropriate indications for adding anti-platelet therapy to prevent blood clots in patients already taking warfarin, researchers say, include a recent history of coronary artery disease or heart attack, peripheral arterial disease, coronary artery stents, bypass surgery, stroke or mini-stroke (TIA), or an autoimmune disorder called anti-phospholipid antibody syndrome.

Adding gastroprotection

What about patients that actually do need to take multiple blood thinners, such as warfarin and clopidogrel?

Researchers cite a decade-old expert consensus that recommends something just a minority of clinicians are doing: adding a proton pump inhibitor such as omeprazole (also known as Prilosec) to help suppress acid production in the stomach.

“For those who remain on warfarin plus an antiplatelet drug, a PPI is appropriate to reduce the risk of gastrointestinal bleeding,” says first author Jacob Kurlander, M. D., M.Sc., a gastroenterologist at Michigan Medicine and clinical lecturer in internal medicine at the U-M Medical School. “We know PPIs can reduce the risk for ulcers by around 80 percent.”

Yet in the Vascular Medicine study, only about one in three patients at high risk for GI bleeding were treated with Prilosec or another PPI.

“We’re failing to take advantage of a very effective medication that can prevent a morbid event for people with ulcer risk factors,” Kurlander says, adding that apprehension about PPIs may be partially to blame — and that not everyone should be prescribed a PPI.

Multiple Adverse Effects

PPIs have been linked with multiple adverse effects, including bone fractures and kidney disease, but research hasn’t yet shown whether they’re at fault or simply linked in a noncausal way, he says.

“The theoretical risks of PPIs need to be weighed against the real risk of bleeding,” says Kurlander, who also cares for patients at the VA Ann Arbor Health Care System. “In patients at high risk for bleeding, like those on warfarin and aspirin, the benefits of PPIs for prevention generally outweigh the risks. Bleeding is a common cause of GI hospitalization that is often quite predictable beforehand.”

Changing habits

Providers may not follow the 2008 expert consensus on PPIs because they don’t know about it, because it wasn’t an official guideline statement or because they’re waiting on newer, high quality studies, Barnes says.

Some recent and ongoing studies are currently trying to address the specific question of whether prescribing a PPI reduces the risk of bleeding in those patients on multiple blood thinners, he adds.

In the meantime, Barnes and Kurlander say anticoagulation clinics, which provided the data for this study, might be the right place to examine the underuse of PPIs among patients who take blood thinners.

“Identifying these patients can be a challenge, which could be a great opportunity for anticoagulation clinics to play a role,” Barnes says. “They know when patients are on one or multiple blood thinners.”

Anticoagulation clinics

The anticoagulation clinics, he says, might be able to identify patients who could be candidates to reduce the number of blood thinner medications or prescribe PPIs, and then reach out to the prescribing doctors to see if one of those actions is appropriate.

“Future studies should look at the feasibility of the anticoagulation clinic to identify patients at high risk for GI bleeding and recommending medication changes that could reduce the risk of bleeding,” Barnes says. His research team is currently testing this within the Michigan Anticoagulation Quality Improvement Initiative.

Another new study out of Michigan Medicine found a significant increase in adverse outcomes for people taking both aspirin and warfarin, without a difference in stroke or heart attack outcomes. That paper, led by Barnes and Jordan Schaefer, M.D., a hematologist at Michigan Medicine and assistant professor of internal medicine, was published in JAMA Internal Medicine.

Barnes and Kurlander are both members of U-M’s Institute for Healthcare Policy & Innovation.

Disclosure: Barnes has received grant support from Pfizer/Bristol-Myers Squibb, NHLBI, and Blue Cross Blue Shield of Michigan. He also has received consulting fees from Pfizer/Bristol-Myers Squibb, Janssen, and Portola.

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Stroke Prevention

Atrial Fibrillation (Afib)

Venous Disease

Cardiovascular: Preventive Cardiology

Blood thinners in combination increase bleeding risk, Mayo study finds

• By

  Joel Streed

  August 5, 2019

Gastrointestinal bleeding is a common side effect for many blood-thinning medications. But new Mayo Clinic research finds that risk is amplified when patients receive more than one blood thinner – especially if they’re 75 or older.

The study, published in Clinical Gastroenterology and Hepatology, found patients receiving an anticoagulant drug and an antiplatelet drug, in combination, were at a significantly higher risk of gastrointestinal bleeding. Anticoagulant drugs (such as warfarin and apixaban) slow down blood clotting, while antiplatelets (such as aspirin and clopidogrel) prevent platelets from clumping. Both types of blood thinners are commonly used to prevent strokes in patients with heart conditions.

Neena Abraham, M.D.

“Most of the literature on bleeding risks for blood-thinning medications compares one medication to another, or focuses on patients with one condition,” says lead author Neena Abraham, M.D., a Mayo Clinic gastroenterologist, and site director in Arizona for health care delivery research in the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery. “By not limiting our investigation to one cardiovascular group, we were successful in demonstrating the magnitude of risk of all commonly prescribed antiplatelet and anticoagulant regimens among a broad range of cardiovascular patients.”

The Mayo team of researchers and physicians analyzed 311,211 patients receiving blood-thinning medication between Oct. 1, 2010, and May 31, 2017, using the OptumLabs Data Warehouse — a longitudinal, real-world data asset with de-identified administrative claims and electronic health record data.  

After one year, patients being treated for both atrial fibrillation and coronary artery disease, for example, had a similar risk of bleeding (4 percent) when getting just an anticoagulant or just an antiplatelet, but a 7.4 percent risk when receiving both. Only 29 patients with atrial fibrillation and coronary artery disease would need to be treated with an anticoagulant and antiplatelet in combination to cause one additional bleeding event, according to the study. The researchers say it’s important for physicians to be aware of the increased risk; patients with both of these conditions received a combination of blood thinners 56.8 percent of the time.

The study also found that patients 75 and older were twice
as likely as younger patients to have gastrointestinal bleeding when on two
blood thinners. Patients were at a similar risk for bleeding when using just an
anticoagulant or just an antiplatelet drug, the researchers say.

“Many providers assume that antiplatelets may be safer compared to anticoagulants for patients at moderate-to-high bleeding risks,” Dr. Abraham says. “However, this study demonstrates that these risks may be similar – an important consideration as providers decide on optimal treatment strategies.”

Study co-investigators are Nilay Shah, Ph.D., Peter Noseworthy, M.D., Jonathan Inselman, Xiaoxi Yao, Ph.D., Lindsey Sangaralingham, Gabriella Cornish, and Che Ngufor, Ph.D., all Mayo Clinic, and Jeph Herrin, Ph.D., Yale School of Medicine.

The research was funded by a grant from the Agency for Healthcare Research and Quality, for which Dr. Abraham is the principal investigator.

All Mayo Clinic investigators on this project are affiliated with the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery. Center research focuses on transforming clinical practice. Researchers seek to discover new ways to improve health; translate those discoveries into evidence-based, actionable treatments, processes and procedures; and apply this new knowledge to improve patient care.

About OptumLabs
OptumLabs is a collaborative center for research and innovation co-founded by Optum and Mayo Clinic, and focused on improving patient care and patient value. The OptumLabs Data Warehouse is a longitudinal, real-world data asset with de-identified administrative claims and electronic health record data.

The Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, which leads the relationship with OptumLabs for Mayo Clinic, has published a number of studies identifying areas for potential improvements in health care delivery using the OptumLabs Data Warehouse.

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Stroke



October 29 – World Stroke Day

Stroke is one of the leading causes of death and disability in the world. It is impossible to predict its occurrence, but reducing the risk is quite simple.

The day was first celebrated in 2004 when the World Health Organization declared stroke a global epidemic. This initiative of WHO and partners is dedicated to disseminating information about such a common and dangerous disease as stroke. This disease to this day remains one of the main causes of death and disability both in the world and in Russia. Vascular diseases account for more than half of deaths, with about a fifth of them occurring in people of working age.

In Russia, the death rate from stroke is one of the highest in the world, about 200,000 people die every year, and the same number remain disabled. According to the National Stroke Registry, 31 percent of stroke survivors need help, 20 percent cannot walk on their own, and only eight percent of survivors can return to work.

Very often, neither the patients themselves nor the people around them even suspect that they have had a stroke. But the further life and health of a person depends on the correct and quick “recognition” of the disease and the provision of first aid.

In Russia, on the initiative of a group of relatives of patients and the National Stroke Association (NASI), in 2006, an interregional fund to help relatives of patients with stroke “ORBI” was created. This public organization teaches relatives of patients the basics of care, provides them with information about treatment and rehabilitation centers, and conducts educational campaigns for the general population.

What is a stroke?

Stroke is a circulatory disorder in the brain caused by blockage or rupture of blood vessels. This is a condition where a blood clot – a blood clot – or blood from a ruptured vessel disrupts blood flow in the brain. The lack of oxygen and glucose leads to the death of brain cells and impaired motor functions, speech or memory.

What happens

Three-quarters of all cases of the disease – ischemic stroke. This term refers to a condition in which a blood clot clogs a vessel and blocks blood flow to a specific part of the brain.

Usually a clot forms somewhere in the peripheral vessels of the body, breaks off and reaches the brain through the bloodstream. There, it gets stuck in the small vessels of the brain and blocks the blood flow in them.

The second type of stroke – hemorrhagic – occurs much less frequently. It occurs when a blood vessel ruptures in the brain.

If the vessel is on the surface of the brain, the leaked blood fills the space between the brain and the skull. This is called subarachnoid bleeding. And if the vessel bursts in the deeper structures of the brain, the blood from it fills the surrounding tissues.

But the result of both types of bleeding is the same – a violation of the blood flow to the nerve cells and the pressure of the accumulated blood on the brain tissue.

Consequences of a stroke

Damage to a small area of ​​the brain leads to minor disorders – weakness of the limbs. Violation of blood circulation in large areas of the brain causes paralysis and even death: the degree of damage depends not only on the extent, but also on the location of the stroke.

Many people who have suffered a stroke remain partially or completely paralyzed on one side of the body, speech, and impaired control of urination and defecation appear. Suffer and intellectual abilities – memory, cognitive functions.

Stroke symptoms

The onset of a stroke is usually asymptomatic. But after a few minutes, the brain cells, deprived of nutrition, begin to die, and the effects of a stroke become noticeable.

Common symptoms of a stroke:

• sudden weakness in the face, arm or leg, most often on one side of the body;
• sudden clouding of consciousness, problems with speech or understanding speech;
• sudden vision problems in one or both eyes;
• sudden disturbance of gait, dizziness, loss of balance or coordination;
• sudden severe headache of unknown cause.

It is very important to immediately recognize its symptoms in order to call an ambulance as soon as possible. After all, the sooner treatment is started, the better a person recovers from a stroke.

Remember! The time during which it is possible to restore blood flow in the artery after an ischemic stroke and stop the death of brain cells – the “therapeutic window” – 6 hours. The sooner you seek medical help, the more effective the treatment will be.

A more detailed description of the symptoms of a stroke.

How to recognize a stroke

If you think you are seeing symptoms of a stroke, take a simple three-question test. If the performance of all three tasks is difficult, immediately call the ambulance team, immediately specifying that we are talking about a suspected stroke.

1. Ask person to smile broadly showing teeth. With a stroke, the smile loses its naturalness, becomes very tense and looks like a grin, or one-sided and crooked.
2. Then ask them to close their eyes, raise their hands and hold them in this position for 10 seconds. With a stroke, the muscles weaken, and it is difficult to keep them raised for a long time. If one arm does not rise at all, this is also a sure sign of a stroke.
3. Next ask to repeat some sentence, for example: “This morning the weather is fine.” Stroke is characterized by speech disorders, and the patient does not cope well with this task.

What causes a stroke

• Blood clots that cause ischemic strokes usually form in arteries that are narrowed due to atherosclerotic plaques . These are deposits of proteins that transport cholesterol.
• Blood clots can form due to poor heart function or due to an injury that ruptures blood vessels in the extremities, abdomen, or chest.
• Hemorrhage caused by increased blood pressure – it leads to rupture of small vessels in the brain.
• Another cause of stroke is the rupture of an aneurysm, an abnormally enlarged portion of a blood vessel. But this problem is often caused and exacerbated by high blood pressure.

Major developmental factors

Stroke can affect anyone. Some risk factors, such as the development of an aneurysm or the development of a blood clot as a result of an injury, are difficult to control.

However, a significant number of factors are mainly due to lifestyle.

These factors include:

• high blood pressure;
• high cholesterol;
• diabetes;
• obesity and overweight;
• cardiovascular diseases;
• smoking;
• drug use;
• drinking alcohol.

In addition, stroke is more likely to develop in people over 55 years of age and those whose close relatives have already suffered a stroke. Between the ages of 45 and 55, stroke is twice as common in men as in women.

To understand whether there is a risk of stroke, complex studies are not needed. It is enough to monitor the condition of blood vessels and pressure, eat normally, do not smoke.

You can get tested free of charge at the Health Centers.

How to prevent it?

Stroke prevention is based on the basic principles of a healthy lifestyle .

• Know and control your blood pressure.
• Do not start smoking or stop smoking as soon as possible.
• Add as little salt as possible to your food and avoid canned and processed foods that contain it in excess.
• Control your blood cholesterol levels.
• Follow the basic principles of a healthy diet – eat more vegetables and fruits, avoid added sugar and saturated animal fat.
• Do not drink alcohol. The risk of stroke is highest in the first hours after drinking alcohol.
• Exercise regularly. Even moderate physical activity – walking or cycling – reduces the risk of developing cardiovascular diseases, including stroke.

What are the signs of a stroke and what should I do?

What is a stroke?

The brain can only function if there is a flow of blood through it. Two large blood vessels located on either side of the neck supply blood from the heart to the brain. The blood vessels branch out and get smaller and smaller until the tiny blood vessels supply oxygen and nutrients to all parts of the brain. A stroke occurs in the same way as a heart attack, but occurs in the brain. If the blood supply to the brain is interrupted, the brain is deprived of oxygen and nutrients. This causes damage to brain tissue, which we call a stroke.

Strokes are mainly caused by an occlusion that blocks the flow of blood to the heart or brain. The most common cause of this is the buildup of fatty deposits on the inner walls of the blood vessels that supply the heart or brain. They constrict blood vessels and make them less flexible. This phenomenon is sometimes called arteriosclerosis or atherosclerosis. In this case, the likelihood of blockage of blood vessels by blood clots increases. When this happens, the blood vessels cannot supply blood to the heart and brain, which become damaged.

Strokes can also be caused by two other causes:

• A blood vessel in the brain can rupture and cause bleeding that damages brain tissue. This is called intracerebral hemorrhage. In this case, an important risk factor is high blood pressure. You can get more information about high blood pressure in Section 9.
• If ​​a person has a weak or irregular heartbeat, blood clots can form in the heart and travel through the blood vessels to the brain.

These clots can become lodged in one of the narrow arteries in the brain, blocking the flow of blood to the area of ​​the brain.

Massive stroke

The most common symptom of a stroke is sudden pallor of the face, weakness in an arm or leg, usually on one side of the body. Other symptoms include sudden onset of:

• numbness of the face, arm or leg, especially on one side of the body;
• confusion, difficulty in pronouncing words or understanding speech;
• difficulty looking with one or both eyes;
• difficulty walking, dizziness, balance or coordination disorders;
• severe headache of unknown cause;
• fainting or unconsciousness.

The effects of a stroke depend on which part of the brain is damaged and how severe the damage is. A stroke may affect only one part of the body, such as the face, arm, or leg. It can also completely paralyze one part of the body. A very severe form of stroke can cause sudden death.

Minor stroke

Minor stroke is also called transient cerebrovascular accident. The symptoms of microstrokes may be similar to those of major strokes, but they are milder and last only a short time, usually less than an hour. The person often recovers without any treatment. These microstrokes are a warning; most people who have had one or more small strokes may later suffer from a major stroke.

Note: A person can have a massive stroke without any previous micro strokes.

What to do if you have a stroke

If you see someone showing signs of a stroke, call a doctor or an ambulance immediately, or take that person to the nearest hospital emergency room. Do this even if the symptoms are not very severe, because the stroke can progress. You should do the same in case of a microstroke. If there is no hospital or health center nearby, call a doctor immediately.

Stroke treatment

The level of care you receive may vary depending on where it happened. The amount of help you need depends on how severe the stroke is.

If you arrive at the hospital within three hours of the first sign of a stroke, your doctor may give you an antithrombotic drug right away to dissolve blood clots in your arteries. However, the choice of treatment will depend on the exact cause of the stroke.

To diagnose the type of stroke you have, your doctor will take your medical history, perform a physical exam, and tests such as computed tomography (CT) and magnetic resonance imaging (MRI).

These tests will show if you have an ischemic disorder (caused by an occlusion) or an intracerebral hemorrhage (caused by a ruptured blood vessel in the brain).

Your doctor may prescribe medication to relieve your symptoms and prevent another stroke, and recommend changes in your lifestyle to reduce your risk. If you follow these guidelines, you will achieve the best results. Listen carefully to your doctor’s instructions and ask questions if necessary.

In some patients, special surgery to remove occluded cervical arteries, such as carotid endarterectomy or stenting, may prevent recurrent strokes.

Rehabilitation and long-term care

Patients paralyzed after a stroke require special care in the hospital in order to recover and avoid complications and long-term disability. Many stroke survivors remain disabled to varying degrees and require long-term care at home.

Much of stroke rehabilitation involves teaching patients how to exercise safely. It also includes:

• assistance with walking, eating, dressing, bathing, cooking, reading, writing and using the toilet;
• speech therapy;
• testing to ensure that patients can live safely at home;
• assistance in organizing medical and rehabilitation assistance and scheduling its provision;
• counseling for patients and their families, including advice on financial, legal, and commercial matters;
• occupational therapy to help patients stay physically active and active;
• physical therapy to help regain mobility.

Medicines used to treat and manage stroke

Medicines commonly used to treat stroke include:

• antiplatelet agents such as aspirin;
• anticoagulants or blood thinners such as warfarin;
• medicines for the control of blood pressure, such as calcium channel blockers and angiotensin-converting enzyme inhibitors;
• medicines for lowering blood fat.

These medicines must be used under medical supervision.

Is it possible to get better after a stroke?

Yes, you can, but the degree of long-term disability depends on how long the brain damage caused by the stroke persists. Many stroke survivors remain disabled due to mental disability and somatic disorders. They need the support of family members and friends to help them cope.

How can I avoid another stroke?

It is important to maintain a healthy lifestyle and be sure to take medical treatment such as aspirin and blood pressure medication. People who have had a stroke are more likely to have another stroke.

If you have an irregular heart beat (atrial fibrillation), it is also important to be aware of this and seek medical attention to prevent another stroke. Consult with your doctor on this matter.

A Broadway star’s leg was amputated due to complications from coronavirus

Komsomolskaya Pravda

Search results

Julia SALNIKOVA

April 19, 2020 12:50

He started having problems with blood clotting

The actor’s wife shares news about his health with subscribersPhoto: Instagram. com

Broadway star Nick Cordero will remain disabled after suffering a coronavirus. He was admitted to the hospital about three weeks ago. And immediately to the intensive care unit. He was first diagnosed with pneumonia. Incorrectly selected treatment led to the fact that the actor lost consciousness at home. When they took him to the hospital, it turned out that the pulse was not palpable, but the actor and dancer were resuscitated.

– My whole world has stopped. Please pray for my husband,” wrote his wife Amanda Kloots on Instagram.

She has been keeping fans informed of his treatment since his hospitalization. The woman believes he was misdiagnosed. The doctors did not realize that he had the coronavirus. Nick Cordero began to have clotting problems on his right foot, the blood did not reach the toes. The blood thinners he received affected his blood pressure. There was internal bleeding in the intestines.

On the 18th day of his stay in intensive care, his leg was amputated.

– I told him to fight. I told him that he was strong and could do it,” his wife said.

Broadway star’s leg amputated due to coronavirusPhoto: amandakloots

She launched an action in support of her husband – she asked Nick’s fans to send a video in which they support him. Since his work and main passion was related to Broadway, people began to send videos of their dances to the star.

Nick Cordero was a Tony Award nominee, best known for his films Gang City, The Bronx Story, Rock of the Ages, The Waitress.

The operation was successful, the woman wrote on social networks.

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