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🫀 ПОАК для лечения ФП и ВТЭ на фоне ХБП: новые мета-аналитические данные
🔥 Главное в 3 пунктах
- У пациентов с ФП и хронической болезнью почек (ХБП) ПОАК значительно снижают риск геморрагического инсульта и внутримозговых кровоизлияний по сравнению с варфарином.
- Риск крупных кровотечений у пациентов с ФП и ХБП при приёме ПОАК также существенно ниже, чем на варфарине.
- Для пациентов с ВТЭ и ХБП ПОАК сопоставимы с варфарином как по эффективности профилактики рецидива, так и по риску кровотечений.
🧪 Контекст
Систематический обзор и мета-анализ 15 РКИ (n = 16 361; только пациенты с ФП или ВТЭ и ХБП). Оценивали исходы: инсульт, системная эмболия, тромбоз/рецидив ВТЭ, большие кровотечения.
📍 Практическая польза
У больных с ФП + ХБП рационально отдавать предпочтение ПОАК для снижения риска кровоизлияний, особенно внутримозговых, без потери эффективности. Для ВТЭ на фоне ХБП ПОАК также допустимы как альтернатива варфарину.
🔗 Источник
PubMed
DOI:10.3389/fphar.2025.1615284
❓ Продлённая терапия ВТЭ: какую дозу ПОАК выбрать?
✅ Ответ исследования
Сетевой мета-анализ 5 РКИ (n = 8 781): сниженная доза ПОАК для продлённого лечения ВТЭ столь же эффективна по предотвращению рецидива (ОШ 0,94; 95% ДИ 0,68–1,29), но существеннее снижает риск крупных и клинически значимых незначительных кровотечений (ОШ 0,71; 95% ДИ 0,61–0,82; р<0,0001).
📍 Как применить
У пациентов с высоким риском кровотечений, нуждающихся в удлинённой антикоагуляции после ВТЭ — разумно рассматривать переход на сниженные дозы ПОАК (апиксабан/ривароксабан). Применимо вне зависимости от активности онкологического процесса.
🔗 Источник
PubMed
DOI:10.1016/j.thromres.2025.109476
🛡️ Быстрое выведение апиксабана при экстренной хирургии: опыт применения ADVOS
🧪 Что изучали
Кейс: 72-летний пациент с ФП на апиксабане, поступил с инфекционным эндокардитом и нуждался в экстренной операции на клапане. Послеоперационно использовался альбумин-гемодиализ ADVOS для ускоренного выведения апиксабана при полиорганной недостаточности.
📈 Ключевые результаты
ADVOS обеспечил существенно более быстрое снижение концентрации апиксабана по данным серийных замеров (данные фармакокинетики). При этом геморрагических осложнений не отмечено.
📍 Что это меняет на практике
В экстренных ситуациях у пациентов на ПОАК (например, апиксабане), невозможность использовать специфический антидот может быть частично компенсирована применением современных внепочечных систем детоксикации, таких как ADVOS.
🔗 Источник
PubMed
DOI:10.1055/a-2682-8640
1. A Sole Case of Concurrent Arterial and Venous Thromboses with Massive Pulmonary Embolism and Carriage of Four Genetic Polymorphisms: Factor V Leiden, PAI-1 4G/5G, MTHFR C677T, and ACE I/D-A Case Report.
title
A Sole Case of Concurrent Arterial and Venous Thromboses with Massive Pulmonary Embolism and Carriage of Four Genetic Polymorphisms: Factor V Leiden, PAI-1 4G/5G, MTHFR C677T, and ACE I/D-A Case Report
journal
Reports (MDPI)
date
2025-09-22
doi
10.3390/reports8030167
pmid
40981125
background
Arterial and venous thromboses are distinct clinical entities with unique mechanisms. The simultaneous occurrence of both, particularly with massive pulmonary embolism, is extremely rare and presents diagnostic/therapeutic challenges.
case_presentation
{'patient_age': 61, 'sex': 'male', 'medical_history': ['well-controlled hypertension', 'type 2 diabetes'], 'thrombotic_events': ['deep vein thrombosis (DVT) of right popliteal vein', 'arterial thrombosis of left iliac artery', 'massive pulmonary embolism (PE)'], 'initial_management': ['conservative management per ESC 2019 PE guidelines', 'unfractionated heparin (UFH)', 'low-molecular-weight heparin', 'direct oral anticoagulant (DOAC)', 'adjunctive therapy'], 'revascularization': {'percutaneous_revascularization': 'failed', 'surgical_intervention': 'thromboendarterectomy (TEA) performed'}, 'provoking_factors_absent': ['trauma', 'surgery', 'malignancy', 'antiphospholipid syndrome'], 'genetic_testing_indication': 'Atypical/severe thrombosis without classical provoking factors'}
genetic_findings
['Factor V Leiden (FVL; R506Q genotype, heterozygous)', 'PAI-1 (Plasminogen Activator Inhibitor-1; 4G/5G genotype)', 'MTHFR (Methylenetetrahydrofolate reductase; c.677C>T genotype)', 'ACE I/D (Angiotensin-Converting Enzyme Insertion/Deletion; DD genotype, homozygous)']
conclusions
Although each genetic variant is individually associated with thrombotic risk, their simultaneous presence in a patient with both arterial and venous thromboses has not been previously documented. The case emphasizes the potential for gene-gene interactions to significantly amplify thrombotic risk, prompting a multidisciplinary approach and future research into cumulative genetic risk and its implications for pharmacogenetics and anticoagulation.
keywords
['Thrombosis', 'Arterial thrombosis', 'Venous thrombosis', 'Pulmonary embolism', 'Genetic polymorphisms', 'Factor V Leiden', 'PAI-1', 'MTHFR', 'ACE I/D', 'Thrombophilia', 'Gene-gene interaction', 'Case report']
Journal: Reports (MDPI)
Impact Factor: —
Date: 2025/9/22
PMID: 40981125
DOI: 10.3390/reports8030167
2. Accelerated Apixaban Removal by Using the ADVanced Organ Support (ADVOS) Albumin Hemodialysis System-A Case Report.
title
Accelerated Apixaban Removal by Using the ADVanced Organ Support (ADVOS) Albumin Hemodialysis System-A Case Report
journal
The Thoracic and Cardiovascular Surgeon Reports
date
2024-07-01
doi
10.1055/a-2682-8640
pmid
40959463
abstract
In patients on direct oral anticoagulants (DOAC), emergency surgery is characterized by the occurrence of a massively increased tendency to bleed. Currently, there is no approved antidote for postoperative patients, making specific therapy challenging in these situations. Emergency surgery was required for a 72-year-old male patient who was in cardiogenic shock due to severe aortic regurgitation resulting from acute prosthetic valve endocarditis. Due to atrial fibrillation, the patient was on apixaban, a factor Xa (FXa) inhibitor anticoagulant, until surgery. We used the ADVanced Organ Support (ADVOS) albumin hemodialysis system postoperatively to treat persisting shock with multi-organ failure, acidosis, and DOAC removal. Serial drug-level measurements revealed strongly accelerated apixaban clearance. In line with this, we observed only moderate drainage losses. ADVOS accelerates the removal of apixaban and is a promising therapy for preventing bleeding complications in patients receiving DOAC therapy after emergency surgery.
authors
[]
keywords
['apixaban', 'ADVOS', 'albumin hemodialysis', 'direct oral anticoagulants', 'emergency surgery', 'bleeding', 'multi-organ failure']
main_findings
['ADVOS albumin hemodialysis system accelerated apixaban clearance in a postoperative emergency surgery patient.', 'ADVOS may help prevent bleeding complications in patients on DOAC therapy after emergency surgery.']
clinical_implications
['ADVOS provides an option for enhanced removal of apixaban when standard antidotes are unavailable.', 'May improve management of bleeding risk in DOAC-treated patients requiring emergency surgical interventions.']
Journal: The Thoracic and cardiovascular surgeon reports
Impact Factor: —
Date: 2024/7/1
PMID: 40959463
DOI: 10.1055/a-2682-8640
3. Efficacy and safety of reduced-dose versus full-dose direct oral anticoagulants for extended treatment of venous thromboembolism: A meta-analysis with trial sequential analysis and reconstructed time-to-event data.
title
Efficacy and safety of reduced-dose versus full-dose direct oral anticoagulants for extended treatment of venous thromboembolism: A meta-analysis with trial sequential analysis and reconstructed time-to-event data
journal
Thrombosis Research
publication_date
2025-06-25
impact_factor
5.05
quartile
Q1
DOI
10.1016/j.thromres.2025.109476
PMID
40957133
CRD
CRD420251048675
objective
To evaluate the efficacy and safety of reduced-dose versus full-dose direct oral anticoagulants (DOACs) for extended treatment of venous thromboembolism (VTE), with attention to cancer-associated cases.
methods
{'study_design': 'Meta-analysis of randomized controlled trials (RCTs) with trial sequential analysis and reconstructed time-to-event data', 'data_sources': 'Comprehensive search of major electronic databases through April 2025', 'inclusion_criteria': 'RCTs comparing reduced-dose versus full-dose DOACs for VTE treatment', 'outcomes': ['Recurrent VTE', 'Major or clinically relevant non-major bleeding', 'All-cause mortality'], 'statistical_analyses': ['Pooled risk ratios (RR) with 95% confidence intervals using random-effects models', 'Reconstructed time-to-event data from Kaplan-Meier curves', 'Hazard ratios (HR)', 'Trial sequential analysis (TSA)']}
study_data
{'number_of_RCTs': 5, 'total_patients': 8781, 'subgroups': ['Patients with and without active cancer', 'DOAC types: apixaban, rivaroxaban']}
results
{'recurrent_VTE': {'RR': 0.94, '95CI': '0.68-1.29', 'p_value': 0.7, 'HR': 0.89, '95CI_HR': '0.78-1.02', 'p_value_HR': 0.1}, 'major_or_CRNM_bleeding': {'RR': 0.71, '95CI': '0.61-0.82', 'p_value': '<0.0001', 'HR': 0.61, '95CI_HR': '0.57-0.66', 'p_value_HR': '<0.001'}, 'all_cause_mortality': 'No differences observed', 'subgroup_results': 'Consistent across cancer status and DOAC types', 'TSA': 'Sufficient evidence for efficacy and safety outcomes'}
conclusion
Reduced-dose DOACs are as effective as full-dose regimens for preventing recurrent VTE and provide a superior safety profile, supporting their use for extended anticoagulation, especially in patients at high risk of recurrence.
Journal: Thrombosis research
Impact Factor: 5.05
Date: 2025/6/25
PMID: 40957133
DOI: 10.1016/j.thromres.2025.109476
4. Intracranial Hemorrhage With Direct Oral Anticoagulants vs Low-Molecular-Weight Heparin in Brain Tumors: A Review and Meta-Analysis.
title
Intracranial Hemorrhage With Direct Oral Anticoagulants vs Low-Molecular-Weight Heparin in Brain Tumors: A Review and Meta-Analysis
journal
Neurology
publication_date
2025-09-16
impact_factor
4.57
quartile
Q1
doi
10.1212/WNL.0000000000214140
pmid
40953341
prospero_id
CRD42025635334
objective
Evaluate the safety of direct oral anticoagulants (DOACs) versus low-molecular-weight heparin (LMWH) on the development of intracranial hemorrhage (ICH) in patients with brain tumors.
data_sources
['MEDLINE', 'Embase', 'Web of Science', 'Cochrane Central Register of Controlled Trials']
search_period
January 2010-June 2025
inclusion_criteria
['Randomized-controlled trials or cohort studies', 'Adults (age ≥18 years)', 'Primary or metastatic brain tumors', 'Therapeutic DOACs (apixaban, rivaroxaban, edoxaban, betrixaban, dabigatran)', 'Therapeutic LMWH (enoxaparin, dalteparin, nadroparin, tinzaparin)']
exclusion_criteria
['Prophylactic dosing', 'Non-brain tumor patients']
study_selection
{'publications_identified': 762, 'studies_included': 10, 'design': 'Retrospective cohort studies'}
patient_numbers
{'total': 1572, 'doac_group': 645, 'lmwh_group': 895}
patient_characteristics
{'age_doac': '60.4-67 years', 'age_lmwh': '53-64 years', 'followup_duration_months': '3-12'}
main_outcomes
[{'description': 'Any ICH (DOAC vs LMWH)', 'rr': 0.5, 'ci_95': '0.29-0.87', 'p_value': 0.01, 'i2': 49.5}, {'description': 'Any ICH (3 month follow-up, DOAC vs LMWH)', 'rr': 0.23, 'ci_95': '0.09-0.57', 'p_value': '<0.01', 'i2': '<0.01'}, {'description': 'Primary brain tumors (DOAC vs LMWH)', 'rr': 0.2, 'ci_95': '0.08-0.54', 'p_value': '<0.01', 'i2': '<0.01'}, {'description': 'Metastatic brain tumors (DOAC vs LMWH)', 'rr': 0.86, 'ci_95': '0.44-1.68', 'p_value': 0.66, 'i2': 36.04}]
robustness_and_bias
{'sensitivity_analysis': 'leave-one-out confirmed robustness', 'cumulative_meta_analysis': 'stable estimates with narrowing CIs', 'publication_bias': {'egger_p': 0.19, 'begg_p': 0.59}}
conclusions
DOACs were associated with significantly lower ICH risk compared to LMWH in anticoagulated patients with brain tumors, particularly primary brain tumors. Findings support DOACs as a safe anticoagulant option for arterial and venous thromboembolism, though cautious interpretation is warranted due to observational study designs.
Journal: Neurology
Impact Factor: 4.57
Date: 2025/9/16
PMID: 40953341
DOI: 10.1212/WNL.0000000000214140
5. Efficacy and safety of oral anticoagulants in the treatment of chronic kidney disease with atrial fibrillation or venous thromboembolism: a systematic review and meta-analysis.
title
Efficacy and safety of oral anticoagulants in the treatment of chronic kidney disease with atrial fibrillation or venous thromboembolism: a systematic review and meta-analysis
journal
Frontiers in Pharmacology
publication_date
2025-04-21
impact_factor
5.35
quartile
Q1
doi
10.3389/fphar.2025.1615284
pmid
40949128
clinical_trials_identifier
CRD42024510727
objective
To compare the efficacy and safety of warfarin and direct oral anticoagulants (DOACs) in the treatment of chronic kidney disease (CKD) with atrial fibrillation (AF) or venous thromboembolism (VTE).
methods
{'databases': ['PubMed', 'Embase', 'Web of Science', 'Cochrane Library', 'ClinicalTrials.gov'], 'date_cutoff': '2024-06-30', 'study_type': 'Randomized Controlled Trials (RCTs)', 'population': 'CKD patients with AF or VTE', 'outcomes': {'CKD + VTE': ['Thrombosis recurrence or VTE-related deaths', 'Major bleeding'], 'CKD + AF': ['Stroke or systemic embolism', 'Major bleeding']}, 'risk_of_bias_tool': "Cochrane Collaboration's tool", 'included_studies': 15, 'total_participants': 16361}
results
{'CKD_and_AF': {'DOAC_vs_warfarin_hemorrhagic_stroke': {'RR': 0.455, 'CI': '0.275-0.752', 'P_value': 0.002, 'interpretation': 'DOACs reduced risk compared to warfarin'}, 'DOAC_vs_warfarin_ischemic_stroke': {'significance': 'no significant difference'}, 'DOAC_vs_warfarin_major_bleeding': {'RR': 0.604, 'CI': '0.442-0.825', 'P_value': 0.002, 'interpretation': 'DOACs reduced risk compared to warfarin'}, 'DOAC_vs_warfarin_intracranial_bleeding': {'RR': 0.424, 'CI': '0.287-0.626', 'P_value': '<0.001', 'interpretation': 'DOACs significantly reduced risk compared to warfarin'}}, 'CKD_and_VTE': {'DOAC_vs_warfarin_recurrent_VTE_or_VTE_deaths': {'RR': 0.663, 'CI': '0.409-1.073', 'P_value': 0.094, 'interpretation': 'no significant difference'}, 'DOAC_vs_warfarin_major_bleeding': {'RR': 0.543, 'CI': '0.209-1.407', 'P_value': 0.208, 'interpretation': 'no significant difference'}}}
conclusion
DOACs demonstrate superior efficacy and safety compared to warfarin in patients with AF and CKD; DOACs show comparable efficacy and safety with warfarin in patients with VTE and CKD.
Journal: Frontiers in pharmacology
Impact Factor: 5.35
Date: 2025/4/21
PMID: 40949128
DOI: 10.3389/fphar.2025.1615284