Antithrombin Deficiency and Thrombosis: A Wide Clinical Scenario Reported in a Single Institution.

Congenital antithrombin (AT) deficiency represents the form of thrombophilia with the highest thrombotic risk. It is characterized by a heterogeneous clinical presentation, depending mostly on the family history of thrombosis and type of genetic mutation. Inherited AT deficiency promotes idiopathic thrombosis at an early age (even in the pediatric population) and at atypical sites. Therefore, a positive family background necessitates ruling out this high-risk thrombophilia at a young age. Studying first-degree relatives, even if they are asymptomatic, is essential to establish thromboprophylaxis and a proper therapeutic approach in case of thrombosis. Patients with congenital AT deficiency require indefinite anticoagulation owing to the high thrombotic recurrence rate. Here, we present four unrelated cases reported in our institution who were diagnosed with hereditary AT deficiency, with a contrasting clinical evolution.

Thrombotic Antiphospholipid Syndrome and Direct Oral Anticoagulants: Unmet Needs and Review of the Literature.

Patients with thrombotic antiphospholipid syndrome (APS) require long-term anticoagulation due to the high-thrombotic recurrence risk. Vitamin K antagonists (VKA) have been traditionally considered the standard of care in thrombotic APS. Nevertheless, the risk of recurrence persists with VKA. There are publications considering different intensities of anticoagulation with VKA; however, the standard-intensity anticoagulation (international normalized ratio between 2.0 and 3.0) is the most recommended. Furthermore, there is no consensus on the role of antiplatelet treatment in thrombotic APS. Nonvitamin K antagonist oral anticoagulants (NOACs) have emerged as an alternative to VKA for many indications. There are, however, discrepancies regarding the management with NOACs in thrombotic APS. In this review, we update the different clinical trials with NOACs in venous, arterial, and microvascular thrombosis and suggest how these patients should be managed in agreement with the expert panels. Although scarce data are published regarding the current role of NOACs in thrombotic APS, the clinical trials failed to demonstrate noninferiority of NOACs compared with VKA, especially in patients with triple antiphospholipid antibodies positivity and/or arterial thrombosis. Single or double antiphospholipid positivity should be analyzed on a case-by-case basis. In addition, we focus on different areas of uncertainty that still remain in thrombotic APS and NOACs. To summarize, emerging clinical trials are needed to provide robust data on the management of thrombotic APS.

Stratification and management of cardiovascular risk in cancer patients. A consensus document of the SEC, FEC, SEOM, SEOR, SEHH, SEMG, AEEMT, AEEC, and AECC.

Both cancer treatment and survival have significantly improved, but these advances have highlighted the deleterious effects of vascular complications associated with anticancer therapy. This consensus document aims to provide a coordinated, multidisciplinary and practical approach to the stratification, monitoring and treatment of cardiovascular risk in cancer patients. The document is promoted by the Working Group on Cardio Oncology of the Spanish Society of Cardiology (SEC) and was drafted in collaboration with experts from distinct areas of expertise of the SEC and the Spanish Society of Hematology and Hemotherapy (SEHH), the Spanish Society of Medical Oncology (SEOM), the Spanish Society of Radiation Oncology (SEOR), the Spanish Society of General and Family Physicians (SEMG), the Spanish Association of Specialists in Occupational Medicine (AEEMT), the Spanish Association of Cardiovascular Nursing (AEEC), the Spanish Heart Foundation (FEC), and the Spanish Cancer Association (AECC).

Abordaje de la fibrilación auricular en pacientes con cáncer activo. Documento de consenso de expertos y recomendaciones / Atrial fibrillation in active cancer patients: expert position paper and recommendations

La mejora en la supervivencia de los pacientes con cáncer ha puesto de manifiesto el impacto clínico que la cardiotoxicidad tiene en el pronóstico tanto cardiovascular como onco-hematológico, sobre todo cuando motiva la interrupción de terapias antitumorales altamente eficaces. La fibrilación auricular es una complicación frecuente en pacientes con cáncer activo y su tratamiento supone un gran reto. Estos pacientes tienen mayores riesgos tromboembólico y hemorrágico y, sin embargo, no se dispone de escalas específicas para guiar la atención clínica. El objetivo de este documento promovido por los grupos de Cardio-Onco-Hematología y Trombosis de la Sociedad Española de Cardiología y elaborado de manera conjunta con las diferentes áreas de conocimiento de la Sociedad Española de Cardiología y con expertos de la Sociedad Española de Oncología Médica, la Sociedad Española de Oncología Radioterápica y la Sociedad Española de Hematología y Hemoterapia, es proporcionar un enfoque multidisciplinario y práctico para la prevención y el tratamiento de la fibrilación auricular de pacientes con cáncer activo y basado en el consenso de expertos

Improvements in survival among cancer patients have revealed the clinical impact of cardiotoxicity on both cardiovascular and hematological and oncological outcomes, especially when it leads to the interruption of highly effective antitumor therapies. Atrial fibrillation is a common complication in patients with active cancer and its treatment poses a major challenge. These patients have an increased thromboembolic and hemorrhagic risk but standard stroke prediction scores have not been validated in this population. The aim of this expert consensus-based document is to provide a multidisciplinary and practical approach to the prevention and treatment of atrial fibrillation in patients with active cancer. This is a position paper of the Spanish Cardio-Oncology working group and the Spanish Thrombosis working group, drafted in collaboration with experts from the Spanish Society of Cardiology, the Spanish Society of Medical Oncology, the Spanish Society of Radiation Oncology, and the Spanish Society of Hematology

Atrial Fibrillation in Active Cancer Patients: Expert Position Paper and Recommendations.

Improvements in survival among cancer patients have revealed the clinical impact of cardiotoxicity on both cardiovascular and hematological and oncological outcomes, especially when it leads to the interruption of highly effective antitumor therapies. Atrial fibrillation is a common complication in patients with active cancer and its treatment poses a major challenge. These patients have an increased thromboembolic and hemorrhagic risk but standard stroke prediction scores have not been validated in this population. The aim of this expert consensus-based document is to provide a multidisciplinary and practical approach to the prevention and treatment of atrial fibrillation in patients with active cancer. This is a position paper of the Spanish Cardio-Oncology working group and the Spanish Thrombosis working group, drafted in collaboration with experts from the Spanish Society of Cardiology, the Spanish Society of Medical Oncology, the Spanish Society of Radiation Oncology, and the Spanish Society of Hematology.

Manejo perioperatorio y periprocedimiento del tratamiento antitrombótico: documento de consenso de SEC, SEDAR, SEACV, SECTCV, AEC, SECPRE, SEPD, SEGO, SEHH, SETH, SEMERGEN, SEMFYC, SEMG, SEMICYUC, SEMI, SEMES, SEPAR, SENEC, SEO, SEPA, SERVEI, SECOT y AEU / Perioperative and periprocedural management of antithrombotic therapy: consensus document of SEC, SEDAR, SEACV, SECTCV, AEC, SECPRE, SEPD, SEGO, SEHH, SETH, SEMERGEN, SEMFYC, SEMG, SEMICYUC, SEMI, SEMES, SEPAR, SENEC, SEO, SEPA, SERVEI, SECOT and AEU

En los últimos años, el número de pacientes anticoagulados y antiagregados está aumentando significativamente. Al ser un tratamiento crónico, es de esperar que a lo largo de su vida necesiten un procedimiento quirúrgico o intervencionista que pueda requerir la interrupción del fármaco antitrombótico. La decisión de retirar o mantener dicho tratamiento estará determinada, por un lado, por el riesgo trombótico y, por otro, por el hemorrágico. De la interacción entre estos 2 factores dependerá la actitud ante la anticoagulación y la antiagregación. El objetivo de este documento de consenso, coordinado desde el Grupo de Trabajo de Trombosis Cardiovascular de la Sociedad Española de Cardiología y certificado por un amplio número de sociedades científicas que participan en el proceso asistencial del paciente durante el periodo perioperatorio o periprocedimiento, consiste en proponer una serie de recomendaciones prácticas y sencillas con el fin de homogeneizar la práctica clínica diaria

During the last few years, the number of patients receiving anticoagulant and antiplatelet therapy has increased worldwide. Since this is a chronic treatment, patients receiving it can be expected to need some kind of surgery or intervention during their lifetime that may require treatment discontinuation. The decision to withdraw antithrombotic therapy depends on the patient's thrombotic risk versus hemorrhagic risk. Assessment of both factors will show the precise management of anticoagulant and antiplatelet therapy in these scenarios. The aim of this consensus document, coordinated by the Cardiovascular Thrombosis Working Group of the Spanish Society of Cardiology, and endorsed by most of the Spanish scientific societies of clinical specialities that may play a role in the patient-health care process during the perioperative or periprocedural period, is to recommend some simple and practical guidelines with a view to homogenizing daily clinical practice

Cardio-Onco-Hematología en la práctica clínica. Documento de consenso y recomendaciones / Cardio-Onco-Hematology in clinical practice. Position paper and recommendations

Los avances en la detección precoz y el tratamiento del cáncer han reducido de manera significativa la mortalidad de los pacientes. Sin embargo, mejorar el pronóstico no es solo curar el tumor, sino prevenir, diagnosticar y tratar eficazmente las complicaciones derivadas de las terapias onco-hematológicas. La toxicidad cardiovascular es un problema ampliamente reconocido con múltiples esquemas terapéuticos; sin embargo, la evidencia científica en el manejo de las complicaciones cardiovasculares de pacientes onco-hematológicos es escasa, pues sistemáticamente se ha excluido de los ensayos clínicos a estos enfermos y las recomendaciones actuales están basadas en consensos de expertos. Es imprescindible crear equipos multidisciplinarios locales para optimizar los resultados en salud de los supervivientes al cáncer. Una preocupación excesiva por la aparición de toxicidad cardiovascular puede impedir terapias potencialmente curativas, mientras que la subestimación de este riesgo compromete el pronóstico vital a largo plazo. El objetivo de este documento, elaborado en colaboración con la Sociedad Española de Cardiología, la Sociedad Española de Oncología Médica, la Sociedad Española de Oncología Radioterápica y la Sociedad Española de Hematología, es actualizar los conocimientos aplicables a la práctica clínica diaria de la cardio-onco-hematología y promover el desarrollo de equipos multidisciplinarios locales que mejoren la salud cardiovascular de los pacientes con cáncer (AU)

Improvements in early detection and treatment have markedly reduced cancer-related mortality. However survival not only depends on effectively cure cancer, but prevention, diagnosis and treatment of cancer-related complications is also needed. Cardiovascular toxicity is a widespread problem across many classes of therapeutic schemes, however scientific evidence in the management of cardiovascular complications of onco-hematological patients is scarce, as these patients have been systematically excluded from clinical trials and current recommendations are based on expert consensus. Multidisciplinary teams are mandatory to decrease morbidity and mortality from both cardiotoxicity and cancer itself. An excessive concern for the occurrence of cardiovascular toxicity, can avoid potentially curative therapies, while underestimating this risk, increases long-term mortality of cancer survivors. The objective of this consensus document, developed in collaboration of the Spanish Society of Cardiology, the Spanish Society of Medical Oncology, the Spanish Society of Radiation Oncology and the Spanish Society of Hematology, is to update the necessary concepts and expertise on cardio-onco-hematology that enable its application in daily clinical practice and to promote the development of local multidisciplinary teams, to improve the cardiovascular health of patients with cancer (AU)

Cardio-Onco-Hematology in Clinical Practice. Position Paper and Recommendations.

Improvements in early detection and treatment have markedly reduced cancer-related mortality. However survival not only depends on effectively cure cancer, but prevention, diagnosis and treatment of cancer-related complications is also needed. Cardiovascular toxicity is a widespread problem across many classes of therapeutic schemes, however scientific evidence in the management of cardiovascular complications of onco-hematological patients is scarce, as these patients have been systematically excluded from clinical trials and current recommendations are based on expert consensus. Multidisciplinary teams are mandatory to decrease morbidity and mortality from both cardiotoxicity and cancer itself. An excessive concern for the occurrence of cardiovascular toxicity, can avoid potentially curative therapies, while underestimating this risk, increases long-term mortality of cancer survivors. The objective of this consensus document, developed in collaboration of the Spanish Society of Cardiology, the Spanish Society of Medical Oncology, the Spanish Society of Radiation Oncology and the Spanish Society of Hematology, is to update the necessary concepts and expertise on cardio-onco-hematology that enable its application in daily clinical practice and to promote the development of local multidisciplinary teams, to improve the cardiovascular health of patients with cancer.

Percepción de los médicos sobre los factores que influyen en la elección de un dicumarínico o de un nuevo anticoagulante oral en pacientes con fibrilación auricular no valvular / Perception of physicians on factors that influence the choice of a dicoumarin or a new oral anticoagulant in patients with non-valvular atrial fibrillation

OBJETIVO: Estudios recientes han demostrado la eficacia y la seguridad de los nuevos anticoagulantes orales (NACO) en la prevención de tromboembolias en pacientes con fibrilación auricular no valvular (FANV). Nuestro objetivo es evaluar qué factores influyen en los médicos para elegir entre dicumarínicos o NACO. DISEÑO: Se analizaron distintas variables, que fueron discutidas y puntuadas siguiendo una metodología Workmat®. EMPLAZAMIENTO: Se realizaron 6 reuniones regionales en España (Levante, Cataluña, Andalucía Extremadura, Madrid, Noroeste y Norte de España). PARTICIPANTES: Participaron 39 especialistas (cardiólogos, neurólogos, hematólogos, internistas y médicos de urgencias y atención primaria). Mediciones: Cada participante puntuó de 1 a 10 (de menor a mayor) el grado de acuerdo con cada variable analizada. RESULTADOS: Se elegiría preferiblemente un NACO en pacientes con fracaso previo del tratamiento dicumarínico (9,7 ± 0,5), riesgo hemorrágico elevado (8,7 ± 1), antecedentes de hemorragia (7,8 ± 1,5) y riesgo trombótico alto (7,7 ± 1,2). Se decantarían por un dicumarínico en casos de disfunción renal grave (1,2 ± 0,4) o moderada (4,2 ± 2,5), buen control con dicumarínicos (2,3 ± 1,5), deterioro cognitivo (3,2 ± 3) y riesgo hemorrágico bajo (4,3 ± 3). La edad, el sexo, el peso, el coste del fármaco, la polimedicación y la existencia de un riesgo trombótico bajo obtuvieron puntuaciones intermedias. CONCLUSIONES: El riesgo trombótico y hemorrágico elevado y el fracaso del tratamiento previo con dicumarínicos predisponen a elegir un NACO. La insuficiencia renal, el deterioro cognitivo, el buen control con dicumarínicos y un riesgo hemorrágico bajo inclinan a decantarse por un dicumarínico clásico

AIMS: Recent studies have demonstrated the efficacy and safety of new oral anticoagulant drugs for the prevention of thromboembolic events in patients with non-valvular atrial fibrillation. Our aim was to evaluate the factors that can influence physicians in their choice between a classic and a new anticoagulant in these patients. DESIGN: Several variables of interest were discussed and analysed using a WorkmatTM methodology. Sites: Six regional meetings were held in Spain (East, Catalonia, Andalusia-Extremadura, Madrid, North-east, and North of Spain). PARTICIPANTS: Meetings were attended by 39 specialists (cardiologists, neurologists, haematologists, internists, and emergency and Primary Care physicians). Measurements: Each participant graded their level of agreement, with a score from 1 to 10, on every analysed variable. RESULTS: A new anticoagulant drug was preferred in patients with previous failure of dicoumarin therapy (9.7 ± 0.5), high haemorrhagic risk (8.7 ± 1), prior bleeding (7.8 ± 1.5), and high thrombotic risk (7.7 ± 1.2). Dicoumarins were preferred in cases of severe (1.2 ± 0.4) or moderate (4.2 ± 2.5) kidney failure, good control with dicoumarins (2.3°æ 1.5), cognitive impairment (3.2 ± 3), and low haemorrhagic risk (4.3 ± 3). Age, sex, weight, cost of drug, polymedication, and low thrombotic risk achieved intermediate scores. There were no differences between the different specialists or Spanish regions. CONCLUSIONS: The presence of a high thrombotic or haemorrhagic risk and the failure of previous dicoumarin therapy lead to choosing a new oral anticoagulant in patients with non-valvular atrial fibrillation, while kidney failure, cognitive impairment, good control with dicoumarins, and a low bleeding risk predispose to selecting a classic dicoumarin anticoagulant

[Perception of physicians on factors that influence the choice of a dicoumarin or a new oral anticoagulant in patients with non-valvular atrial fibrillation]. / Percepción de los médicos sobre los factores que influyen en la elección de un dicumarínico o de un nuevo anticoagulante oral en pacientes con fibrilación auricular no valvular.

AIMS: Recent studies have demonstrated the efficacy and safety of new oral anticoagulant drugs for the prevention of thromboembolic events in patients with non-valvular atrial fibrillation. Our aim was to evaluate the factors that can influence physicians in their choice between a classic and a new anticoagulant in these patients. DESIGN: Several variables of interest were discussed and analysed using a WorkmatTM methodology. SITES: Six regional meetings were held in Spain (East, Catalonia, Andalusia-Extremadura, Madrid, North-east, and North of Spain). PARTICIPANTS: Meetings were attended by 39 specialists (cardiologists, neurologists, haematologists, internists, and emergency and Primary Care physicians). MEASUREMENTS: Each participant graded their level of agreement, with a score from 1 to 10, on every analysed variable. RESULTS: A new anticoagulant drug was preferred in patients with previous failure of dicoumarin therapy (9.7±0.5), high haemorrhagic risk (8.7±1), prior bleeding (7.8±1.5), and high thrombotic risk (7.7±1.2). Dicoumarins were preferred in cases of severe (1.2±0.4) or moderate (4.2±2.5) kidney failure, good control with dicoumarins (2.3±1.5), cognitive impairment (3.2±3), and low haemorrhagic risk (4.3±3). Age, sex, weight, cost of drug, polymedication, and low thrombotic risk achieved intermediate scores. There were no differences between the different specialists or Spanish regions. CONCLUSIONS: The presence of a high thrombotic or haemorrhagic risk and the failure of previous dicoumarin therapy lead to choosing a new oral anticoagulant in patients with non-valvular atrial fibrillation, while kidney failure, cognitive impairment, good control with dicoumarins, and a low bleeding risk predispose to selecting a classic dicoumarin anticoagulant.

El TAFI antigénico no se encuentra elevado en pacientes con enfermedad tromboembólica venosa portadores de las mutaciones factor V Leiden o protrombina 20210A / TAFI plasma levels are not increased in patients with venous thromboembolic disease and factor V Leiden or prothrombin 20210A mutations

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Marcadores de hipercoagulabilidad y daño endotelial en pacientes con disfunción sistólica de origen isquémico / Thrombogenic and Endothelial Damage Markers in Patients with Ischemic Systolic Impairment

Introducción. En raras ocasiones se indica el tratamiento anticoagulante en pacientes con disfunción sistólica de origen isquémico, en ritmo sinusal. Sin embargo, teóricamente podrían estar presentes los 3 brazos que inician el proceso trombótico (tríada de Virchow): estasis sanguínea, lesión del endotelio y marcadores protrombóticos. El objetivo de nuestro estudio ha sido analizar estos dos últimos brazos. Pacientes y método. Estudiamos a 82 pacientes con cardiopatía isquémica demostrada, en ritmo sinusal, y se compararon con 32 sujetos controles de similar edad y sexo. El estudio se realizó al menos 3 meses después de un acontecimiento coronario agudo o descompensación hemodinámica. Determinamos la concentración plasmática de factor von Willebrand como marcador de daño endotelial, y de dímero D y fibrinógeno como marcadores protrombóticos. Mediante ecocardiografía definimos como disfunción sistólica una fracción de acortamiento inferior al 29 por ciento. Resultados. Los pacientes con cardiopatía isquémica demostraron valores estadísticamente superiores de factor von Willebrand (109,2 ñ 31,9 por ciento frente a 85,5 ñ 32,6 por ciento; p < 0,01), no así de dímero D ni fibrinógeno. De los 82 pacientes estudiados, 26 cumplieron criterios de disfunción sistólica. Los pacientes con disfunción sistólica tuvieron valores más elevados de dímero D (0,36 ñ 0,22 frente a 0,26 ñ 0,10 µg/ml, p = 0,04) y fibrinógeno (386 ñ 118 frente a 322 ñ 102 mg/dl, p = 0,03), sin diferencias con los valores de factor von Willebrand. Conclusiones. Los pacientes con cardiopatía isquémica, una vez transcurrido el acontecimiento agudo, presentan datos de daño endotelial, pero no de hipercoagulabilidad. Sin embargo, aquellos con disfunción sistólica presentan un estado hipercoagulable (AU)