SPECIAL ISSUE: DABIGATRAN – PRVNÍ NOAC DOSTUPNÉ V KLINICKÉ PRAXI: PŘÍBĚHY MOLEKULY V 10 KAZUISTIKÁCH
Cor et Vasa Case Reports
Svazek | Volume 2 • Special issue
Květen| May 2019
SPECIAL ISSUE: DABIGATRAN – PRVNÍ NOAC DOSTUPNÉ V KLINICKÉ PRAXI: PŘÍBĚHY MOLEKULY V 10 KAZUISTIKÁCH
Cor et Vasa Case Reports
Svazek | Volume 2 • Special issue
Květen| May 2019
L. Janušová
The case report below discusses the effect of dabigatran in a patient older than 80 years on reducing renal function or quality of life. At that time, the patient is dispensarized in a nephrological clinic for chronic renal disease G2 A2 according to KDIGO, in 2010 the patient is examined for the first-time atrial fibrillation with the need to address subsequent anticoagulation therapy. We know that about one third of patients with atrial fibrillation suffer from significant kidney disease and that reduced renal function is a risk factor for thromboembolic events, but also increases the risk of bleeding. New anticoagulants in patients with renal insufficiency could be a better efficacy and less risk of thromboembolic events.
T. Kvasnička
The present report shows a case of 47-year-old patient who was preoperatively (LCA ligament of LDK ligament sculpture) assessed as “low-risk” for thrombosis and who had postoperative manifestation of DVT (no thromboprophylaxis postoperatively). FVLeiden mutation in heterozygous constitution has been demonstrated. The patient was treated with apixaban (Eliquis) from the beginning, in accordance with the recommended SPC dosage standards. After reducing the dose of Eliquis after 6 months of therapy, recurrence of DVT was found (ileofemoral phlebothrombosis and pulmonary embolism). Calibrated anti Xa monitoring (IU/ml) for apixaban showed insufficient effect in treatment. The reason for the recurrence of thromboembolism, from our point of view, was inadequate anticoagulant therapy with apixaban at a reduced dose of 2.5 mg twice daily. Further, Pradaxa therapy was selected at 2×150 mg daily in the indication of prevention of recurrence of thromboembolism. The therapy is monitored by calibrated tests (Hemoclot). Treatment is effective without bleeding complications and is chosen as a long-term therapy.
R. Havlíček
With the increasing number of patients on anticoagulant therapy, there is a natural increase in cases where the physician must, if necessary, address acute situations where this treatment is a complicating factor. With the expanding portfolio of this drug group, there is a growing need to be familiar with the ever-expanding possibilities of eliminating the effects of anticoagulants safely and without delay. This case report refers to a 62-year-old man who was brought to emergency room with an acute stroke. Essential in the decision making algorithm was the information on his use of dabigatran for previous pulmonary embolism.
A. Novák, P. Vondráček, J. Mayer
Pulmonary embolism is life-threatening disease with incidence 100–200 cases to 100 000 inhabitants. Immediate diagnose and correct therapy has positive impact on the patient. On presented case we want to show a quick correct diagnosis by means of echocardiography and concurrently duplex sonography. If these two ultrasound methods are immediately available, we call them „bed side“. Echocardiography + duplex sonography of deep veins = „double bedside sonography“. The direct finding of thrombus deep vein with clinical status and result of bedside echocardiography can provide anticoagulant or thrombolytic therapy, without indication of the computer pulmonary tomography. Further, we want to demonstrate the differential diagnosis againts acute coronary syndrome. ECG finding in emergency ambulance showed the picture of acute anterior myocardial infarction, the elevation ST segments of V1–V3 electrocardiogram. First, this almost typical ECG picture of myocardial infarction was consulted with physician of angiography laboratory of region cardiology department.
P. Sternthal
Prevention of ischemic stroke is one of the main reasons, why patients with atrial fibrillation and risks (according to CHADS-VASc score) are treated with anticoagulant therapy. Yet, this therapy is not a 100% protection against ischemic stroke, and so even in the era of DOAC we occasionally encounter patients, who suffer from ischemic stroke, despite having received anticoagulant therapy. Reasons may vary, but the possibility of providing adequate effective therapy, whenever possible, is essential (systemic thrombolysis). This is also the case in cases where a patient undergoing long-term treatment with DOAC suffers from an acute ischemic stroke and, despite therapy, is being treated with systemic thrombolysis.
J. Kordík
Idarucizumab, a monoclonal antibody designed for the reversal of anticoagulant effects of dabigatran, has one considerable advantage. Idarucizumab can be administered to patients without time limits. therefore this therapy can be used for successful cessation of bleeding even later when we realize taking medical history, especially medication history, was inaccurate.
M. Hromádka, V. Pechman, O. Sirotek, R. Rokyta
This report presents the case of a 78-year-old male patient with diabetes, treated with dabigatran for atrial fibrillation, complicated by urosepsis with sudden collapse and hypotension. Cardiac tamponade was detected by echocardiography performed in regional hospital. The patient was transferred to our department. Diluted thrombin time (dTT) at admission was 700 ng/mL. dTT was promptly restored to normal values after idarucizumab administration (2× 2,5 g i.v.), allowing us to perform pericardiocentesis. The patient required haemodialysis due to worsening renal function and oliguria. The dTT value was 479 ng/mL 24 hours after idarucizumab administration and the second dose of idarucizumab was administered. Despite the concomitant haemodialysis, the value of dTT was 410 ng/mL 48 hours after the second idarucizumab administration. The third dose of idarucizumab was administered before removal of pericardial drain. Again, no bleeding complication occurred. Diuresis gradually resolved and renal function improved during the comprehensive treatment. The patient was discharged from the hospital on low molecular weight heparin. In total, invasive procedures were not accompanied by bleeding complications. Recurrent high levels of dabigatran are attributable to its redistribution between intravascular and extravascular space and concurrent acute renal failure.
S. Jakubíček, M. Reif
Spontaneous intracerebral hemorrhage (ICH) is a life threatening condition. Up to 40% of patients have fatal outcome within the first 30 days. Mortality rate is 50% per year. The most frequent cause of ICH is arterial hypertension, which as a result of hypertensive arteriolopathy based on hypertrophy and degeneration in the tunica media of small arteries and fibrinoid necrosis, can induce the hematoma located in deep brain structures such as basal ganglia, thalamus, pons. Patients treated with chronic anticoagulation therapy have higher risk of hematoma progression and thus worse clinical outcome. Basal therapeutic approach for these patients is aimed to cancel the anticoagulation effect as soon as possible. This can be difficult in cases when novel oral anticoagulants (NOAC) are used for anticoagulation. Dabigatran is the only NOAC having effective specific antidote called idarucizumab (Praxbind) that is used in clinical practice. A recent clinical research has shown that in patients with intracerebral hemorrhage on dabigatran, idarucizumab can prevent the growth of hemorrhage and improve the clinical outcome.
M. Polák
The case report describes a patient with an implanted pacemaker who has experienced a pacing disorder after performing electrical cardioversion for persistent atrial fibrillation. Due to the anticoagulant therapy by DOAC and the necessity of securing the patient with temporary transvenous stimulation, a reversal of the anticoagulant effect was necessary. This was simple in the patient due to the possibility of administration of the specific antidote idarucizumab. The reverse then enabled the urgent procedure and subsequent revision of the pacemaker complex to be performed safely.
L. Husová
Budd-Chiari syndrome is a serious condition which, if becoming chronic, leads to the development of liver cirrhosis. Anticoagulation therapy in this syndrome is fully indicated, with dabigatran being one of the medications available. Advanced liver cirrhosis as a sequel of this syndrome may be an indication for liver transplantation. A major advantage in this particular case is the availability of the antidote dabigatran (idarucizumab) capable of modulating the coagulation pattern while preventing hemorrhagic episodes. This case report presents initial experience with idarucizumab used in a patient with Budd-Chiari syndrome scheduled for liver transplantation. This is an exceptional case both in terms of indicating a patient with Budd-Chiari syndrome for liver transplantation and idarucizumab use prior to such a demanding procedure that liver transplantation no doubt is.