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Huisarts en wetenschap

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01-07-2016 | Nascholing

Bloedverdunning anno 2016

Auteurs: Robert Willemsen, prof.dr. Geert Jan Dinant, prof.dr. Freek Verheugt, prof.dr. Hugo ten Cate, Nico Weerkamp

Gepubliceerd in: Huisarts en wetenschap | Uitgave 7/2016

Samenvatting

Willemsen R, Dinant GJ, Verheugt F, Ten Cate H, Weerkamp N. Bloedverdunning anno 2016. Huisarts Wet 2016;59(7):312-8.

Naar aanleiding van vragen van huisartsen vatten we in dit artikel de actuele stand van zaken rond antitrombotische medicatie samen. We gaan in op de pathofysiologie van de trombusvorming en behandelen de verschillende soorten antitrombotische medicamenten die beschikbaar zijn. Vervolgens bespreken we per indicatie welke middelen de voorkeur hebben. Pathologische trombusvorming kan onderverdeeld worden in veneuze trombose (zoals bij longembolieën) en arteriële trombose (zoals bij hartinfarcten en herseninfarcten zónder atriumfibrilleren). In beide gevallen is er in de regel een indicatie voor preventie met antitrombotische middelen. In orale vorm zijn er twee soorten antitrombotische medicamenten: de plaatjesremmers en de orale anticoagulantia (OAC). Bij een verhoogd risico op arteriële trombose is er veelal een plaatjesremmer geïndiceerd. Dit is het geval bij stabiel kransslagaderlijden, een doorgemaakt herseninfarct en perifeer arterieel vaatlijden. Bij veneuze trombose of een risico daarop (zoals bij atriumfibrilleren, diepe veneuze trombose of longembolie) is er meestal een indicatie voor behandeling met een OAC. Per indicatie varieert de voorkeursbehandeling echter en soms is er plaats voor combinaties van verschillende antitrombotische medicamenten. Daarnaast moet men het bloedingsrisico per individuele patiënt meewegen, al vormt dat risico maar zelden een harde contra-indicatie voor antitrombotische medicatie. Combinaties van twee verschillende plaatjesremmers zijn in sommige situaties (tijdelijk) te prefereren boven monotherapie met één plaatjesremmer, bijvoorbeeld na een doorgemaakt myocardinfarct. Incidenteel kan men drie middelen combineren, bijvoorbeeld bij patiënten met een doorgemaakt myocardinfarct én atriumfibrilleren.

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Cals J, Willemsen R. Risicoreductie en number needed to treat. Huisarts Wet 2012;56:19.

Kooij A. Cardiovasculair risicomanagement. Houten: Prelum Uitgevers, 2012.

Chung I, Lip GY. ‘Virchow’s triad revisited: blood constituents’. Pathophysiol Haemost Thromb 2003;33:449–54.CrossRefPubMed

Antithrombotic Trialists’ Collaboration,. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 2002;324:71–86.CrossRef

Seshasai SRK, Wijesuriya S, Sivakumaran R, Nethercott S, Erqou S, Sattar N, et al. Effect of aspirin on vascular and nonvascular outcomes. Metaanalysis of randomized controlled trials. Arch Intern Med 2012;172:209–16.CrossRefPubMed

Ogawa H, Nakayama M, Morimoto T, Uemura S, Kanauchi M, Doi N. Lowdose aspirin for primary prevention of atherosclerotic events in patients with type 2 diabetes: a randomized controlled trial. JAMA 2008;3000:2134–41.CrossRef

Daly CA, De Stavola B, Sendon JL, Tavazzi L, Boersma E, Clemens F, et al. Predicting prognosis in stable angina: results from the Euro heart survey of stable angina: prospective observational study. BMJ 2006;332:262–7.CrossRefPubMedPubMedCentral

Tendera M, Aboyans V, Bartelink ML, Baumgartner I, Clément D, Collet JP, et al. ESC Guidelines on the diagnosis and treatment of peripheral artery diseases: document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC). Eur Heart J 2011;32:2851–906.CrossRefPubMed

Stergiopoulos K, Brown DL. Initial coronary stent implantation with medical therapy vs medical therapy alone for stable coronary artery disease: meta-analysis of randomized controlled trials. Arch Intern Med 2012;172:312–9.CrossRefPubMed

10.

Bangalore S, Pursnani S, Kumar S, Bagos PG. Percutaneous coronary intervention vs. optimal medical therapy for prevention of spontaneous myocardial infarction in subjects with stable ischemic heart disease. Circulation 2013;127:769–81.CrossRefPubMed

11.

Sedlis SP, Hartigan PM, Teo KK, Maron DJ, Spertus JA, Mancini GB, et al. Effect of PCI on long-term survival in patients with stable ischemic heart disease. N Engl J Med 2015;373:1937–46.CrossRefPubMed

12.

Juul-Möller S, Edvardsson N, Jahnmatz B, Rosén A, Sørensen S, Ömblus R. Double-blind trial of aspirin in primary prevention of myocardial infarction in patients with stable chronic angina pectoris. Lancet 1992;340:1421–5.CrossRefPubMed

13.

Bhatt DL, Fox KA, Hacke W, Berger PB, Black HR, Boden WE, et al. Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. N Eng J Med 2006;354:1706–17.CrossRef

14.

Roe MT, Armstrong PW, Fox KA, White HD, Prabhakaran D, Goodman SG, et al. Prasugrel versus clopidogrel for acute coronary syndromes without revascularization. N Eng J Med 2012;367:1297–309.CrossRef

15.

Montalescot G, Sechtem U, Achenbach S, Andreotti F, Arden C, Budaj A, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J 2013;34:2949–3003.CrossRefPubMed

16.

CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 1996;348:1329–39.CrossRef

17.

NHG-Standaard Cardiovasculair risicomanagement. www.nhg.org.

18.

Cacoub PP, Bhatt DL, Steg PG, Topol EJ, Creager MA. Patients with peripheral arterial disease in the CHARISMA trial. Eur Heart J 2009;30:192–201.CrossRefPubMed

19.

Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, et al. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The task force for the diagnosis and treatment of aortic diseases of the European Society of Cardiology (ESC). Eur Heart J 2014;35:2873–926.CrossRefPubMed

20.

Mueller C. Biomarkers and acute coronary syndromes: an update. Eur Heart J 2014;35:552–6.CrossRefPubMed

21.

Steg PG, James SK, Atar D, Badano LP, Blömstrom-Lundqvist C, Borger MA, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). Eur Heart J 2012;33:2569–619.CrossRefPubMed

22.

Ten Berg JM, Plokker HWT, Verheugt FWA. Antiplatelet and anticoagulant therapy in elective percutaneous coronary intervention. Curr Control Trials Cardiovasc Med 2001;2:129–40.CrossRefPubMedPubMedCentral

23.

Udell JA, Bonaca MP, Collet JP, Lincoff AM, Kereiakes DJ, Costa F, et al. Long-term dual antiplatelet therapy for secondary prevention of cardiovascular events in the subgroup of patients with previous myocardial infarction: a collaborative meta-analysis of randomized trials. Eur Heart J 2016;37:390–9.PubMed

24.

Bonacaa MP, Bhatt DL, Cohen M, Steg PG, Storey RF, Jensen EC, et al. Longterm use of ticagrelor in patients with prior myocardial infarction. N Engl J Med 2015;372:1791–1800.CrossRef

25.

Magnani G, Storey F, Steg G, Bhatt DL, Cohen M, Kuder J, et al. Efficacy and safety of ticagrelor for long-term secondary prevention of atherothrombotic events in relation to renal function: insights from the PEGASUS-TIMI 54 trial. Eur Heart J 2016;37:400–8.PubMed

26.

Wallentin L, Becker RC, Budaj A, Cannon CP, Emanuelsson H, Held C, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2009;361:1045–57.CrossRefPubMed

27.

Wiviott SD, Braunwald E, McCabe CH, Montalescot G, Ruzyllo W, Gottlieb S, et al. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2007;357:2001–15.CrossRefPubMed

28.

Roffi M, Patrono C, Collet JP Mueller C, Valgimigli M, Andreotti F, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2015; doi:10.1093/eurheartj/ehv320.

29.

Sandercock PA, Counsell C, Gubitz GJ, Tseng MC. Antiplatelet therapy for acute ischemic stroke. Cochrane Database Syst Rev 2008;CD000029.

30.

Halkes PH, Van Gijn J, Kappelle LJ, Koudstaal PJ, Algra A. Aspirin plus dipyridamole versus aspirin alone after cerebral ischaemia of arterial origin (ESPRIT): randomised controlled trial. Lancet 2006;367:1665–73.CrossRefPubMed

31.

Sacco RL, Diener HC, Yusuf S, Cotton D, Ounpuu S, Lawton WA, et al. Aspirin and extended-release dipyridamole versus clopidogrel for recurrent stroke. N Engl J Med 2008;359:1238–51.CrossRefPubMedPubMedCentral

32.

Zinkstok SM, Zuurbier SM, Roos YBWEM. Plaatjesremming na een TIA of herseninfarct: de stand van zaken. Tijdschr Neurol Neurochir 2015;116:26–34.

33.

Verheugt FW, Geersing GJ, Van Kapelle LJ. Toegevoegde waarde van clopidogrel in cardiologie en neurologie. Ned Tijdschr Geneeskd 2014;158:A7609.PubMed

34.

Diener HC, Bogousslavsky J, Brass LM, Cimminiello C, Csiba L, Kaste M, et al. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial. Lancet 2004;364:331–7.CrossRefPubMed

35.

Adam SS, McDuffie JR, Ortel TL, Williams JW jr. Comparative effectiveness of warfarin and new oral anticoagulants for the management of atrial fibrillation and venous thromboembolism: a systematic review. Ann Intern Med 2012;157:796–807.CrossRefPubMed

36.

Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galie N, et al. (The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC) Endorsed by the European Respiratory Society (ERS)). 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014;35:3033–80.CrossRefPubMed

37.

Van der Hulle T, Kooiman J, Den Exter PL, Dekkers OM, Klok FA, Huisman MV. Effectiveness and safety of novel oral anticoagulants as compared with vitamin K antagonists in the treatment of acute symptomatic venous thromboembolism: a systematic review and meta-analysis. J Thromb Haemost 2014;12:320–8.CrossRefPubMed

38.

Van Leent MW, Stevanović J, Jansman FG, Beinema MJ, Brouwers JR, Postma MJ. Cost-effectiveness of dabigatran compared to vitamin-K antagonists for the treatment of deep venous thrombosis in The Netherlands using real-world data. PloS One 2015 Aug 4;10:e0135054.

39.

Simes J, Becattini C, Agnelli G, Eikelboom JW, Kirby AC, Mister R, et al. Aspirin for the prevention of recurrent venous thromboembolism: the INSPIRE collaboration. Circulation 2014;130:1062–71.CrossRefPubMed

40.

NHG-Standaard Diepe veneuze trombose en longembolie. www.nhg.org.

41.

Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 1991;22:983–8.CrossRefPubMed

42.

Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Schron EB, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 2002;347:1825–33.CrossRefPubMed

43.

Van Gelder IC, Hagens VE, Bosker HA, Kingma JH, Kamp O, Kingma T, et al. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med 2002;347:1834–40.CrossRefPubMed

44.

Hobbs FR, Taylor CJ, Jan Geersing G, Rutten FH, Brouwer JR; on behalf of the European Primary Care Cardiovascular Society (EPCCS) SPAF working group. European Primary Care Cardiovascular Society (EPCCS) consensus guidance on stroke prevention in atrial fibrillation (SPAF) in primary care. Eur J Prev Cardiol 2016;23:460–73.CrossRef

45.

Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med 2007;146:857–67.CrossRefPubMed

46.

Mant J, Hobbs FD, Fletcher K, Roalfe A, Fitzmaurice D, Lip GY, et al. Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation of the Aged Study, BAFTA): a randomised controlled clinical trial. Lancet 2007;370:493–503.CrossRefPubMed

47.

Hobbs FD, Roalfe AK, Lip GY, Fletcher K, Fitzmaurice DA, Mant J, et al. Performance of stroke risk scores in older people with atrial fibrillation not taking warfarin: comparative cohort study from BAFTA trial. BMJ 2011;342:d3653.CrossRefPubMedPubMedCentral

48.

Diener HC, Lowenthal A. Antiplatelet therapy to prevent stroke: risk of brain hemorrhage and efficacy in atrial fibrillation. J Neurol Sci 1997;153:112.CrossRef

49.

NHG-Standaard Atriumfibrilleren. www.nhg.org.

50.

Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH, et al. 2012 focused update of the ESC guidelines for the management of atrial fibrillation: an update of the 2010 ESC guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J 2012;33:2719–47.CrossRefPubMed

51.

Ten Cate H. Trombosediensten blijven van waarde. Med Contact 2015;42:2002–3.

52.

Eikelboom JW, Connolly SJ, Brueckmann M, Granger CB, Kappetein AP, Mack MJ, et al. Dabigatran versus warfarin in patients with mechanical heart valves. N Engl J Med 2013;369:1206–14.CrossRefPubMed

53.

Wallentin L Yusuf S, Ezekowitz MD, ALings M, Flather M, Franzosi MG, Pais P, et al. Efficacy and safety of dabigatran compared with warfarin at different levels of international normalised ratio control for stroke prevention in atrial fibrillation: an analysis of the RE-LY trial. Lancet 2010;376:975–83.CrossRefPubMed

54.

Abraham NS, Singh S, Alexander GC, Heien H, Haas LR, Crown W, et al. Comparative risk of gastrointestinal bleeding with dabigatran, rivaroxaban, and warfarin: population based cohort study. BMJ 2015;350:h1857.

55.

Hernandez I, Baik SH, Piñera A, Zhang Y. Risk of bleeding with dabigatran in atrial fibrillation. JAMA Intern Med 2015;175:18–24.

56.

Hess CN, Peterson ED, Peng SA, de Lemos JA, Fosbol EL, Thomas L, et al. Use and outcomes of triple therapy among older patients with acute myocardial infarction and atrial fibrillation. J Am Coll Cardiol 2015;66:616–27.CrossRefPubMed

57.

Verheugt FW. Triple therapy for percutaneous coronary intervention in atrial fibrillation: standard of care, or a nightmare soon to end? J Thromb Haemost 2015;Suppl 1:S332–5.

58.

Lin HJ, Wolf PA, Kelly-Hayes M, Beiser AS, Kase CS, Benjamin EJ, et al. Stroke severity in atrial fibrillation. The Framingham study. Stroke 1996;27:1760–4.CrossRefPubMed

59.

Budnitz DS, Shebab N, Kegler SR, Richards CL. Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med 2007;147:755–65.CrossRefPubMed

60.

Ruiter R, Visser LE, Rodenburg EM, Trifirò G, Ziere G, Stricker BH. Ziekenhuisopnames door geneesmiddelbijwerkingen bij 55-plussers in Nederland. Ned Tijdschr Geneeskd 2012;156:A5182.

61.

Van der Meer FJ, Rosendaal FR, Vandenbroucke JP, Briet E. Bleeding complications in oral anticoagulant therapy. An analysis of risk factors. Arch Intern Med 1993;153:1557–62.CrossRefPubMed

62.

Donze J, Clair G, Hug B, Rodondi N, Waeber G, Cornuz J, et al. Risk of falls and major bleeds in patients on oral anticoagulation therapy. Am J Med 2012;125:773–8.CrossRefPubMed

63.

Devereaux PJ, Anderson DR, Gardner MJ, Putnam W, Flowerdew GJ, Brownell BF, et al. Differences between perspectives of physicians and patients on anticoagulation in patients with atrial fibrillation: observational study. BMJ 2001;323:1218–22.CrossRefPubMedPubMedCentral

64.

Pisters R, Lane DA, Nieuwlaat R, De Vos CB, Crijns HJ, Lip GY. A novel userfriendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest 2010;138:1093–100.CrossRefPubMed

65.

Olesen JB, Lip GY, Hansen PR, Lindhardsen J, Ahlehoff O, Andersson C, et al. Bleeding risk in ‘real world’ patients with atrial fibrillation: comparison of two established bleeding prediction schemes in a nationwide cohort. J Thromb Haemost 2011;9:1460–7.CrossRefPubMed

66.

Hansen ML, Sørensen R, Clausen MT, Fog-Petersen ML, Raunsø J, Gadsbøll N, et al. Risk of bleeding with single, dual or triple therapy with warfarin, aspirin, and clopidogrel in patients with atrial fibrillation. Arch Intern Med 2010;170:1433–41.CrossRefPubMed

Titel: Bloedverdunning anno 2016
Auteurs: Robert Willemsen
prof.dr. Geert Jan Dinant
prof.dr. Freek Verheugt
prof.dr. Hugo ten Cate
Nico Weerkamp
Publicatiedatum: 01-07-2016
Uitgeverij: Bohn Stafleu van Loghum
Gepubliceerd in: Huisarts en wetenschap / Uitgave 7/2016
Print ISSN: 0018-7070
Elektronisch ISSN: 1876-5912
DOI: https://doi.org/10.1007/s12445-016-0187-9

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