Alejandra Guillon Ojesto, of the Internal Medicine Service of the Hospital Universitario de La Princesa, has been the one who, together with Raúl Quirós López, from the Costa del Sol Hospital in Marbella, has been in charge of talking about the anticoagulation in complex clinical situations with atrial fibrillation. And he has done so with an “equation” that has become more complicated as its exponential progress progressed during the 22 Meeting on Heart Failure and Atrial Fibrillation organized by the Spanish Society of Internal Medicine (SEMI), on October 15 and 16. In it, they have made clear four messages, including that the
“We have discussed a practical way to make decisions regarding anticoagulation in situations that are quite frequent in daily clinical practice, but that lead us to doubts because the decision goes far beyond evaluating, exclusively, a thrombotic risk and a bleeding risk, but it involves meditating a series of factors, such as how the patient is or what characteristics they have. After all, like all Medicine, we must individualize“, he assures.
“Don’t deprive patients of the opportunity to receive anticoagulation up front”
Quirós reviewed scenarios such as cognitive impairment, when a patient has an ischemic stroke, when it is convenient to start anticoagulation, if it is convenient to use it early or wait, what treatments would be advisable to start in an intermediate way until a long-term anticoagulation.
Under the title “rsolve the equationn “have made” an escalation of equations, from a first degree, to a second degree, to a third, “adding multiple pathologies and comorbidities, such as cognitive impairment or admission due to stroke. For these situations, internists must know how to find cWhat is the risk benefit balance of each specific patient to make the decision.
Quirós presented Guillón with a case in which the relationship between the Cancer and the atrial fibrillation. They also reviewed how to cope with anticoagulation in a patient with anemia, what risks they have to correct and how they should select patients.
“To complete the equation we have raised it to the third power by adding cancer together with anemia and a situation of frailty, another term that is something that is very in vogue and that is a reality of the day to day. The patients we treat them internists are patients fragile, complicated and it is not always easy to make the decision whether or not they will be able to benefit from it anticoagulant treatment“He explains. So they reviewed the scientific evidence they have available to make a decision.
The final four messages
And with all this review, finally, the presentation left four messages. “The first is that patients are not deprived of the opportunity to receive entry antigulation because they are not contraindications absolute “, Guillón points out. Thus, he explains that” in a complex patient, whether with cognitive impairment or a frail patient, the global and comprehensive assessment will be essential. We must take into account aspects far beyond the thrombotic and hemorrhagic risk, and also assess your situation social Y functional, so that you can find a breakeven in which the patient can benefit from anticoagulation “.
“We know that inexperienced clinicians tend not to use anticoagulation in many of these complex patients. we are taking away the opportunity to prevent a stroke which is a complication that is going to be associated with a lot of morbidity, mortality and dependence, “he says.
The four conclusions of the presentation.
“The comorbilidades -continues- are not contraindications to anticoagulation, you simply have to know how to know them and, above all, quantify them in some way to be able to establish where would the profit limit be. The same in fragility: in itself it is not a contraindication for anticoagulation, but we have to try, as far as possible, to select patients who are less fragile patients or who have ability to correct that condition and thus offer them anticoagulation. We know that they will be able to benefit and we will be able to avoid emboic complications that will mark your prognosis. “
The second message is, therefore, that “you have to carefully assess the risk you have in front of you and try to correct everything that can be modified”
The third – he continues – is to use the safer and more effective anticoagulant strategy. “Based on current evidence data, direct-acting anticoagulants appear to be the most useful option for these types of scenarios, either cognitive impairment, in patients with previous stroke The fragile patients. Even in cancer patients, direct-acting anticoagulants are the safest and most effective option for all their benefits and simplicity of use. And, finally, we must reevaluate “, he concludes.
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