Hémorragie grave et scores prédictifs (étude longitudinale sur 1 an de patients ambulatoires, éduqués, sous AVK)

En 2011, 1,1 million de français ont été traités par AVK avec un âge moyen de 72,5 ans. Les AVK sont en France la première cause d hospitalisation pour accidents iatrogènes (17000 /an) et la première cause de mortalité par iatrogénie directe (5000 à 6000 /an). L évaluation de la balance bénéfices-risques du traitement AVK est délicate. Malgré les indications posées, il y a beaucoup de sous-prescriptions ou non prescriptions du fait d une perception subjective d un risque élevé de saignements graves. Il existe, dans la littérature, des scores prédictifs individuels du risque hémorragique grave mais avec chacun leurs limites, et établis pour la plupart, uniquement sur une population hospitalière. Pourtant, les AVK sont prescrits majoritairement par les généralistes. Nous avons mené une étude épidémiologique descriptive longitudinale multicentrique par suivi d une cohorte de mai 2009 à décembre 2010. Les patients ont bénéficié d un programme d éducation thérapeutique par un réseau ville-hôpital isérois. L analyse a porté sur 949 patients, d âge médian 70 ans (54-81), suivis en médecine générale. L étude a montré qu aucun score existant dans la littérature ne peut être utilisé en médecine ambulatoire après éducation thérapeutique pour prédire le risque de survenue d hémorragie grave à 1 an. L étude nous a permis de mettre en évidence trois facteurs de risque d hémorragie grave à 1 an : l anémie sévère (Hgb65ans, l antécédent de chute dans l année ayant nécessité un recours à un médecin. Le risque élevé d hémorragie grave à 1 an est déterminé uniquement par la présence d une anémie sévère. Nous avions une population rendue plus homogène dans ses comportements vis-à-vis des AVK car éduquée. Lorsque ce nouveau score fera l objet d une validation prospective sur une autre série de patients, cela augmentera la possibilité d extrapoler les résultats aux nouveaux anticoagulants oraux. Ces nouveaux anticoagulants oraux sont caractérisés par un meilleur profil d utilisation : posologie standard pour tous les patients, pas de surveillance biologique. Mais ils ont les mêmes risques hémorragiques indépendamment du comportement du patient et de son médecin. La problématique de la caractérisation des populations à risque reste donc entière.GRENOBLE1-BU Médecine pharm. (385162101) / SudocSudocFranceF

Anaemia as an independent key risk factor for major haemorrhage in patients treated with vitamin K antagonists: Results of the SCORE prospective cohort

International audienc

Rivaroxaban vs Dalteparin in Cancer-Associated Thromboembolism

International audienc

Health-status outcomes with invasive or conservative care in coronary disease

BACKGROUND In the ISCHEMIA trial, an invasive strategy with angiographic assessment and revascularization did not reduce clinical events among patients with stable ischemic heart disease and moderate or severe ischemia. A secondary objective of the trial was to assess angina-related health status among these patients. METHODS We assessed angina-related symptoms, function, and quality of life with the Seattle Angina Questionnaire (SAQ) at randomization, at months 1.5, 3, and 6, and every 6 months thereafter in participants who had been randomly assigned to an invasive treatment strategy (2295 participants) or a conservative strategy (2322). Mixed-effects cumulative probability models within a Bayesian framework were used to estimate differences between the treatment groups. The primary outcome of this health-status analysis was the SAQ summary score (scores range from 0 to 100, with higher scores indicating better health status). All analyses were performed in the overall population and according to baseline angina frequency. RESULTS At baseline, 35% of patients reported having no angina in the previous month. SAQ summary scores increased in both treatment groups, with increases at 3, 12, and 36 months that were 4.1 points (95% credible interval, 3.2 to 5.0), 4.2 points (95% credible interval, 3.3 to 5.1), and 2.9 points (95% credible interval, 2.2 to 3.7) higher with the invasive strategy than with the conservative strategy. Differences were larger among participants who had more frequent angina at baseline (8.5 vs. 0.1 points at 3 months and 5.3 vs. 1.2 points at 36 months among participants with daily or weekly angina as compared with no angina). CONCLUSIONS In the overall trial population with moderate or severe ischemia, which included 35% of participants without angina at baseline, patients randomly assigned to the invasive strategy had greater improvement in angina-related health status than those assigned to the conservative strategy. The modest mean differences favoring the invasive strategy in the overall group reflected minimal differences among asymptomatic patients and larger differences among patients who had had angina at baseline

Initial invasive or conservative strategy for stable coronary disease

BACKGROUND Among patients with stable coronary disease and moderate or severe ischemia, whether clinical outcomes are better in those who receive an invasive intervention plus medical therapy than in those who receive medical therapy alone is uncertain. METHODS We randomly assigned 5179 patients with moderate or severe ischemia to an initial invasive strategy (angiography and revascularization when feasible) and medical therapy or to an initial conservative strategy of medical therapy alone and angiography if medical therapy failed. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. A key secondary outcome was death from cardiovascular causes or myocardial infarction. RESULTS Over a median of 3.2 years, 318 primary outcome events occurred in the invasive-strategy group and 352 occurred in the conservative-strategy group. At 6 months, the cumulative event rate was 5.3% in the invasive-strategy group and 3.4% in the conservative-strategy group (difference, 1.9 percentage points; 95% confidence interval [CI], 0.8 to 3.0); at 5 years, the cumulative event rate was 16.4% and 18.2%, respectively (difference, 121.8 percentage points; 95% CI, 124.7 to 1.0). Results were similar with respect to the key secondary outcome. The incidence of the primary outcome was sensitive to the definition of myocardial infarction; a secondary analysis yielded more procedural myocardial infarctions of uncertain clinical importance. There were 145 deaths in the invasive-strategy group and 144 deaths in the conservative-strategy group (hazard ratio, 1.05; 95% CI, 0.83 to 1.32). CONCLUSIONS Among patients with stable coronary disease and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years. The trial findings were sensitive to the definition of myocardial infarction that was used