Antithrombotic Medication Research Articles

Thrombosis in hereditary hemorrhagic telangiectasia

Thrombosis in hereditary hemorrhagic telangiectasia

Measuring Thrombus Stability at High Shear, Together With Thrombus Formation and Endogenous Fibrinolysis: First Experience Using the Global Thrombosis Test 3 (GTT-3).

Thrombus formation in a severely stenosed artery is initiated by high shear activation of platelets, with soluble platelet agonists, such as ADP and thromboxane, playing only a secondary role in the growth and stability of the thrombus. Conventional platelet function tests, however, assess only the soluble agonist-dependent pathway of platelet aggregation. As the thrombus evolves, its stability and ability to withstand dislodgement by arterial flow will determine whether complete and persistent vessel occlusion will occur. The Global Thrombosis Test (GTT), an automated point-of-care technique, simulates the formation of thrombus in whole blood under high shear flow (shear rate >12 000 s-1) and measures the time for occlusive thrombus formation and spontaneous, endogenous thrombolysis/fibrinolysis. The latest GTT-3 model subjects the growing thrombus to upstream pressure, resembling that in a medium-sized artery, and provides an additional assessment of thrombus stability and fibrinolysis rate. It can be used in 3 programs, including a new "hypershear" mode, whereby repetitive cycles of pressure are applied to the growing thrombus, increasing shear rate to ∼22 000 s-1, such as that in patients on mechanical circulatory support. In addition to assessing the risk of arterial thrombosis, the GTT-3 could be used to assess the impact of antithrombotic medications on thrombus stability at high shear. Although current antiplatelet medications target the biochemical axis of platelet aggregation (soluble agonists) and also increase bleeding risk, novel shear-selective antiplatelet therapies may prevent thrombosis while preserving hemostasis. Future studies are needed to assess the usefulness of assessing thrombus stability on cardiovascular and pharmacological evaluation.

Factor XI inhibitors — a breakthrough in prevention and treatment of thromboembolic disorders

Available pharmacological antithrombotic prophylaxis is associated with a low but noticeable risk of bleeding. Hence, there is an ongoing search for effective antithrombotic medications which do not significantly increase bleeding risk. Factor XI inhibitors seem to fulfil these requirements. Results of presently available randomized clinical trials on the use of factor XI inhibitors in venous thromboembolism prophylaxis and prevention of arterial thrombosis are presented.

Dual-layer carotid stenting for symptomatic carotid web: Results from the Caroweb study

Background & purposeCarotid Web (CaW) is a growingly recognized cause of ischemic stroke, associated with a high recurrence risk. Several therapeutic strategies have been proposed as a tertiary prevention including carotid stenting, endarterectomy and antithrombotic medications. Among these, carotid stenting with dual-layer stent may be promising to adequately cover the focal arterial dysplasia. Our aim was to investigate the safety and efficacy of the Casper stent in the treatment of symptomatic CaW. MethodsWe conducted a retrospective analysis of consecutive patients presenting with a symptomatic CaW and included in the ongoing prospective observational multicenter CAROWEB registry. The study period was January 2015 to December 2021. Inclusion criteria were CaW treated with dual-layer Casper stent. Patients treated with other types of carotid stent, endarterectomy or antithrombotic medication were excluded. Clinical and radiological initial data and outcomes were recorded. Resultstwenty-seven patients (with 28 caw) were included. median age was 52 (iqr: 46–68). median delay between index cerebrovascular event and cervical stenting was 9 days (IQR: 6–101). In all cases, the cervical carotid stenting was successfully performed. No major perioperative complication was recorded. No recurrent stroke or transient ischemic attack was observed during a median follow-up time of 272 days (IQR: 114–635). Long-term imaging follow-up was available in 25/28 (89.3%) stented CaW with a median imaging follow-up of 183 days (IQR: 107–676; range: 90–1542). No in-stent occlusion or stenosis was detected. ConclusionIn this study, carotid stenting with dual-layer Casper stent in the treatment of symptomatic CaW was effective regarding stroke recurrence prevention and safe, without procedural nor delayed detected adverse event. However, the optimal therapeutic approach of symptomatic CaW still needs to be explored through randomized trials.

The potential impact of nanomedicine on COVID-19-induced thrombosis

Extensive reports of pulmonary embolisms, ischaemic stroke and myocardial infarctions caused by coronavirus disease 2019 (COVID-19), as well as a significantly increased long-term risk of cardiovascular diseases in COVID-19 survivors, have highlighted severe deficiencies in our understanding of thromboinflammation and the need for new therapeutic options. Due to the complexity of the immunothrombosis pathophysiology, the efficacy of treatment with conventional anti-thrombotic medication is questioned. Thrombolytics do appear efficacious, but are hindered by severe bleeding risks, limiting their use. Nanomedicine can have profound impact in this context, protecting delicate (bio)pharmaceuticals from degradation en route and enabling delivery in a targeted and on demand manner. We provide an overview of the most promising nanocarrier systems and design strategies that may be adapted to develop nanomedicine for COVID-19-induced thromboinflammation, including dual-therapeutic approaches with antiviral and immunosuppressants. Resultant targeted and side-effect-free treatment may aid greatly in the fight against the ongoing COVID-19 pandemic.

Antithrombotic therapy and digestive endoscopy.

Antithrombotic therapy and digestive endoscopy Antithrombotic therapy comprises anticoagulation and antiplatelet treatment. The number of patients treated with various forms of antithrombotic therapy is growing. Procedures of digestive endoscopy are very frequently indicated by general practitioners and doctors of various specialisations. Interdisciplinary cooperation and mutual understanding are required in order for digestive endoscopy to be effective and safe. Hence, we present an overview based on recent European, British (1), and North American guidelines (2) for endoscopic procedures, with respect to guidelines for perioperative care in general (3). Antithrombotic therapy management in patients undergoing digestive endoscopy procedures is based on individual consideration of postprocedural bleeding (particularly a delayed one) on one hand, and thromboembolic risk on the other hand, ideally in cooperation with the physician prescribing antithrombotic therapy. Despite all efforts, patients taking antithrombotic medication are at a higher risk of postprocedural bleeding in comparison with those without this risk; this fact should be accepted by attending physicians and patients should be informed of it. Postprocedural bleeding is mostly manageable with a subsequent endoscopic procedure. By contrast, cerebral and cardiovascular thromboembolic complications are often life-threatening and not uncommonly disabling. One should always consider postponing an elective procedure in a patient with temporary antithrombotic therapy (after pulmonary embolism or after coronary stent insertion). Basic principles of administration of antithrombotic therapy in the context of an endoscopic procedure are described in Table 1. Digestive endoscopy procedures can be categorized according to postprocedural bleeding risk (Table 2). Postprocedural bleeding risk can be specifically reduced in some procedures (ERCP with papillary balloon dilation instead of sphincterotomy, mechanical securing of polypectomy base, etc.). Acetylsalicylic acid administered as secondary prevention (primary preventive indications are very narrow nowadays) should not be discontinued perioperatively (discontinuation is associated with an approximately threefold increase in thrombotic complications!). The riskiest procedures are the only exception in which discontinuation is explicitly requested by the digestive endoscopist. Reduction of dual antiplatelet therapy is better abandoned in high-risk patients - particularly those with recently implanted coronary stents (Table 3) - and postponement of an elective procedure should always be considered. Bridging of warfarin with low-molecular-weight heparin (LMWH) is not indicated routinely (in some cases, this practice increases the bleeding risk). Bridging with LMWH is appropriate in patients with high (or moderate) thromboembolic risk (Table 5). Furthermore, LMWH therapy carries specific risks, particularly in patients with renal function impairment (Table 4). In patients with a high thromboembolic risk, a statement of the physician indicating anticoagulation is always appropriate before an elective procedure (Table 6). Direct oral anticoagulants (DOACs) should not be administered on the day of the procedure, not even in one with a low risk (e.g., biopsy); a longer withdrawal is recommended in high-risk procedures (this cessation should not be bridged with LMWH given the rapid onset and elimination half-time) (Table 7). Recommencement of antithrombotic therapy after a high-risk endoscopic procedure should always be determined by the endoscopist and the recommended intervals should be considered minimal: 1-2 days after the procedure in the case of P2Y12 inhibitors; 2-3 days after the procedure in the case of DOACs; in the evening of the day of the procedure for warfarin with a maintenance (not saturation) dose; and 48 hours after the procedure in the case of LMWH at a therapeutic dose. Earlier administration of a lower-than-therapeutic dose of LMWH (twice a day per weight) can be considered in this context: prophylactic (once a day) or higher prophylactic (once a day per weight) doses. In general, a full anticoagulation effect should not be achieved earlier than approximately 48 hours after the procedure. The patient should be properly informed of the course of antithrombotic therapy before and after the endoscopic procedure, including a written form (a calendar can be downloaded online for this purpose).

Perioperative Management of Dental Surgery Patients Chronically Taking Antithrombotic Medications.

The development of medicine is based not only on the introduction of new methods of treatment, but also on the use of increasingly effective drugs, including antithrombotic drugs. Drugs that inhibit the activity of platelets (antiplatelet and anti-aggregating drugs) and pharmaceuticals that inhibit the activity of plasma coagulation factors (anticoagulants) are used in antithrombotic therapy. In our daily practice we encounter patients who take chronic antiplatelet or anticoagulant drugs. However, more and more often we are dealing with patients who are treated with two antiplatelet drugs, an antiplatelet and an anticoagulant or even undergoing triple antithrombotic therapy. When preparing the patient for invasive craniofacial procedures, it should be assessed whether the temporary discontinuation of antithrombotic treatment due to the fear of excessive perioperative bleeding is justified and will not result in life-threatening thromboembolic complications. The authors discuss in detail the medications used in modern antithrombotic treatment and present a perioperative management procedure with a patient who takes l4 z of these medications chronically.

Delayed pericardial effusion or tamponade following left atrial appendage closure: A single-center experience

Pericardial effusion or pericardial tamponade (PE/PT) is a relatively common complication of left atrial appendage closure (LAAC). However, delayed PE/PT is rare with limited data. The aim of the study was to analyze the incidence and clinical consequences of delayed PE/PT following LAAC. Patients with nonvalvular AF who were successfully implanted with LAAC devices from October 2014 to April 2021 were consecutively screened. Subjects experiencing delayed PE/PT after LAAC were included. All treatment sessions of the subjects were recorded in detail. After discharge, the patients were followed up for clinical outcomes. A total of 748 patients with successful LAAC [nitinol cage device (475 Watchman 2.5), nitinol plug device (131 ACP and 142 LAmbre)] were screened. Six patients experienced delayed PE/PT (1 Watchman, 2 ACP, 3 LAmbre). The incidence of delayed PE/PT was higher in patients with a nitinol plug device (1.8% vs. 0.2%, P=0.027). Bloody PE only occurred in patients with a nitinol plug device (5/273, 1.8%). All the patients accepted pericardiocentesis and discontinuing antithrombotic medication, and none of the patients died or needed cardiac surgery. All patients were followed up for 810 (598, 1174) days after discharge. None of them developed constrictive pericarditis or thromboembolic or major bleeding events. Delayed PE/PT is rare but can occur, and the incidence of delayed bloody PE/PT for the nitinol plug device was higher than that for the nitinol cage device. The strategy of emergency pericardiocentesis combined with discontinuing antithrombotic medication may be effective for delayed bloody PE/PT.

Values and Preferences Towards Antithrombotic Therapy in Patients with Myeloproliferative Neoplasms: A Qualitative Study

Background: Philadelphia chromosome-negative (Ph-) myeloproliferative neoplasms (MPNs), including polycythemia vera (PV) and essential thrombocythemia (ET), confer a high risk for thrombotic events. The primary and secondary prevention of thrombotic events is managed with antithrombotic therapy, which is complicated by a high frequency of bleeding in Ph- MPN patients. When making shared decisions about antithrombotic therapy, physicians and patients must weigh thrombotic and bleeding risks and their consequences. However, little is known about the preferences and perceptions of patients with MPNs regarding antithrombotic therapy. The objectives of this study were therefore to identify: 1) patient-important factors and 2) barriers and facilitators to the use of antithrombotic therapy as thromboprophylaxis among patients with MPNs. Methods: In this qualitative study, semi-structured focus groups (FGs) were conducted with people diagnosed with PV and ET recruited via email from Canadian MPN Patient Support Groups. Focus groups were stratified based on previous history of a bleed requiring medical attention, previous history of thrombosis, or no history of bleeding or thrombosis. Open-ended questions and probes were used to guide FG discussions and FGs concluded with a polling exercise in which participants selected the most important facilitators and barriers to antithrombotic medication use. Data were analyzed using thematic analysis and the techniques of the Framework Method (Gale et al., 2013). Two team members independently reviewed and coded FG audio transcripts using NVivo to develop a coding framework. Coding comparison queries were run to assess agreement, discussion was used to resolve discrepancies, and the coding framework was iteratively refined. Data were reviewed by two members of the study team and preliminary themes were identified, guided by the research objectives. Results: We present preliminary results of our analysis. Four FGs were conducted with a total of 18 participants (range 3-6 participants). The average age of participants was 59 years, 13 (72%) were female and 10 (56%) had ET. Participants were taking aspirin (16/18, 89%), warfarin (1/18, 5%), and apixaban (1/18, 5%). Three participants (17%) had a prior thrombotic event, (ischemic stroke, myocardial infarction, and splanchnic vein thrombosis), and 3 (17%) had a prior bleeding event (epistaxis, gastrointestinal [GI] bleeding). The most important factors identified for taking antithrombotic therapy were preventing thrombotic events (94%) and a physician's recommendation (83%). Many participants perceived there was no choice when it came to the decision to use antithrombotic therapy; rather it was a physician-prescribed, necessary treatment to prevent thrombosis. Perceived downsides to antithrombotic therapy included the higher risk of bleeding, prolonged bleeding, and bruising, with specific concern about the visibility of bruises. Several participants also voiced concerns about the impact of long-term aspirin use on GI health and the potential for ulcer formation. A few participants reported lowering their dose of aspirin, as per physician recommendations or by self-adjusting the dose based on concerns about GI bleed risk. However, some participants did not perceive any downsides to using antithrombotic therapy or considered that the benefits outweighed the risks, while others were less certain. Additional analyses are underway. Conclusion: Patients with MPNs accept antithrombotic therapy use, motivated by trust in their physician's recommendations and the desire to prevent a stroke or myocardial infarction. While these values and preferences align with PV and ET treatment guidelines, it is important to recognize the influence that physician recommendations have on patients' perceptions towards antithrombotic therapy in the shared decision-making process.

Abstract 13642: Post-Operative Bleeding Risk in TAVR Patients With Atrial Fibrillation

Introduction: Antithrombotic medications are the subject of multiple transcatheter aortic valve replacement (TAVR) randomized control trials. Pragmatically, decisions are complicated by conditions such as atrial fibrillation (AF) that also require lifetime anticoagulation. Our study examines antithrombotic medications in a real-world cohort to identify risk factors for bleeding by 1-year post-TAVR. Methods: This retrospective study includes 844 patients undergoing transfemoral TAVR between 2015 and 2020. Pre- and post-operative medications, comorbidities, and 1-year outcomes were recorded based on review of the medical record. Antithrombotic regiment decisions were made on a case-by-case basis. Bleeding classification followed VARC2 definitions. Patients were stratified into two groups based on history of AF. Multivariable logistic regression was used to determine independent predictors of bleeding. Results: Among the 844 patients, 290 had comorbid AF (34%). Patients with AF were older (80.3 vs 77.8 years; p<0.001), more frequently had cardiovascular comorbidities, and had lower LVEF (52.4% vs 56.8%; p<0.001). Patients with AF were more likely to experience major or life-threatening bleeding (10% vs 5%; p<0.001), but there were no differences in rates of myocardial infarction, cerebrovascular accident, nor death by 1-year follow-up. After controlling for risk factors including anticoagulation and increases to antithrombotic regiment post-operatively, the independent risk predictors of major or life-threatening bleed included female sex [OR 1.522 (1.118-1.741); p=0.018], severe baseline anemia [2.938 (1.146-7.533); p=0.025], and atrial fibrillation [2.195 (1.206-3.997); p=0.010]. Conclusions: Female sex, severe baseline anemia, and comorbid atrial fibrillation are predictors of major or life-threatening bleed by 1 year in patients undergoing transfemoral TAVR, independent of antithrombotic regiment.

Abstract 12051: Anticoagulation Use After Percutaneous Left Atrial Appendage Occlusion in Medicare Beneficiaries

Background: In the pivotal trials of percutaneous left atrial appendage occlusion (pLAAO), patients received warfarin for 45 days followed by dual antiplatelets up to 6 months post pLAAO; however, real-world use of anticoagulants post pLAAO implantation is unknown. Objectives: To assess prescription anticoagulation and antiplatelet use after pLAAO in Medicare beneficiaries. Methods: We used a 15% sample of Medicare claims data (2015-2018) to identify patients who received pLAAO. Prescriptions claims were used to assess anticoagulant and antiplatelet use (other than over the counter aspirin) up to 12 months post pLAAO. Results: A total of 2,780 patients were included. The mean CHA2DS2-VASc score was 4.9. There were 2,171 (78.1%) patients who were prescribed anticoagulants after pLAAO. The most common drug was warfarin (63.8% of total anticoagulants used), followed by apixaban in 23.2% of the patients. At 3 months, 54.3% of the patients were taking a potent antithrombotic (anticoagulant or a P2Y12 inhibitor) medication. The number of patients taking potent antithrombotics decreased over time but remained high at 6 months (40.9%) and at 12 months (19.0%). Conclusion: Anticoagulation use remained high at 6- and 12-months post pLAAO; longer than what’s used in the pivotal trials. Further studies are needed to determine if this is associated with increased bleeding risk. Furthermore, this data should be taken into consideration when assessing stroke risk post pLAAO.

Frequency of Hemorrhagic Side Effects of Botulinum Neurotoxin Treatment in Patients with Blepharospasm and Hemifacial Spasm on Antithrombotic Medication.

The aim of this study was to investigate the frequency of hemorrhagic side effects of botulinum neurotoxin A injections (BoNT/A) for the treatment of benign essential blepharospasm (BEB) and hemifacial spasm (HFS) in patients taking antithrombotic drugs (ATD). A total of 140 patients were included (female: 65%; BEB: 75%; mean age: 70 ± 12 years). According to their current antithrombotic medication, participants were either assigned to the ATD group (41%), or to the control group (59%). The ATD group was further divided into subgroups depending on the medication administered: acetylsalicylic acid, ADP receptor antagonists, direct oral anticoagulants, vitamin-K antagonists, or dual antiplatelet therapy. The frequency of hemorrhagic side effects was recorded by retrospective analysis of past treatments as documented in the patient's file set in relation to the number of past treatments (hematoma frequency of past treatments, HFretro) as well as by a prospective survey capturing the side effects of one single treatment (hematoma frequency of actual treatment, HFactual). There was no significant difference in hematoma frequency between the ATD group and the control group, neither for past (HFretro: ATD: 2%; 45/2554; control: 4%; 109/2744) nor for the current BoNT/A treatments (HFactual: ATD: 30%; 16/53; control: 31%; 22/72). Even between ATD subgroups, hematoma frequency did not differ significantly. Overall, hemorrhagic side effects of the BoNT/A treatment for BEB and HFS were mild and non-disabling.

Creation of a novel specialty residency in thrombosis and hemostasis management

AbstractAntithrombotic and hemostatic medications are essential, yet high‐risk therapies commonly used for the prevention and treatment of thrombosis and bleeding. Since first demonstrating the ability to improve the safety and quality of heparin and warfarin‐related care many years ago, pharmacists now play an important expanded role in more comprehensive and complex thrombosis and hemostasis management programs. Such programs encompass the prevention and treatment of thrombosis and bleeding across care settings, medical indications, and professional services. These programs impact not only appropriate use of antithrombotic medications, but also of antidotes, blood products, medical devices, laboratory testing, and other important aspects of care. In addition to providing direct patient care, pharmacists are increasingly involved in the development and implementation of system‐level processes and quality improvement activities that require technical knowledge, leadership skills, and effective multidisciplinary collaboration. Evolution in health care regulation and accreditation standards, along with national efforts to advance the concept of Anticoagulation Stewardship, will likely accelerate the growth and expansion of thrombosis and hemostasis management programs, increasing the demand for well‐trained and experienced clinical pharmacists. However, none of the existing accredited specialty pharmacy residency programs encompasses the full range of skills and experiences necessary for new pharmacists to practice effectively in this complex and rapidly evolving field. This manuscript describes the evolution of the Hemostasis and Antithrombotic Stewardship program at Brigham and Women's Hospital and the development of a novel postgraduate year 2 (PGY2) pharmacy residency in this specialty area. It provides details of the new PGY2 residency program curriculum and puts forth a vision of success for such programs at the local and national levels.

160 A CLOSED-LOOP AUDIT EXAMINING THE USE OF PROPHYLACTIC ANTI-COAGULATION IN OLDER ADULTS ADMITTED TO A SPECIALIST GERIATRIC SERVICE

Abstract Background Guidelines recommend prescription of Prophylactic Anticoagulation (PA) to all hospitalized older adults unless a contraindication exits. In many cases this does not happen at the time of admission increasing the risk of thromboembolic events. We aimed to assess the use of PA across the medicine for the geriatric service of a level 3 hospital (average daily census of service 120) then use quality improvement to achieve our goal of 95% prescription of prophylactic anticoagulation when appropriate. Methods Medication kardexes and clinical notes were reviewed to collect variables including age, length of stay, creatinine clearance, weight, mobility status, use and dose of antithrombotic medications and documentation of reason if not prescribed. Following initial data collection, cause and effect analysis was performed to identify reasons for under-prescription and small tests of change were conducted across 4 PDSA cycles before data collection was repeated. Results Initial data collection revealed that only 80% of older adults admitted to the service were receiving prophylactic anticoagulation. Cause and effect analysis identified many reasons for failure to prescribe PA including inadequate history taking, lack of clinician education and training, poor documentation, lack of handover between clinicians, failure to complete medication reconciliation on admission and lack of pharmacy support on some wards. Each of these contributory factors were addressed in turn. After a month of QI activities prescription of PA improved to 83% and by 3 months 98.1% (104/106) of patients were receiving PA with only 2 patients for whom PA was not prescribed without clear documentation of the reason. Conclusion Sustained quality improvement resulted in a culture change across our service improving rates of appropriate prescription of PA and raising the quality of care delivered to older adults. This model of quality improvement is now being replicated across our department to address other gaps in service delivery.

Safety of cholecystectomy in patients under antithrombotic Drugs: A systematic review and meta-analysis.

This review aimed to assess evidence on the safety of cholecystectomy in patients under antithrombotic therapy. PubMed, Embase, Science Direct, CENTRAL, and Google Scholar databases were searched from inception up to 20th January 2022 for studies comparing outcomes of patients undergoing cholecystectomy surgeries with or without concomitant antithrombotic therapy. Nine studies were included. Meta-analysis revealed that the use of antithrombotic medications had no statistically significant effect on intra-operative blood loss in patients undergoing cholecystectomy (MD: 82.31 95% CI: -283.38, 448 I2=98% p=0.66). However, incidence of blood transfusion (OR: 5.65 95% CI: 1.10, 28.86 I2=83% p=0.04) and bleeding complications (OR: 8.02 95% CI: 1.71, 37.58 I2 = 71% p=0.008) were significantly increased in patients under antithrombotic therapy. Pooled analysis indicated that cholecystectomy patients under antithrombotic are at an increased risk of conversion to open surgery (OR: 2.02 95% CI: 1.21, 3.36 I2=0% p=0.007). Meta-analysis revealed significantly shorter LOS in patients under antithrombotic (MD: -5.01 95% CI: -8.29, -1.73 I2=97% p=0.03). Current evidence from a limited number of studies indicates that the use of antithrombotic may be associated with an increased risk of bleeding-related complications in patients undergoing cholecystectomies. Antithrombotic use may also increase the risk of conversion to open surgery in patients undergoing laparoscopic cholecystectomies.

Medication intake and hemorrhage risk in patients with familial cerebral cavernous malformations.

The objective of this study was to analyze the impact of medication intake on hemorrhage risk in patients with familial cerebral cavernous malformation (FCCM). The authors' institutional database was screened for patients with FCCM who had been admitted to their department between 2003 and 2020. Patients with a complete magnetic resonance imaging (MRI) data set, evidence of multiple CCMs, clinical baseline characteristics, and follow-up (FU) examination were included in the study. The authors assessed the influence of medication intake on first or recurrent intracerebral hemorrhage (ICH) using univariate and multivariate logistic regression adjusted for age and sex. The longitudinal cumulative 5-year risk of hemorrhage was calculated by applying Kaplan-Meier and Cox regression analyses adjusted for age and sex. Two hundred five patients with FCCMs were included in the study. Multivariate Cox regression analysis revealed ICH as a predictor for recurrent hemorrhage during the 5-year FU. The authors also noted a tendency toward a decreased association with ICH during FU in patients on statin medication (HR 0.22, 95% CI 0.03-1.68, p = 0.143), although the relationship was not statistically significant. No bleeding events were observed in patients on antithrombotic therapy. Kaplan-Meier analysis and log-rank test showed a tendency toward a low risk of ICH during FU in patients on antithrombotic therapy (p = 0.085), as well as those on statin therapy (p = 0.193). The cumulative 5-year risk of bleeding was 22.82% (95% CI 17.33%-29.38%) for the entire cohort, 31.41% (95% CI 23.26%-40.83%) for patients with a history of ICH, 26.54% (95% CI 11.13%-49.7%) for individuals on beta-blocker medication, 6.25% (95% CI 0.33%-32.29%) for patients on statin medication, and 0% (95% CI 0%-30.13%) for patients on antithrombotic medication. ICH at diagnosis was identified as a risk factor for recurrent hemorrhage. Although the relationships were not statistically significant, statin and antithrombotic medication tended to be associated with decreased bleeding events.

Real-world treatment patterns and stroke risks among patients with atrial fibrillation in China.

Aim: To describe patient characteristics, treatment patterns and stroke risks for patients with newly diagnosed atrial fibrillation (AF) in China. Patients & methods: Patients with AF were identified from an electronic medical record database in China (n =22,535). Results: Less than half of patients (n =9971; 44.2%) received antithrombotic medications following AF diagnosis; of these patients, 93.7% received anticoagulants and 71.3% received antiplatelets. Only 27.6% of patients received oral anticoagulants. Multivariate Cox proportional hazard model analysis found that patients treated with antithrombotic medications had a significantly lower risk of stroke compared with patients who were not treated (hazard ratio: 0.4; 95% CI: 0.37-0.43). Conclusion: The results suggest that antithrombotic medications, especially oral anticoagulants, are underused in China.

Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline.

Acute lower gastrointestinal bleeding (LGIB) is a common reason for hospitalization in the United States and is associated with significant utilization of hospital resources, as well as considerable morbidity and mortality. These revised guidelines implement the Grading of Recommendations, Assessment, Development, and Evaluation methodology to propose recommendations for the use of risk stratification tools, thresholds for red blood cell transfusion, reversal agents for patients on anticoagulants, diagnostic testing including colonoscopy and computed tomography angiography (CTA), endoscopic therapeutic options, and management of antithrombotic medications after hospital discharge. Important changes since the previous iteration of this guideline include recommendations for the use of risk stratification tools to identify patients with LGIB at low risk of a hospital-based intervention, the role for reversal agents in patients with life-threatening LGIB on vitamin K antagonists and direct oral anticoagulants, the increasing role for CTA in patients with severe LGIB, and the management of patients who have a positive CTA. We recommend that most patients requiring inpatient colonoscopy undergo a nonurgent colonoscopy because performing an urgent colonoscopy within 24 hours of presentation has not been shown to improve important clinical outcomes such as rebleeding. Finally, we provide updated recommendations regarding resumption of antiplatelet and anticoagulant medications after cessation of LGIB.

Effect of Chronic Antiplatelet and Anticoagulant Medication in Neck Hematoma and Perioperative Outcomes after Carotid Endarterectomy

A retrospective analysis of neck hematoma, stroke, and mortality after symptomatic and asymptomatic carotid endarterectomy (CEA) was conducted, to determine the most appropriate perioperative medication for these patients. Thirty-day outcomes of moderate and severe neck bleeding were also investigated. Patients undergoing CEA in a Vascular Surgery department were analyzed (2015-2019). Preprocedure antithrombotic medication (from the 5 days prior to surgery) was identified. End point predictors were identified by univariate and multivariable analyses and adjusted for confounders. A total of 304 CEA were included. Almost half of the included patients (49.67%) were under low-dose aspirin, 17.55% other single antiplatelet agent, 12.59% dual antiplatelet therapy, 8.61% anticoagulation, and 10.92% no antithrombotic therapy. There was a 8.22% rate of important hematoma, including 4.93% severe (requiring surgical exploration) hematomas and a 30-day all-stroke incidence of 2.94% in symptomatic and 1.79% asymptomatic patients (P=0.51). When compared to aspirin, severe hematoma was more prevalent with single clopidogrel or triflusal (relative risk [RR] 4.25, P=0.11), dual antiplatelet group (RR 11.84, P=0.002), and anticoagulation (RR 8.604, P=0.02). Dual antiaggregation and anticoagulation did not confer postoperative stroke protection compared to single aspirin in either symptomatic or asymptomatic patients. Nonsignificant higher intrahospital mortality was noted in no medication, dual antiplatelet, and anticoagulation groups in contrast to aspirin. Severe neck bleeding was associated with increased congestive heart failure (9.26-fold, P=0.03) and longer hospital stay (11.20±24.69days vs. 3.18±4.79 with no bleeding, P<0.001), with a tendency for higher hospital readmission at 30 days (4.66-fold, P=0.13). Mortality and stroke rates were similar. Double antiaggregation and anticoagulation did not confer better perioperative outcomes after elective CEA in our study. These regimens were associated with an increased risk of neck hematoma, especially severe bleeding, with similar rates of neurologic events in both symptomatic and asymptomatic patients and no mortality benefit. Monotherapy with aspirin appears to be the safest perioperative antithrombotic regimen for elective CEA.

Antithrombotic treatment and outcome after endovascular treatment and acute carotid artery stenting in stroke patients with atrial fibrillation

BackgroundOral anticoagulation (OAC) is the mainstay of secondary prevention in ischemic stroke patients with atrial fibrillation (AF). However, in AF patients with large vessel occlusion stroke treated by endovascular therapy (ET) and acute carotid artery stenting (CAS), the optimal antithrombotic medication remains unclear.MethodsThis is a subgroup analysis of the German Stroke Registry—Endovascular Treatment (GSR-ET), a prospective multicenter cohort of patients with large vessel occlusion stroke undergoing ET. Patients with AF and CAS during ET were included. We analyzed baseline and periprocedural characteristics, antithrombotic strategies and functional outcome at 90 days.ResultsAmong 6635 patients in the registry, a total of 82 patients (1.2%, age 77.9 ± 8.0 years, 39% female) with AF and extracranial CAS during ET were included. Antithrombotic medication at admission, during ET, postprocedural and at discharge was highly variable and overall mortality in hospital (21%) and at 90 days (39%) was high.Among discharged patients (n = 65), most frequent antithrombotic regimes were dual antiplatelet therapy (DAPT, 37%), single APT + OAC (25%) and DAPT + OAC (20%). Comparing DAPT to single or dual APT + OAC, clinical characteristics at discharge were similar (median NIHSS 7.5 [interquartile range, 3–10.5] vs 7 [4–11], p = 0.73, mRS 4 [IQR 3–4] vs. 4 [IQR 3–5], p = 0.79), but 90-day mortality was higher without OAC (32 vs 4%, p = 0.02).ConclusionsIn AF patients who underwent ET and CAS, 90-day mortality was higher in patients not receiving OAC.Registration: https://www.clinicaltrials.gov; Unique identifier: NCT03356392.