Anticoagulation Regimen Research Articles

An analysis of risk factors for venous thromboembolism in primary versus revision total joint arthroplasty

BackgroundOne of the most serious complications after primary or revision lower extremity total joint arthroplasty (TJA) is venous thromboembolism disease (VTE). Identifying patients at high risk for VTE allows tailoring of prophylactic anticoagulation regimens to those most vulnerable. This study aimed to identify risk factors for VTE in primary and revision lower extremity TJA. MethodsThe Electronic Medical Record was queried from a single academic institution for all patients who underwent a lower extremity TJA between 2007 and 2020. Demographics, comorbid conditions, perioperative characteristics, and postoperative complications were identified. An Elastic Net Multiple Logistic Regression Model was used to assess 49 covariates and predict those associated with a significant risk of VTE. ResultsWe identified 4900 primary and revision total knee arthroplasty (TKA) and total hip arthroplasty (THA) patients. There was no significant difference between primary and revision THA. Primary TKA had a higher rate of VTE than revision TKA. Significant risk factors identified for VTE in THA patients include histories of deep vein thrombosis (DVT), pulmonary embolism (PE), metastatic tumors, hemiplegia, and Hispanic ethnicity. Risk factors for VTE in TKA patients include histories of DVT, PE, metastatic tumors, and postoperative warfarin and heparin use. In all patients, age was a significant predictor of VTE risk. ConclusionOur work identifies many risk factors for VTE following TJA. While the increased rate of VTE in some populations may represent selection bias, it also highlights the incomplete understanding of the etiology and prevention of this complication in the joint arthroplasty population and requires further study.

Primary Care in Management of Pulmonary Embolism in Prolonged Recumbences

A frequent and possibly fatal kind of venous thromboembolic illness is pulmonary embolism (PE). It is a significant issue for public health. A typical diagnosis as a primary care in an emergency room is pulmonary embolism (PE). Additionally, it makes up a sizable portion of the patients admitted to hospital wards. In selected low-risk individuals with acute PE, there is mounting evidence that outpatient therapy, or treatment without hospitalization, is practical, safe, and efficient. PE patients may be risk-classified and given an early release from the emergency department. As a result, there are more hospital beds available for other patients, which lowers treatment expenses for the healthcare system. There is growing support for the outpatient care of low-risk, hemo-dynamically stable patients with acute symptomatic pulmonary embolism (PE). There is assistance in identifying patients who are eligible for outpatient (primary) care. This move has been made easier by the accessibility and simplicity of direct oral anticoagulants. Acute PE is currently mostly treated with direct, non-vitamin K-dependent oral anticoagulants. In comparison to vitamin K antagonists, they have been demonstrated to simplify initial and prolonged anticoagulation regimes while lowering the risk of bleeding. In this consensus practice document, we present a thorough analysis of primary care in the diagnosis, treatment, and follow-up of acute PE.

DOACs vs Vitamin K Antagonists During Cardiac Rhythm Device Surgery: A Multicenter Propensity-Matched Study

BackgroundThere is a paucity of data comparing vitamin K antagonists (VKAs) to direct oral anticoagulants (DOACs) at the time of cardiac implantable electronic device (CIED) surgery. Furthermore, the best management of DOACs (interruption vs continuation) is yet to be determined. ObjectivesThis study aimed to compare the incidence of device-related bleeds and thrombotic events based on anticoagulant type (DOAC vs VKA) and regimen (interrupted vs uninterrupted). MethodsThis was an observational multicenter study. We included patients on chronic oral anticoagulation undergoing CIED surgery. Patients were matched using propensity scoring. ResultsWe included 1,975 patients (age 73.8 ± 12.4 years). Among 1,326 patients on DOAC, this was interrupted presurgery in 78.2% (n = 1,039) and continued in 21.8% (n = 287). There were 649 patients on continued VKA. The matched population included 861 patients. The rate of any major bleeding was higher with continued DOAC (5.2%) compared to interrupted DOAC (1.7%) and continued VKA (2.1%) (P = 0.03). The rate of perioperative thromboembolism was 1.4% with interrupted DOAC, whereas no thromboembolic events occurred with DOAC or VKA continuation (P = 0.04). The use of dual antiplatelet therapy, DOAC continuation, and male sex were independent predictors of major bleeding on a multivariable analysis. ConclusionsIn this large real-world cohort, a continued DOAC strategy was associated with a higher bleeding risk compared to DOAC interruption or VKA continuation in patients undergoing CIED surgery. However, DOAC interruption was associated with increased thromboembolic risk. Concomitant dual antiplatelet therapy should be avoided whenever clinically possible. A bespoke approach is necessary, with a strategy of minimal DOAC interruption likely to represent the best compromise.

FRI111 Venous Thromboembolism In Cushing Syndrome - A Call For Standardized Anticoagulation Regimen In Hypercortisolism

Abstract Disclosure: M. Minasyan: None. A. Bryk-Wiazania: None. E. Rzepka: None. A. Bogusławska: None. A. Hubalewska-Dydejczyk: None. A. Gilis-Januszewska: None. Venous thromboembolism in Cushing Syndrome - a call for standardized anticoagulation regimen in hypercortisolism. Cushing Syndrome (CS) is associated with a 18-fold higher risk of venous thromboembolism (VTE) when compared to the general population with the similar demographic characteristics. Despite numerous studies on hypercoagulability in CS, the unequivocal recommendations regarding timing and dosing of thromboprophylaxis in hypercortisolism are still lacking. We present a case series of patients with CS and VTE, hospitalized in the Endocrinology Department of University Hospital in Krakow. Among 135 patients with CS, we found 7cases of VTE (5.19%), aged 35-65 years, mostly females (n=6). The etiology of CS was predominately pituitary (n=3), the other tissue origins of CS were: adrenal (n=2), ectopic(n=1) and adrenal carcinoma (n=1). Pulmonary embolism (PE) was found in 3 patients, deep venous thrombosis (DVT) in 2 patients, while 2 patients suffered from concomitant DVT and PE. We found that one patient had VTE 5 months before inducing the biochemical remission by a transsphenoidal surgery, while 2 patients within the 30 days after inducing the biochemical remission by either a transsphenoidal surgery in one, or metyrapone treatment in 2nd case. In the remaining 4 patients, VTE episode preceded the diagnosis of CS, ranging from 1 year to 2 months prior to the diagnosis. Among them, 2 PE episodes were associated with other predisposing factors, such as (1) postpartum PE in a 36-year-old women, who was subsequently diagnosed with Cushing disease, and (2) combined oral contraceptive in a 35-year-old woman, who suffered from the peripheral PE, and was eventually diagnosed with adrenal CS. Of note, at the time of VTE episode, 1 patient was treated with warfarin (international normalized ratio at the time of VTE, 1.66), another one took apixaban. One fatal PE occurred on the thromboprophylaxis with low molecular weight heparin, in the hypocortisolemia following metyrapone implementation. To summarize, VTE episode: 1. may be the first, life-threatening presentation of CS; 2. may occur after treatment of hypercortisolism; 3. may happen in patients on thromboprophylaxis or anticoagulant treatment; 4. should be included in the differential diagnosis of a thrombotic event despite coexisting transient factor (e.g. oral contraceptive, delivery). 5. Further multicenter studies are essential to understand the hypercoagulability in CS, and to create the recommendations on this topic. Presentation: Friday, June 16, 2023

Direct Oral Anticoagulants: An Overview of Indications, Pharmacokinetics, Comorbidities, and Perioperative Management.

Direct oral anticoagulants (DOACs) have catalyzed a significant paradigm shift in the landscape of anticoagulant therapy, emerging as pivotal agents for the prevention of stroke in atrial fibrillation and venous thromboembolism. Although the absolute advantages of DOACs over vitamin K antagonists (VKAs) may appear modest, clinical guidelines advocate for their preference across various indications, attributing this endorsement to their ease of administration and heightened safety. DOACs find application in preventing and treating diverse cardiovascular conditions. With the progressive expansion of DOAC utility, clinicians encounter intricate decisions concerning the selection of appropriate agents, determination of optimal treatment duration, and utilization within specialized patient subgroups. Extensive evidence has substantiated the noninferiority or superiority of DOACs compared with VKAs in both prophylaxis and treatment of thromboembolic events. Notably, routine monitoring to evaluate treatment efficacy is not mandated for DOACs; however, they exhibit interactions with co-administered drugs and exert influence on functional coagulation assessments. This review aims to synthesize existing literature, encompassing the delineation of appropriate clinical indications, tailored employment in patients with specific concurrent conditions, needs in monitoring parameters, seamless transitions during shifts between anticoagulant regimens, and a glimpse into forthcoming perspectives in this evolving field.

Conservative therapy and secondary prevention of PAD

Today, peripheral artery disease (PAD) is treated with the most modern endovascular and open surgical revascularisation procedures. But the short and long-term success of these interventions is decisively determined by the conservative therapy of PAD, which therefore represents the absolute basic therapy of every PAD. Conservative treatment addresses the "Big Five" of atherosclerosis risk factors: smoking, lack of exercise and overweight, diabetes, hypertension, and hyperlipidemia. Despite the knowledge that PAD as a peripheral manifestation of the systemic atherosclerosis needs the same risk factor management as e.g., coronary heart disease, not even every second PAD patient in Germany receives the required therapy. This paper presents the spectrum of both drug and non-drug strategies and focuses on aspects such as platelet inhibition and anticoagulation regimes, lipid-lowering options as well as the benefits and necessity of exercise programs to promote collaterals and improve quality of life by extending the pain-free walking distance. Proven strategies to overcome smoking addiction, use and purpose of vasoactive substances are highlighted as well as the potential risks of diabetic foot syndrome for limb salvage and prevention of wounds.

Venous thromboembolism in Cushing syndrome - A call for standardized anticoagulation regimen in hypercortisolism

Venous thromboembolism in Cushing syndrome - A call for standardized anticoagulation regimen in hypercortisolism

Patient-Specific Venous Thromboembolic Event Prophylaxis in Total Joint Arthroplasty - Literature-Supported Guidelines.

Following total joint arthroplasty (TJA), venous thromboembolic events (VTE) are a known complication that may result in increased hospitalization cost as well as morbidity. Numerous investigations have documented patient-specific factors that place an individual at increased risk of VTE after TJA. Potential risk factors for VTE include genetic predisposition, history of a prior VTE event, revision surgery and patient comorbidity factors. The American Academy of Orthopedic Surgeons and The American College of Chest Physicians have both provided recommendations for VTE prophylaxis after orthopedic surgery. However, among orthopedic surgeons, there remains a lack of consensus regarding the appropriate agent and time course for prophylactic anticoagulation after TJA. In this study, we review the evidence-supported patient-specific factors that confer an increased risk of VTE in the TJA postoperative period. Furthermore, we describe the VTE prophylaxis regimen used at our home institution after TJA for low- and high-risk patients as well as a recommendation for cessation or continuation of anticoagulation regimens that patients were on preoperatively for comorbid conditions.

Improving the Effectiveness of Anticoagulant Therapy: The Promise of Factor XI Inhibition

This continuing medical education-accredited symposium, held at the 2023 International Society for Thrombosis and Haemostasis (ISTH) congress in Montréal, Canada, focused on current unmet needs in anticoagulation, especially in the atrial fibrillation (AF) population, and reflected on the promise of the emerging class of Factor XI inhibitors for stroke prevention (SPAF) in susceptible patients. The faculty agreed that, although direct oral anticoagulants (DOAC) have represented a major advance compared with vitamin K antagonists, their utilisation remains suboptimal, often due to the prevailing fear of bleeding in many types of patients. Older age alone can be a reason for withholding anticoagulation, due to the risk and implications of bleeding. Frailty and comorbidities, such as chronic kidney disease (CKD), which can adversely affect the bioavailability of DOACs, are also deterrents to optimal anticoagulant use. Clinicians may try to avoid or mitigate bleeding by inappropriately prescribing low doses of DOACs, an off-label practice that has been found to fail to protect patients from thrombotic risk, without attenuating the risk of bleeding. In addition, the potential for drug-drug interactions and poor adherence also limit the optimal use of DOACs in real-world clinical practice. A recent patient survey focusing on the topic of ‘minor bleeding’, often referred to by clinicians as ‘nuisance bleeding’, and typically not well captured in clinical trials, revealed the far-reaching impact of ongoing problems with bleeding on quality of life, and the possibility that these experiences may deter patients from adherence to their prescribed anticoagulant regimen. Factor XI represents a promising new target for anticoagulation, which may minimise the risk of bleeding by pharmacologically ‘uncoupling’ the clotting pathway, leading to pathological thrombosis from the cascade largely responsible for physiological haemostasis. Phase II research with investigational Factor XI inhibitors has established their antithrombotic and safety potential, and some of these agents may also avoid other practical drawbacks of DOACs. Phase III evaluation of Factor XI inhibition is ongoing in a number of clinical settings.

Late Bleeding Events in Patients Undergoing Percutaneous Coronary Intervention in the Workup Pre-TAVR

BackgroundIn patients undergoing percutaneous coronary intervention (PCI) in the work-up pre–transcatheter aortic valve replacement (TAVR), the incidence and clinical impact of late bleeding events (LBEs) remain largely unknown. ObjectivesThis study sought to determine the incidence, clinical characteristics, associated factors, and outcomes of LBEs in patients undergoing PCI in the work-up pre-TAVR. MethodsThis was a multicenter study including 1,457 consecutive patients (mean age 81 ± 7 years; 41.5% women) who underwent TAVR and survived beyond 30 days. LBEs (>30 days post-TAVR) were defined according to the Valve Academic Research Consortium-2 criteria. ResultsLBEs occurred in 116 (7.9%) patients after a median follow-up of 23 (IQR: 12-40) months. Late bleeding was minor, major, and life-threatening or disabling in 21 (18.1%), 63 (54.3%), and 32 (27.6%) patients, respectively. Periprocedural (<30 days post-TAVR) major bleeding and the combination of antiplatelet and anticoagulation therapy at discharge were independent factors associated with LBEs (P ≤ 0.02 for all). LBEs conveyed an increased mortality risk at 4-year follow-up compared with no bleeding (43.9% vs 36.0; P = 0.034). Also, LBE was identified as an independent predictor of all-cause mortality after TAVR (HR: 1.39; 95% CI: 1.05-1.83; P = 0.020). ConclusionsIn TAVR candidates with concomitant significant coronary artery disease requiring percutaneous treatment, LBEs after TAVR were frequent and associated with increased mortality. Combining antiplatelet and anticoagulation regimens and the occurrence of periprocedural bleeding determined an increased risk of LBEs. Preventive strategies should be pursued for preventing late bleeding after TAVR, and further studies are needed to provide more solid evidence on the most safe and effective antithrombotic regimen post-TAVR in this challenging group of patients.

Pharmacological cardioversion of atrial fibrillation: practical considerations.

The choice between rhythm and rate control strategy represents one of the most intriguing dilemmas in the management of atrial fibrillation (AF). Although the advantage of rhythm over rate control in terms of outcome has not been equivocally proven, the initial management of patients with symptomatic episodes of AF frequently involves an attempt of early cardioversion. As electrical cardioversion (EC) is challenging in terms of fasting status and involvement of anesthesiology team, pharmacological cardioversion (PC) is usually selected as the first step towards rhythm conversion. Proper qualification for PC or EC is similar and should comprise assessment of hemodynamic status, estimation of duration of arrhythmic episode, evaluation of anticoagulation regimen, exclusion of other supraventricular arrhythmias and assessment of the chance of rhythm conversion and persistence of sinus rhythm. Finally, the choice of adequate antiarrhythmic drug (AAD) depends on the presence of structural heart disease and local experience. In patients without structural heart disease, complications occur rarely, hence traditional (propafenone, flecainide) or nonclassical Vaughan-Williams class I (antazoline) or class III (vernakalant, ibutilide or dofetilide) drugs are preferred. The presence of structural heart disease consistent with any left ventricular hypertrophy, heart failure, myocardial ischemia or valvular heart disease confines the choice of AAD to amiodarone. Given the risk of ventricular proarrhythmia of AAD, safety should always prevail over the enticing possibility of rhythm conversion. The present review aims to provide a comprehensible summary of proper qualification for PC, selection of suitable AAD and state-of-the-art periprocedural management of patients with recent-onset AF.

The prevalence of thrombocytopenia in patients with acute cancer-associated thrombosis.

Venous thromboembolism (VTE) and thrombocytopenia are frequently encountered complications in patients with cancer. Although there are several studies evaluating the safety and efficacy of anticoagulation regimens in patients with cancer-associated thrombosis (CAT) with thrombocytopenia, there is a paucity of data assessing the scope of the concurrent diagnoses. This study evaluates the prevalence of thrombocytopenia among patients with acute CAT. A retrospective cohort analysis of adult patients with cancer was conducted at Beth Israel Deaconess Medical Center between 2010 and 2021 with CAT (acute VTE within 6 months after new diagnosis of malignancy). VTE included acute deep vein thrombosis, pulmonary embolism, abdominal or intrathoracic venous thrombosis, and cerebral sinus thrombosis. The lowest platelet count within 2 weeks of (before or after) the index VTE event was identified to assess the frequency and grade of concurrent thrombocytopenia. We identified 3635 patients with CAT (80% solid tumors, 18% hematologicmalignancies, and 2% multiple concurrent cancer diagnoses). Thrombocytopenia (defined as platelet count <100 000/μL) occurred in 22% (95% CI 21%-24%) of patients with CAT with solid tumors diagnoses and 47% (95% CI 43%-51%) of patients withCAT and hematologic malignancies. Severe thrombocytopenia (platelet count <50000/μL) occurred in 7% (95% CI6%-8%) of patients with solid tumors and 30% (95% CI 27%-34%) of patients with hematologic malignancies. Concurrent diagnoses of CAT and thrombocytopenia are very common, especially among patients with hematologic malignancies.

Comparative evaluation of preventive anticoagulant therapy regimens in the wounded

Introduction. Currently, the issues of prescribing anticoagulant therapy to the wounded are poorly studied, the doses of drugs and the timing of its implementation have not been determined.Aim. To study various modes of anticoagulant therapy for the prevention of venous thrombosis of the lower extremities in the wounded after surgery using the parameters of the plasma hemostasis system and the Thrombodynamics test.Materials and methods. A prospective study was conducted, which included 90 wounded with mine-explosive/gunshot injury receiving anticoagulant therapy in preventive doses. The studies were carried out on the equipment of the Thrombodynamics recorder (HemaCor, Moscow). The patients were divided into 3 groups: 1 group, which included 30 patients taking rivaroxaban at a dose of 10 mg/day, 2 group of 30 patients receiving enoxaparin sodium at a dose of 40 mg once a day, 3 group consisting of 30 patients receiving enoxaparin sodium 40 mg 2 times a day. In the dynamics of treatment, the parameters of the plasma hemostasis system and the parameters of the Thrombodynamics test were evaluated.Results. It was revealed that during preventive anticoagulant therapy, there were no significant differences in the standard parameters of the coagulogram, when studying the parameters of the Thrombodynamics test, significant differences wereobserved between groups 1 and 3 in values (V/VSt, Vi, Tlag, СS), between group 2 and 3 in parameter (V/VSt, Vi, Tlag, СS), between group 1 and group 2 in the value of D. A statistically significant relationship was found between the Thrombodynamics parameter D and the indicators of TV, prothrombin by Quick, and fibrinogen content.Conclusion. The Thrombodynamics test can be used as a potential tool for a personalized approach to monitoring the hemostasis system in the wounded.

Atrial fibrillation catheter ablation associated silent cerebral emboli: A narrative review.

The incidence of silent cerebral emboli (SCE) associated with atrial fibrillation catheter ablation (AFCA) is much higher than that of stroke/transient ischemic attack (TIA). Interventional electrophysiologists have been increasingly alerted to asymptomatic cerebral infarction over the years. Plentiful studies revealed that diagnostic definitions, detection modalities, energy sources, ablation strategies, perioperative anticoagulation regimens, and patient-related factors were associated with the risk of AFCA-associated SCE. Studies related to non-interventional procedures found that SCE may prompt stroke, cognitive decline, and dementia later in life, suggesting a possible role of AFCA-associated SCE in the cognitive function of patients with AF. However, there is no consistent evidence for this view to date. Given that the majority of patients with AF being elderly and the increased risk of cognitive impairment in AF itself, efforts should be made to minimize the occurrence of AFCA-associated SCE.

COVID-19 patients hospitalized after the fourth wave of the pandemic period in Vietnam: Clinical, laboratory, therapeutic features, and clinical outcomes

Despite having relatively high COVID-19 vaccine coverage in Vietnam, a fraction of COVID-19 patients required hospitalization due to severe symptoms. The purpose of this study was to describe the clinical, laboratory, complications, and treatment of COVID-19 patients hospitalized during the pandemic's fourth wave. Genome sequencing was performed on COVID-19 patients. Data on clinical characteristics, treatment, complications, and outcomes were consistently collected. The clinical classifications were mild (37.43%), moderate (24.2%), and severe (38.37%). Patients with co-morbidities, high fever >39°C, hypertension, tachycardia, tachypnea, and SpO2<90%, had a 1.2-4 folds higher of severe progression than those with mild/moderate. Serious consequences were much more common in the severe patients than in the mild/moderate. The respiratory system of severe patients was generally documented as fine, coarse crackles, and CT scanner shown ground glass, consolidation, and opacity, with Delta variant accounting for 92.6%. Complications were common in the severe patients, including bacteria pneumonia (36.42%), ARDS (61.11%), blood clotting disorder (7.14%), infection (46.92%), and acute kidney injury (12.35%). Antiviral, antifungal, corticosteroid, anticoagulant, and ECMO regimens were utilized. Patients died mostly as a result of co-morbidities, low SpO2, lung injury, and complications such as bacterial+fungal pneumonia (83.9%), ARDS (83.9%), bacteremia (56.5%), injury acute renal failure (27.4%), and coagulopathy (12.9%). Severe and critical COVID-19 patients frequently have several comorbidities, multiple lung lesions along with a variety of clinical signs. Despite receiving antivirals, antibiotics, corticosteroids, anticoagulants, and even ECMO therapy, the patient encountered multiple complications, with a fatality rate of up to 38.27%.

Studies on Atrial Fibrillation and Venous Thromboembolism in the Past 20 Years: A Bibliometric Analysis Via CiteSpace and VOSviewer.

The conjunction of atrial fibrillation (AF) and venous thromboembolism (VTE) is common in clinical practice. Over the last 2 decades, a significant number of articles (2500) have been published about AF and VTE. To effectively analyze and present these vast amounts of information, this study uses bibliometric research methods to categorize and consolidate these publications. The number of publications has increased yearly, especially since 2012. The United States was the most prolific country, with 1054 studies published. The most productive institution was McMaster University. Gregory Y.H. Lip was the most prolific author. The keyword analysis identified that the research focuses from 2003 to 2014 were factor Xa inhibitor, dabigatran etexilate, direct thrombin inhibitor, double-blind, deep vein thrombosis, molecular weight heparin, stroke prevention, etc. From 2015 to 2016, research mainly focused on venous thromboembolism, antithrombotic therapy, anticoagulant, warfarin, atrial fibrillation, stroke, and pulmonary embolism. Studies during 2017 to 2022 focused on apixaban, direct oral anticoagulant, rivaroxaban, dabigatran, hemorrhage, edoxaban, medicine efficacy and safety, risk factors, clinical management, and vitamin K antagonists. Since 2018, novel oral anticoagulants have been the most commonly used keywords. On the whole, most studies of AF and VTE focus on pathogenesis and therapeutic drugs. The causal relationship between AF and VTE, the effectiveness and safety of novel oral anticoagulants in the treatments, the anticoagulant regimen of AF and VTE co-disease, and the treatment regimen for vulnerable populations such as the elderly or obese people were the focus of current research and will continue to be the central point of future research.

Venous thromboembolism and anticoagulation in spinal cord lesion rehabilitation inpatients: A 10-year retrospective study.

Venous thromboembolism (VTE) is a concern following the onset of spinal cord lesions (SCL). To assess the current efficacy and risks of anticoagulation after SCL and consider changes in thromboprophylaxis. This retrospective cohort study included individuals admitted to inpatient rehabilitation within 3 months of SCL onset. Main outcome measures were the incidence of deep vein thrombosis (DVT), pulmonary embolism (PE), bleeding, thrombocytopenia, or death, which occurred within 1 year of the SCL onset. VTE occurred in 37 of the 685 patients included in the study (5.4%, 95% CI 3.7-7.1%, 2.8% PE), and in 16 of 526 patients who received prophylactic anticoagulation at rehabilitation (3%, 95% CI 1.6-4.5%, 1.1% PE, with at least 1 fatality). Of these 526, 1.3% developed clinically significant bleeding and 0.8% thrombocytopenia. Prophylactic anticoagulation, most commonly 40 mg/day, continued until a median period of 6.4 weeks after SCL onset (25% -75% percentiles 5.8-9.7), but in 29.7%, VTE occurred more than 3 months after SCL onset. The VTE prophylaxis used for the present cohort contributed to a considerable but limited reduction of VTE incidence. The authors recommend conducting a prospective study to assess the efficacy and safety of an updated preventive anticoagulation regimen.

Assessment of prescribing pattern and adverse drug reaction in patients receiving anticoagulant therapy: A prospective observational study.

Cardiovascular diseases (CVD) are the leading cause of death worldwide as well as a major blockade to sustainable human development. It is among the leading causes of morbidity and mortality. Anticoagulants are among the most essential life-saving drugs that are generally used in cardiology for the prevention and treatment of many CVD. To assess the prescribing pattern and adverse drug reaction (ADR) in patients receiving anticoagulant therapy for cardiac diseases. This was a Prospective Observational study conducted in the Department of Cardiology, SRM Medical College Hospital and Research Center, Kattankulathur including 88 patients for 6 months. Out of the 88 patients, the majority were males (73%) compared to females (27%), and the prevalence of CVD was found to be higher in patients above 40 years of age. Various categories of drugs prescribed to the patients were antiplatelets (14.88%), anticoagulants (8.79%), antianginal (13.82%), antihypertensives (15.7%), antihyperlipidemic (7.83%), thrombolytics (0.68%), Ionotropic agents (2.13%), antibiotics (5.31%), and other miscellaneous drugs (36.61%). The anticoagulant dosage regimens prescribed to the patients were categorized into monotherapy (9%), combinational therapy with antiplatelets (38%), and triple therapy (53%). The most commonly prescribed anticoagulant to the patients was Heparin (93.41%), followed by Warfarin (5.49%) and lastly Rivaroxaban (1.10%) respectively. From the details of the prescriptions analyzed, the average number of drugs per patient (prescription) was found to be 11.7. Heparin was found to be the most commonly used anticoagulant, Combination therapy of antiplatelets and antihypertensives was observed in most of the prescriptions, which is more effective than a single therapy. Polypharmacy was encountered in the study with an average number of 11.7 drugs per prescription. Several anticoagulant-related drug interactions were identified and there were two adverse drug reactions with Heparin. The prescribing pattern can be improved by reducing the number of drugs prescribed.

DOACs/vitamin K antagonists induced hemorrhagic adverse effects; How to bridge therapy before procedures

Direct oral anticoagulants (DOACs) are emerging as attractive alternatives to vitamin K antagonist which have long been the standard of care in anticoagulation. DOACs are indicated for both prevention and treatment. DOACs have emerged as more effective, safe, and convenient treatment options in thromboembolic settings. With the availability of a gamut of DOACs, clinicians are faced with challenging decisions relating to its hemorrhagic adverse effects. This review will provide an overview on how to manage the hemorrhagic adverse effects of DOACs/vitamin K antagonists and act as a practical guide for clinicians to optimize DOAC use in such challenging scenarios. Topics addressed include transitioning between anticoagulant regimens known as the bridge therapy.

Pulmonary Thrombosis despite Therapeutic Anticoagulation in COVID-19 Pneumonia: A Case Report and Literature Review

The rate of thrombotic complications in COVID-19 patients is high and could be associated with the risk of unfavourable outcomes. Moreover, pulmonary thrombotic events can occur even in patients already on anticoagulant treatment. We present the case of a patient with severe COVID-19 pneumonia, without traditional risk factors for thrombosis, who developed massive pulmonary thrombosis (PT) despite therapeutic anticoagulation. The diagnosis was challenging, and the case raised concerns about the protective role of conventional anticoagulant treatment in COVID-19 pneumonia. Thus, we searched for literature reports on COVID-19 patients who developed PT despite being under anticoagulation therapy. We identified 13 cohort studies including 4058 patients of which 346 (8.5%) developed PT and nine case reports/series enrolling 14 patients. Four cohorts were further analysed, which reported data on risk factors for thrombosis, outcomes and biological characteristics. We found that there were no differences between patients with and without PT regarding the classical risk factors for thrombosis. PT occurred regardless of the anticoagulation regimen, and the risk factor identified was severe COVID-19 pneumonia and a stay in an intensive care unit (ICU). Pulmonary thrombotic events in patients with COVID-19 are rather inflammation-related than correlated with traditional thromboembolic risk factors, and the therapeutic approach must take into consideration this aspect.