Anticoagulant Research Articles

Abstract 15315: Cardiac MRI Tissue Characterization for Intra-Cardiac Thrombi Therapeutic Response in Systemic Cancer Patients

Introduction: Cardiac MRI (CMR) is often used to identify thrombi (C THR ) based on absence of contrast enhancement but its utility as a predictor of therapeutic response of anticoagulation (AC) is unknown. Methods: Adult (≥18yo) pts with systemic cancer were matched 1:1 for cancer etiology/stage and presence/absence of C THR on CMR. Cine-CMR assessed cardiac structure/function and localization of C THR . Contrast-enhanced CMR (0.2 mmol/kg gadolinium) was performed for identification of C THR and quantitative tissue properties. C THR resolution was evaluated on serial TTE at a time point of 3 months post CMR; clinical f/u and anticoagulation therapy were determined by chart review. Results: 189 pts (54±16 yo; 50% M) were studied, 106 with C THR and 83 without. Cancer etiology varied (heme 30%

Abstract 14201: Double the Trouble: Extremely Rare Incidental Finding of a Double Interatrial Septum With Atrial Septal Aneurysm and Coexisting Patent Foramen Ovale

Case: A 59-year-old female with a past medical history of hypothyroidism and IgG deficiency presents to cardiology clinic due to palpitations and premature ventricular complexes (PVCs) noted at a recent urgent care visit. In-office vitals, physical exam, labs, and EKG were unremarkable. Ambulatory cardiac monitoring showed predominantly sinus rhythm with a PVC burden of 1.4%. Echocardiogram revealed an extremely rare structural anomaly – a double interatrial septum (DIAS) with atrial septal aneurysm. Cardiac MRI (cMRI) further confirmed the presence of a DIAS enclosing an interatrial space, along with blood flow within the interatrial space and a discontinuity in the anterior right lateral atrial septum suggestive of a patent foramen ovale (PFO). There was no evidence of thrombus within the interatrial or intracardiac spaces. Mild right atrial enlargement was seen. The patient was initiated on aspirin for cardioembolic stroke prophylaxis. Discussion: DIAS is a highly rare congenital cardiac anomaly with limited number of cases in literature. It has been described as a midline third atrium resulting in a “tri-atrial heart”. As of 2018, less than 20 cases have been cited. DIAS is characterized by two parallel interatrial septa along with a clear echo lucent midline space that expands in systole and collapses in diastole. This case is unique as it is one of the few to include additional characterization with cMRI. Patients with DIAS are usually asymptomatic but can experience cardioembolic events as the interatrial space is at risk for thrombus formation. Communication across the DIAS makes these events more likely. Unlike with atrial fibrillation/flutter, no current criteria for anticoagulation (AC) initiation exists for DIAS given the scarcity of cases. While some sources advocate for use of anti-platelet agents, others have indicated a preference for oral AC. Our patient had an interatrial space and a PFO but lacked communication across the DIAS, had low bleeding risk, and no other classic risk factors of Virchow’s triad. We determined her risk for thrombus formation to be relatively low, and thus initiated her on aspirin over oral AC. Percutaneous closure of the interatrial space was deferred as it has been dismissed as a viable treatment option in the literature.

Abstract 16332: Atrial Fibrillation Monitoring in Patients on Ibrutinib

Introduction: Ibrutinib increases risk of atrial and ventricular arrythmias, especially atrial fibrillation (AF). No guidelines exist for arrhythmia monitoring, but experts suggest 24h Holter assessments for patients at risk of new or recurring AF or with CHA2DS2-VASc score ≥2. We sought to describe current practices in cardiac event monitoring in high risk or symptomatic patients on ibrutinib. Methods: We performed a single-center retrospective analysis of 168 ibrutinib-treated patients with no prior AF or atrial flutter (AFL). Patients were followed from 2013 to 2022. Event monitor data was obtained by a single reviewer through chart review. Results: Among 168 patients followed over a median of 6.4 years, 44 developed AF/AFL (25%) with 31 (70%) with paroxysmal AF. Mean (SD) age at ibrutinib initiation was 66 (11.1) years. Fewer than half (n=50; 30%) were female. Event monitoring was performed for 31 (18.4%) patients, 18 (58%) during treatment and 13 (42%) after treatment completion ( Table 1 ). The most common monitoring reasons were palpitations (10, 32%) and assessing AF burden (9, 29%). Cardiologists outside electrophysiology and cardio-oncology ordered the most monitors (17, 55%). Monitors most captured unspecified SVT (11, 36%) or no significant findings (9, 29%). Monitors most likely resulted in no management changes (19, 61%). The most common management changes were: placement of DC-PM (3, 10%), discontinuing anticoagulation (AC) (3, 10%) and diagnosis of AF (3, 10%). Of note, 14 monitors were done after AF diagnosis of which 7 (50%) showed no AF. Conclusions: Even with increased risk of arrythmias, use of monitors was low across a cohort of 168 patients. Notably, 3 monitors were used to discontinue AC and 3 monitors found new AF. Recent studies show most AF/AFL in ibrutinib users occurs within the first 6 months of initiation which may inform decisions in screening. Further guidance and standardization are needed for the use of monitors in the ibrutinib population.

Natural History of Isolated Splanchnic Vein Thrombosis in Cancer Patients

Introduction : Venous thromboembolism (VTE), especially pulmonary embolism (PE) and deep vein thrombosis (DVT), is associated with increased morbidity in cancer patients. However, the clinical course and optimal management of unusual and isolated splanchnic vein thrombosis (iSpVT) remain unclear. Past studies often excluded cancer patients or combined them in heterogeneous cohorts. We aimed to describe the natural history of cancer associated iSpVT. Methods : We queried a cancer registry linked database from a large safety-net hospital system from 2011-2020. Patients with incident cancer diagnosis and intra-abdominal venous thrombosis were identified by a combination of International Classification of Diseases (ICD) code and natural language processing (NLP) algorithm (Figure 1). iSpVT was defined as symptomatic or incidental portal, hepatic, splenic, mesenteric vein thrombosis without concurrent PE/DVT. Patients were excluded for remote SpVT >6 months (mo) before or >36 mo after cancer diagnosis, concurrent PE/DVT, existing anticoagulation (AC), or inadequate follow-up <3 mo (unless death). Thrombus type was classified as bland vs. tumor/mixed based on radiology impression. AC was defined by intention for extended therapeutic AC. Venous recanalization was defined as resolution or reduction in thrombus size in a subset of patients with repeat contrast radiology scans in 3-12 mo. VTE was defined as PE or DVT. Bleeding was defined as ISTH major (MB) or clinically relevant non-major (CRNMB). Cumulative incidence of VTE at 180 days (d) was estimated using competing risk method and overall mortality was assessed by Kaplan Meier estimator. Results : Figure 1 highlights the cohort selection where 298 of 15,342 patients (1.9%) met inclusion criteria for iSpVT. Median time from cancer diagnosis to iSpVT was 19d (IQR 0-138). Most occurred in upper gastrointestinal cancers; 54% were bland and 46% were tumor/mixed. Tumor (n=99) and bland (n-44) thrombi in hepatocellular carcinoma (HCC), along with bland thrombi in pancreatic ductal adenocarcinoma (PDCA) (n=24) comprised over half of iSpVT. AC rate differed by cancer and thrombus type. Most tumor thrombi regardless of cancer type did not receive AC (97%). Most HCC and PDCA regardless of thrombus type did not receive AC (96%). Among those with bland thrombi in other cancers, 39% received AC. Due to strong selection bias for AC, we analyzed future VTE, bleeding, recanalization, and mortality in different subgroups: 1) untreated iSpVT in HCC/PDCA (compare to similar patients without SpVT); 2) all other cancers with bland iSpVT (compare AC vs. no AC) (Table 2). Among 143 HCC patients with untreated iSpVT, 44 had bland thrombi. The 180d VTE incidence was 2.4% (95% CI 0.2-10.7), which was non-significantly lower than HCC patients without iSpVT at 4.7% (95% CI 3.2-6.7). In contrast, 99 HCC patients with tumor thrombi had twice the risk of VTE and mortality compared to bland thrombi. Among 32 PDCA patients with untreated iSpVT, 24 had bland splenic vein thrombi due to tumor encasement. The 180d VTE incidence was 13.5% (3.3-30.7), similar to PDCA patients without SpVT at 17.2% (13.2-21.7). Among 87 mixed cancer type patients with bland iSpVT, the overall 180d VTE incidence was 4.6% (1.5-10.6). Thirty-four received AC with a median duration of 81d (IQR 31-181). AC was associated with increased recanalization rate (46.7% vs. 21.7%); however, it was not associated with decreased VTE (12.1% vs. 0%) or mortality (42% vs. 42%) due to confounding by treatment indication. Notably, 3 of 4 VTE occurred < 2 weeks after stopping AC. Bleeding occurred in 26% (n=9) of patients on AC with 15% MB (n=5) and 12% CRNMB (n=4), at a median of 28d (IQR 7.5-115) after starting AC. Conclusion: iSpVT in cancer patients is not a singular entity but rather a heterogeneous disease based on cancer and thrombus type. Tumor thrombi are associated with higher risk of future VTE and mortality. Untreated iSpVT in HCC and PDCA appear to have similar risk of VTE as those without SpVT, which supports current practice of not anticoagulating these patients. Beyond these cancers, AC varies by perceived risk of thrombosis vs bleeding. Despite strong selection bias, AC is associated with higher recanalization rate but at a cost of high bleeding risk. Prospective studies in a cancer-specific context are needed to determine if iSpVT should be treated similarly as PE/DVT among cancer patients.

Risk Factors for Thrombosis in Pregnant People with Sickle Cell Disease: A Multinational Study.

Background People with sickle cell disease (SCD) have exceptionally high rates of maternal morbidity, including increased risk for venous thromboembolic events (VTE). Data from the National Inpatient Sample shows that VTE risk in hospitalized Black pregnant people with SCD is 14 times that of unaffected Black and non-Black pregnant people. 1 There is little disease-specific data to inform anticoagulation (AC) use during pregnancy. 2 The purpose of this study is to describe VTE events in a SCD pregnancy cohort and to identify risk factors for VTE during pregnancy and compare maternal-fetal outcomes for subjects with or without VTE in pregnancy. Methods The Mount Sinai Hospital (MSH) Research Ethics Board and The Johns Hopkins Hospital (JHH) Institutional Review Board approved this retrospective study of pregnant people with SCD of ≥ 20 weeks gestation cared for at MSH, Toronto (1990-2017) or JHH (2000-2021). At MSH and JHH, all pregnant people with SCD and VTE history are prescribed antenatal prophylactic LMWH and for 6-weeks postpartum. At MSH, but not JHH, all receive AC prophylaxis for 6-weeks postpartum. At both centers, hospitalized pregnant people receive prophylactic AC. We stratified subjects by VTE occurrence during pregnancy. First, we described the cohort with VTE during pregnancy, including subject characteristics, VTE recurrence and pregnancy outcomes. Second, we compared cases with a first pregnancy with VTE to controls without VTE. We excluded repeat pregnancies in both groups. We compared cases and controls by SCD characteristics, medication use before pregnancy, and pregnancy outcomes. Painful events were defined as pain requiring acute care or hospital admission. Chronic transfusion therapy (CTT) was defined as pregnancies treated with scheduled, prophylactic transfusion; opioid use was defined as receiving an outpatient opioid prescription during pregnancy. We used the Chi-squared test for categorical variables and Wilcoxon signed-rank tests for continuous variables. A p-value of <0.05 was considered significant. Results There were 290 singleton pregnancies in 199 subjects. Half of the pregnancies were first pregnancies (142/290), with fewer second (51/290), third (2/290), fourth (3/290) or fifth (1/290) pregnancies. The cohort comprised of 58% subjects with HbSS/HbSβ 0, while 42% had HbSC/HbSβ+ genotype (Table 1). VTE occurred in 7% of pregnancies (20/290) including deep vein thrombosis (DVT, N=9), pulmonary embolism (PE, N=8), DVT+PE (N=3). Median age was 27 years (IQR 23,30). Before pregnancy, most VTE subjects received hydroxyurea (N=10). During pregnancy, six received CTT. Fourteen subjects had VTE in a single pregnancy; three had VTE recurrence in subsequent pregnancies. All three had HbSS/HbSβ 0. Two subjects had VTE history outside of pregnancy. One had DVT in two consecutive pregnancies and was prescribed AC in both pregnancies due to history of VTE. VTE occurred in first (N=4), second (N=8), third (N=4), fourth (N=1) and fifth (N=4) pregnancies. Most VTE occurred at JHH (11 JHH vs 6 MSH, p=0.008). To investigate SCD-specific risk factors for VTE in pregnancy, we compared characteristics in VTE subjects (N=17) to no-VTE subjects (N=182) by first study pregnancy with an event or first study pregnancy while enrolled in the study. VTE was associated with markers of disease severity including history of VTE before pregnancy (6/17 VTE vs 8/182 no-VTE, p<0.001), ACS during pregnancy (7/17 VTE vs 19/182 no-VTE, p<0.001), painful events requiring acute care during pregnancy (16/17 VTE vs 119/182 no-VTE, p=0.015) and hydroxyurea use before pregnancy (10/17 VTE vs 35/184 no-VTE, p<0.001). There was no difference in age or genotype. VTE was associated with earlier delivery and c-section delivery (Table 1). Conclusion In this study, 7% of cohort pregnancies had VTE. This rate exceeds reports from administrative datasets. 1 This may be due to the acuity of patients cared for at our centers and/or reflect undercounting of VTE in administrative datasets. In pregnant people with SCD, VTE is associated with VTE history, intrapartum painful events and ACS. Interventions to reduce acute events in pregnancy may help reduce VTE risk. While AC can be beneficial in preventing thrombotic events, careful assessment is essential to manage bleeding risks. Prospective data is needed to define the subpopulation of pregnant SCD patients who would benefit from AC prophylaxis antenatally.

Anticoagulant treatment and COVID-19 mortality among older adults living in nursing homes in Sweden.

Anticoagulants (AC) were introduced in March 2020 as standard of care in nursing home (NH) residents affected with COVID-19 in the Stockholm region, Sweden. ACs are proven to reduce the risk of complications and mortality from COVID-19 among patients of other ages and settings, but there is limited scientific evidence underpinning this practice in the NH setting. This matched cohort study included 182 NH residents in the Stockholm Region diagnosed with COVID-19 in March-May 2020. The main exposure was any AC treatment. Exposed (n = 91), 49% prevalent (pre-COVID-19 diagnosis) AC and 51% incident AC were compared with unexposed controls (n = 91). The outcome was 28-days all-cause mortality after COVID-19 infection. The mortality odds ratios (OR) were assessed using logistic regression, adjusted for age, sex, multimorbidity, and mobility, also stratified by incident or prevalent AC-type, age group, and sex. Of the 182 individuals diagnosed with COVID-19 (median age 88 years, 68% women), 39% died within 28 days after diagnosis. Use of either incident or prevalent AC was associated with a reduced, adjusted 28-day mortality (OR[95% CI]: 0.31[0.16-0.62]). In stratified analyses, the association was significant in both age groups: 70-89 (OR: 0.37 [0.15-0.89]) and 90-99 years of age (OR: 0.22 [0.07-0.65]. In sex-stratified analysis, the AC-lowering effect was significant in women only (OR: 0.28[0.11-0.67]). In the analyses stratified by AC type, the mortality-lowering effect was observed for both prevalent AC (OR: 0.35[0.12-0.99]) and incident AC (OR: 0.29[0.11-0.76]). Both prevalent and incident use of ACs in prophylactic dosing was associated with reduced 28-day mortality among older individuals with COVID-19 in a NH setting. The effect was seen across age-strata and in women. The findings present new insight in best practice for individuals diagnosed with COVID-19 in the NH setting.

Modified Brain Injury Guidelines for preinjury anticoagulation in traumatic brain injury: An opportunity to reduce health care resource utilization.

The Brain Injury Guidelines (BIG) stratify patients by traumatic brain injury (TBI) severity to provide management recommendations to reduce health care resource burden but mandates that patients on anticoagulation (AC) are allocated to the most severe tertile (BIG 3). We sought to analyze TBI patients on AC therapy using a modified BIG model to determine if this population can offer further opportunity for safe reductions in health care resource utilization. Patients 55 years or older on AC with traumatic intracranial hemorrhage (ICH) from two centers were retrospectively stratified into BIG 1 to 3 risk groups using modified BIG criteria excluding AC as a criterion. Intracranial hemorrhage progression, neurosurgical intervention (NSI), death, and worsened discharge status were compared. A total of 221 patients were included, with 23%, 29%, and 48% classified as BIG 1, BIG 2, and BIG 3, respectively. The BIG 3 cohort had a higher rate of AC reversal agents administered (66%) compared with the BIG 1 (40%) and BIG 2 (54%) cohorts ( p < 0.01), as well as ICH progression discovered on repeat head computed tomography (56% vs. 38% vs. 26%, respectively; p < 0.001). No patients in the BIG 1 and 2 cohorts required NSI. No patients in BIG 1 and 3% of patients in BIG 2 died secondary to the ICH. In the BIG 3 cohort, 16% of patients required NSI and 26% died. Brain Injury Guidelines 3 patients had 15 times the odds of mortality compared with BIG 1 patients ( p < 0.01). The AC population had higher rates of ICH progression than the BIG literature, but this did not lead to more NSI or mortality in the lower tertiles of our modified BIG protocol. If the modified BIG used the original tertile management on our population, then NS consultation may have been reduced by up to 52%. These modified criteria may be a safe opportunity for further health care resource and cost savings in the TBI population. Prognostic and Epidemiological; Level IV.

Trends in Atrial Fibrillation Management—Results from a National Multi-Center Urgent Care Network Registry

Background: Atrial fibrillation (AF) is a common diagnosis in patients presenting to urgent care centers (UCCs), yet there is scant research regarding treatment in these centers. While some of these patients are managed within UCCs, some are referred for further care in an emergency department (ED). Objectives: We aimed to identify the rate of patients referred to an ED and define predictors for this outcome. We analyzed the rates of AF diagnosis and hospital referral over the years. Finally, we described trends in patient anticoagulation (AC) medication use. Methods: This retrospective study included 5873 visits of patients over age 18 visiting the TEREM UCC network with a diagnosis of AF over 11 years. Multivariate analysis was used to identify predictors for ED referral. Results: In a multivariate model, predictors of referral to an ED included vascular disease (OR 1.88 (95% CI 1.43–2.45), p &lt; 0.001), evening or night shifts (OR 1.31 (95% CI 1.11–1.55), p &lt; 0.001; OR 1.68 (95% CI 1.32–2.15), p &lt; 0.001; respectively), previously diagnosed AF (OR 0.31 (95% CI 0.26–0.37), p &lt; 0.001), prior treatment with AC (OR 0.56 (95% CI 0.46–0.67), p &lt; 0.001), beta blockers (OR 0.63 (95% CI 0.52–0.76), p &lt; 0.001), and antiarrhythmic medication (OR 0.58 (95% CI 0.48–0.69), p &lt; 0.001). Visits diagnosed with AF increased over the years (p = 0.030), while referrals to an ED decreased over the years (p = 0.050). The rate of novel oral anticoagulant prescriptions increased over the years. Conclusions: The rate of referral to an ED from a UCC over the years is declining but remains high. Referrals may be predicted using simple clinical variables. This knowledge may help to reduce the burden of hospitalizations.

Efficacy and Safety of Anticoagulation, Catheter-Directed Thrombolysis, or Systemic Thrombolysis in Acute Pulmonary Embolism

BackgroundThe optimal treatment strategy of patients with pulmonary embolism (PE) (especially those with intermediate risk) continues to evolve and remains controversial. ObjectivesThis study sought to compare the efficacy and safety of anticoagulation (AC) alone, catheter-directed thrombolysis (CDT), and systemic thrombolysis (ST) in patients with acute PE. MethodsPubMed and EMBASE were searched for randomized controlled trials or observational studies which compared outcomes of AC alone, CDT, and ST in acute PE. Efficacy outcome was all-cause mortality. Safety outcomes were major bleeding and intracranial hemorrhage (ICH). ResultsWe identified 45 studies (17 randomized controlled trials, 2 prospective nonrandomized trials, and 26 retrospective observational trials), which included 81,705 patients. When compared with AC alone, CDT had lower mortality (OR: 0.55; 95% CI: 0.39-0.80) but higher major bleeding (OR: 1.84; 95% CI: 1.10-3.08) and numerically higher ICH (OR: 1.51; 95% CI: 0.75-3.04). ST was associated with no difference in mortality but higher major bleeding (OR: 2.16; 95% CI: 1.38-3.38) and ICH (OR: 2.26; 95% CI: 1.14-4.48) when compared with AC alone. The risk of mortality (OR: 2.05; 95% CI: 1.46-2.89) and ICH (OR: 1.50; 95% CI: 1.13-1.99) was higher with ST when compared with CDT. Findings were similar when analysis was restricted to trials of intermediate risk PE. ConclusionsIn patients with acute PE, when compared with AC alone, CDT was associated with a lower mortality but higher risk of bleeding. Moreover, CDT had an enhanced safety profile when compared with ST.

The Effect of Pre-Stenting on Bleeding-Related Complications Following Ureteroscopy in Patients on Anticoagulation or Antiplatelet Therapy.

Introduction: The American Urological Association guidelines state that continuing anticoagulant (AC) and antiplatelet (AP) agents during ureteroscopy (URS) is safe. Through a multi-institutional retrospective study, we sought to determine whether pre-stenting in patients on AP or AC was associated with fewer URS bleeding-related complications. Methods: A series of 8614 URS procedures performed across three institutions (April 2010 to September 2017) was electronically reviewed for AC/AP use at time of URS. Records indicating AC or AP use at time of URS were then manually reviewed to characterize intraoperative and 30-day postoperative (intraoperative bleeding, postoperative hematuria, emergency department visits, hospital readmission, unplanned reoperation, phone calls, and other minor 30-day complications). Results: A total of 293 identified URS procedures were completed on patients on AC/AP therapy-112 cases were on AC only (38 were pre-stented), 158 on AP only (51 pre-stented), and 23 on both AP and AC (8 pre-stented). Patient characteristics and comorbidities were similar between the pre-stented and non-pre-stented groups. For AC and AP subjects, pre-stenting did not decrease the composite risk of bleeding complications (10.3% pre-stent vs 12.2% non-prestent, p = 0.6). Pre-stented patients did have a significantly lower likelihood of requiring an unplanned reoperation (1.0% vs 5.6%, p = 0.04). In the subgroup of patients on AP alone, pre-stented patients had significantly fewer episodes of intraoperative bleeding (0% vs 9%, p = 0.04), unplanned reoperations (0% vs 6.5%, p = 0.02), and 30-day complications (14% vs 27%, p = 0.05). In the subgroup of patients on AC alone, there were no significant differences in outcomes based on stent status. Conclusions: In this multi-institutional study, we found that pre-stenting before URS was not associated with fewer bleeding complications. However, pre-stenting appeared to be associated with improved outcomes for those patients on AP therapy. These results suggest a need for prospective studies to clarify the role of pre-stenting for URS.

Diagnosis and treatment of coagulopathy using thromboelastography with platelet mapping is associated with decreased risk of pulmonary failure in COVID-19 patients.

Treatment of coronavirus disease 2019 (COVID-19) patients may require antithrombotic and/or anti-inflammatory medications. We hypothesized that individualized anticoagulant (AC) management, based on diagnosis of coagulopathy using thromboelastography with platelet mapping (TEG-PM), would decrease the frequency of pulmonary failure (PF) requiring mechanical ventilation (MV), mitigate thrombotic and hemorrhagic events, and, in-turn, reduce mortality. Hospital-admitted COVID-19 patients, age 18 or older, with escalating oxygen requirements were included. Prospective and supplemental retrospective chart reviews were conducted during a 2-month period. Patients were stratified into two groups based on clinician-administered AC treatment: TEG-PM guided vs. non-TEG guided. Highly-elevated inflammatory markers (D-dimer, C-reactive protein, ferritin) were associated with poor prognosis but did not distinguish coagulopathic from noncoagulopathic patients. TEG-guided AC treatment was used in 145 patients vs. 227 treated without TEG-PM guidance. When managed by TEG-PM, patients had decreased frequency of PF requiring MV (45/145 [31%] vs. 152/227 [66.9%], P < 0.0001), fewer thrombotic events (2[1.4%] vs. 39[17.2%], P = 0.0019) and fewer hemorrhagic events (6[4.1%] vs. 24[10.7%], P = 0.0240), and had markedly reduced mortality (43[29.7%] vs. 142[62.6%], P < 0.0001). Platelet hyperactivity, indicating the need for antiplatelet medications, was identified in 75% of TEG-PM patients. When adjusted for confounders, empiric, indiscriminate AC treatment (not guided by TEG-PM) was shown to be an associated risk factor for PF requiring MV, while TEG-PM guided management was associated with a protective effect (odds ratio = 0.18, 95% confidence interval 0.08-0.4). Following COVID-19 diagnosis, AC therapies based on diagnosis of coagulopathy using TEG-PM were associated with significantly less respiratory decompensation, fewer thrombotic and hemorrhagic complications, and improved likelihood of survival.

Management of acute cholecystitis in patients on anti-thrombotic therapy: A single center experience

BackgroundAcute cholecystitis in patients on anti-thrombotic therapy (ATT) presents a clinical dilemma at the intersection between conflicting guidelines, specifically between timing of early operative management (OM) versus time-to-reversal of certain ATT agents. With growing recognition that nonoperative management (NOM) is associated with considerable morbidity, and evidence in the literature that early OM in patients on ATT is safe, we reviewed our own practice to examine how we addressed these conflicting guidelines. Materials and methodsWe performed a retrospective review of patients with acute cholecystitis between December 2017 and March 2022. Patients were classified as ATT or non-ATT; ATT patients were subdivided into anticoagulation (AC) and antiplatelet (AP) groups. Rates of OM were compared. Results502 patients with acute cholecystitis were identified, 464 non-ATT and 38 ATT. 30 ATT patients were on AC, 7 on AP, and 1 on both. Non-ATT patients were significantly more likely to receive OM at index presentation compared to those on ATT: 89.9 % vs 63.2 % (p < 0.05). Subgroup analysis of the ATT group showed AP patients were significantly less likely to receive OM compared to those on AC, 12.5 % vs 77 % (p < 0.05). ConclusionsAt our institution, patients on ATT were significantly less likely to undergo OM for acute cholecystitis compared with non-ATT patients. Those on AC received OM significantly more than patients on AP. Further study is needed to better define the management of this growing population so that acute cholecystitis guidelines might address this issue in the future.

The Role of Anticoagulants and Antiplatelets in Reducing Mortality in COVID-19 Patients: A Systematic Review and Meta-Analysis of Studies Reporting Adjusted Data.

The coronavirus disease 2019 (COVID-19) is associated with prolonged prothrombin time (PT), active partial thromboplastin time (aPTT), and increased D-dimer levels. Therefore, we aim to investigate if anticoagulants (AC) and antiplatelet (AP) therapy playa role in mitigating COVID-19 and its associated thrombosis along with its effect on the mortality rate, the need for mechanical ventilation, and the risk of hospital admission. Electronic databases were searched from their inception to July 19, 2022. The studies were divided into two groups: Group A (any dose of AC/AP versus no AC/AP) and Group B (therapeutic dose of AC (tAC)/AP versus prophylactic dose of AC (pAC)/AP). Review Manager (RevMan) version 5.4.1 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark) was used for all statistical analyses. Adjusted data ratios were extracted from all included studies and pooled using the random effects model. A total of 33 studies were taken for the analysis of two groups (Group A: 285,065COVID-19-positive patients, Group B: 2,421 COVID-19-positive patients). Overall analysis in Group A showed that the AC/AP group had a low risk of mortality in COVID-19 patients compared to the control group (risk ratio (RR): 0.77, 95% confidence interval (CI): 0.69-0.86). There was no significant difference in the need for mechanical ventilation (RR: 0.80, 95% CI: 0.60-1.08) and hospital admission (RR: 1.12, 95% CI: 0.78-1.59) between the AC/AP and no AC/AP group. Alongside, in Group B, tAC/AP did not demonstrate a significant decrease in mortality as compared to pAC/AP (RR: 0.62, 95% CI: 0.37-1.06). Treatment with AC and AP drugs can significantly decrease the mortality rate in COVID-19-infected patients, while AC also significantly reduces the need for mechanical ventilation.

Cannula-Associated Deep Vein Thrombosis After Venovenous Extracorporeal Membrane Oxygenation in Patients with and Without Systemic Anticoagulation

To identify and compare the rates of cannula-associated deep vein thrombosis (CaDVT) in patients on venovenous extracorporeal membrane oxygenation (VV-ECMO) who receive systemic anticoagulation (AC) and those who do not receive AC. Retrospective observational study. Tertiary academic medical center. Consecutive patients who successfully have been decannulated from VV-ECMO for treatment of refractory acute respiratory distress syndrome between 2017 and 2022. None. After decannulation of ECMO, a duplex sonograph was performed on the cannulation sites to determine the incidence and characteristics of cannula-related thrombosis. Thrombosis was classified as occlusive or nearly occlusive. Ninety-four of 161 patients were weaned from VV-ECMO. Nineteen patients who were placed on VV-ECMO due to COVID-19 were excluded. Twenty-seven of 52 patients (52%) who did not receive AC were identified to have thrombus. Twelve of 23 patients (52%) who received AC were identified to have thrombus. Patients who received AC required more blood products during the ECMO run and required longer support on VV-ECMO. This study showed a high incidence of cannula-related venous thrombosis after VV-ECMO decannulation. Surprisingly, the incidence of CaDVT in anticoagulation-free patients was the same as in patients requiring anticoagulation. Anticoagulated patients required longer support on VV-ECMO and required more transfusions. Routine post-decannulation screening for DVT is recommended due to the high incidence of CaDVT.

Preexisting anticoagulation is an independent predictor of mortality in geriatric trauma patients - a retrospective cohort study.

Preexisting anticoagulation is common among geriatric trauma patients. Geriatric trauma patients have a higher risk of mortality compared to younger patients. We sought to evaluate the association of preexisting anticoagulation with mortality in a group of geriatric trauma patients. A retrospective review of geriatric trauma patients was conducted for those admitted to a Level 1 trauma center from January 2018 to December 2020. Vital signs, demographics, injury characteristics, laboratory data, and mortality were all collected. Multivariable logistic regression analysis was performed for the association of preexisting anticoagulation and a primary endpoint of all-cause mortality. These groups were controlled for preexisting comorbidities, injury severity scores, and systolic blood pressure in the emergency department. Four thousand four hundred thirty-two geriatric patients were admitted during the study period. This cohort was made up of 36.9% men and 63.1% women. Three thousand eight hundred fifty-nine (87.2%) were white; the average age was 81±8.5 years, and the median injury severity score (ISS) was 5. The mean systolic blood pressure was 150±32mmHg, mean heart rate was 81±16bpm, mean lactate was 2.3±1.3, mean hematocrit was 37.3±8.8, and mean international normalized ratio (INR) was 1.7±10.3. One thousand five hundred ninety-two (35.9%) patients were on anticoagulation (AC) upon presentation. One hundred and sixty-five (3.7%) mortalities were recorded. Multivariable logistic regression analysis results show that preexisting anticoagulation [ odds ratio (OR) 1.92, 95% CI 1.36-2.72] was independently predictive of death. The analysis was adjusted for systolic BP in the emergency department less than90mmHg (OR 5.55, 95% CI 2.83-10.9), having more than 1 comorbidity (OR 2.30, 95% CI 1.57-3.38) and ISS (OR 1.13, 95% CI 1.10-1.15). Our study indicates that preexisting anticoagulation is associated with mortality among geriatric trauma patients.

Outcomes and Readmissions after Left Atrial Appendage Occlusion in Octogenarians: A Contemporary Analysis

Introduction and ObjectivesThe outcomes of left atrial appendage occlusion (LAAO) with the Watchman device in octogenarians are unknown as this population was underrepresented in major clinical trials. This study aims at examining the causes and outcomes of readmission after LAAO. DesignA retrospective cohort study based on the National Readmission Database in the United States. Settings and ParticipantPatients aged ≥80 years, admitted between January 2016 and December 2018, with the primary diagnosis of atrial fibrillation or flutter or who had LAAO were included in the study. Patients who died during index admission were excluded. MethodsWe used the National Readmission Database and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes to identify study participants. Data analysis was performed through Stata, version 17. Univariate and multivariate aggression analysis was used to adjust for confounders using Student t tests and χ2 tests. ResultsWe identified 491,329 patients on anticoagulation (AC) and 2030 patients who underwent LAA closure. Neither group differed regarding hypertension, previous myocardial infarction, or valvular heart disease. All-cause readmissions were lower in the LAAO group at 45 days (adjusted P < .01). All-cause readmissions at 45 and 90 days were similar in both groups. There was an increase in gastrointestinal bleeding (GIB) readmissions in the LAAO at 45 (P < .01), 90 (P < .01), and 180 (P < .01) days. There was no difference in GIB readmission between the 2 groups. There was no also difference in stroke or intracranial hemorrhage rates between the 2 groups throughout the follow-up period. Conclusion and ImplicationsIn octogenarians who received LAAO, the rate of GIB increased during the first 6 months after the procedure; however, it was not different from that of AC after that. Special attention should be given to the antithrombotic regimens after LAAO to avoid bleeding in this vulnerable patient population.

Strategies to reduce morbidity following pleurectomy and decortication for malignant pleural mesothelioma.

Pleurectomy and decortication (PD) in malignant pleural mesothelioma has a high morbidity mostly associated with aspiration pneumonia (PNA), deep vein thrombosis (DVT), and foreign catheter sepsis. We instituted four strategies to reduce these complications and report our experience. This was a retrospective review of patients who underwent PD at the University of Pennsylvania between 2015 and 2022. Our patients underwent standard of care PD in addition to tracheostomy and gastrostomy/jejunostomy tube with therapeutic anticoagulation (AC) leading up to surgery. Measured outcomes were postoperative PNA, DVT, and sepsis. The predicted risk of those same outcomes had patients not undergone the interventions was calculated based on the American College of Surgeons (ACS) surgical risk calculator (SRC). A McNemar's test was used to determine whether the risk of having PNA, DVT and sepsis differed between the two subgroups. Fifty-five patients were included in the study. The mean age was 70 years (SD 6.2) with a mean of 21 (SD 19) pack-years of smoking. PNA, DVT, and catheter-related sepsis occurred in 12, four, and seven patients, respectively. Upon using the ACS SRC prediction model of the nonintervention group, PNA, DVT and catheter related sepsis was predicted to occur in 24 (paired data OR 5, 95% CI: 1.4-17.2; McNemar's test p = 0.008), 14 (paired data OR 3.5, 95% CI: 1.15-10.6; McNemar's test p = 0.03), and 17 (paired OR 3, 95% CI: 1.09-8.3; McNemar's test p = 0.04) patients, respectively. Patients undergoing tracheostomy creation, therapeutic AC at the time of diagnosis, and gastrostomy tube placement had a reduced risk of aspiration PNA, DVT, and catheter sepsis.

Balancing Bleeding Risk and Thromboembolic Complications in Elderly Chronic Subdural Hematoma Patients Undergoing Burr Hole Trephination : A Multicenter Retrospective Cohort Study and Literature Review.

Chronic subdural hematoma (CSDH) patients using antithrombotic agents (AT) at high risk for cardiovascular disease are increasing. The authors aimed to analyze the factors influencing outcome by targeting patients using AT and to establish a desirable treatment strategy. A retrospective analysis was performed on data from 462 patients who underwent burr hole trephination (BHT) surgery for CSDH at five hospitals from March 2010 to June 2021. Outcomes included incidence of postoperative acute bleeding, recurrence rate, and morbidity or mortality rate. Patients were divided into the following four groups based on their history of AT use : no AT. Only antiplatelet agents (AP), only anticoagulants (AC), both of AP and AC. In addition, a concurrent literature review was conducted alongside our cohort study. Of 462 patients, 119 (119/462, 25.76%) were using AT. AP prescription did not significantly delay surgery (p=0.318), but AC prescription led to a significant increase in the time interval from admission to operation (p=0.048). After BHT, AP or AC intake significantly increased the period required for an in-dwelling drain (p=0.026 and p=0.037). The use of AC was significantly related to acute bleeding (p=0.044), while the use of AP was not (p=0.808). Use of AP or AC had no significant effect on CSDH recurrence (p=0.517 and p=1.000) or reoperation (p=0.924 and p=1.000). Morbidity was not statistically correlated with use of either AP or AC (p=0.795 and p=0.557, respectively), and there was no significant correlation with mortality for use of these medications (p=0.470 and p=1.000). Elderly CSDH patients may benefit from maintenance of AT therapy during BHT due to reduced thromboembolic risk. However, the use of AC necessitates individualized due to potential postoperative bleeding. Careful post-operative monitoring could mitigate prognosis and recurrence impacts.

Evaluation of bone mineral density and bone turnover in children on anticoagulation.

Childhood and adolescence are critical periods of bone mineral acquisition. Children on anticoagulation (AC) might have an increased risk for reduced bone mineral density (BMD). Risk factors for impaired bone accumulation include chronic diseases, immobility, and medication. Vitamin K (VK) deficiency reflected by undercarboxylated osteocalcin levels (ucOC) has been identified as a predictor of osteoporosis and fractures. Data on bone health in children under AC are sparse. To evaluate BMD in children on AC and characterize the risk factors of low BMD, including VK and Vitamin D (VD) status. Single-center cross-sectional study of clinical, biochemical, and densitometric parameters. Assessment of VK surrogate parameters included ucOC and matrix gla protein (MGP). A total of 39 children (4-18 years; 12 females) receiving AC were included, 31 (79%) on VK antagonists and 8 (21%) on direct oral anticoagulants. Overall, BMD was decreased for both the lumbar spine (LS; -0.7SDS) and total body less head (TBLH; -1.32SDS) compared with pediatric reference data. Significant associations were found between early pubertal development and TBLH-BMD, and between BMI and LS-BMD. VK surrogate parameters were highly related to patients' age and pubertal development. Neither serum parameters nor AC-related factors predicted BMD. VD was detected in 10/39 patients with lower values during puberty. Our data indicate BMD reduction in pediatric patients on AC. Although AC-related factors did not predict reduced BMD, low BMI and pubertal stages represented important risk factors. Awareness of risk factors for low BMD and high prevalence of VD deficiency during puberty could contribute to the improvement of bone health in this vulnerable patient group.

Effect of long-term anticoagulant therapy on the outcome of chronic subdural hematoma: a propensity score-matched analysis.

Chronic subdural hematomas (cSDHs) are particularly common in older adults who have increased risk of falls and the conditions that require anticoagulants (ACs). In such cases, clinicians are often left with the dilemma of co-managing the cSDH and the ongoing need for ACs. Patients who underwent surgical management for cSDH at the authors' institution between January 2006 and June 2022 were identified. Propensity score-matched analysis was used to obtain a balance in patients who were on ACs before the procedure versus those who were not, and in patients who were on ACs postprocedure versus those who were not. Length of hospitalization, periprocedural complications, reintervention rate during the same admission, rebleeding risk, and reintervention rates after discharge were compared. In total, 104 patients were on long-term ACs before the procedure, whereas 372 were not. After matching, 55 pairs were included in the analysis. Postprocedure, 74 patients were started on long-term ACs; the rest were not. A total of 49 patients in each group were then included in the analysis after matching. Comparing the preprocedure AC group with the non-AC group, no significant differences were found in length of hospitalization (8.5 ± 6.7 days vs 8.1 ± 7.7 days, p = 0.75), periprocedural complications (7.3% vs 7.3%, p > 0.99), or reintervention during the same admission (1.8% vs 5.5%, p = 0.31). In the comparison of postprocedure AC and non-AC groups, no significant differences were seen in recurrence rate (8.2% vs 14.3%, p = 0.52), reintervention rate after discharge (4.1% vs 14.3%, p = 0.16), or disability (i.e., mRS ≤ 2; 83.7% vs 89.8%, p = 0.55). Being treated with long-term ACs before cSDH procedures does not affect length of hospitalization, periprocedural complications, or reintervention during the same admission. Similarly, administration of long-term ACs after a procedure for cSDH does not increase rebleeding risk or reintervention rate. Patients who are on long-term ACs can have similar interventions to those who are not on ACs. In addition, it is safe to restart patients on AC agents in a 7- to 14-day window after admission for cSDH with or without acute/subacute components.