Initiation Of Anticoagulation Research Articles

Left atrial thrombus in atrial fibrillation/flutter patients in relation to anticoagulation strategy: LATTEE registry

Abstract Funding Acknowledgements Type of funding sources: None. Background Atrial fibrillation (AF) and flutter (AFl) increase the risk of thromboembolism by promoting clot formation in the left atrium. Current guidelines recommend initiation of oral anticoagulation (OAC) with vitamin K antagonists (VKAs) or, preferably, non-VKA-OACs (NOACs) in men and women with a CHA2DS2VASc score of ≥2 and ≥3, respectively. Effective OAC is also recommended 3 weeks before elective AF cardioversion or catheter ablation with pre-procedural ttransesophageal echocardiography (TEE) as an alternative. However, TEE before AF/AFl cardioversion or ablation is often performed even in anticoagulated patients, given that, in clinical practice, "effective" OAC may be difficult to achieve and/or verify. Purpose The aim of the study was to assess the prevalence of left atrial thrombus (LAT) in AF/AFl in relation to OAC strategy. Methods The Left Atrial Thrombus on Transesophageal Echocardiography (LATTEE) registry was a prospective, observational study enrolling consecutive patients with AF or AFl in whom TEE was performed before direct current cardioversion or catheter ablation, hospitalized in 13 cardiology departments in Poland. Patients’ recruitment process started from November 2018 in the coordinating centre and lasted 12 months since the beginning of the study in each participating centre or longer, i.e., until the inclusion of at least 200 patients at each participating centre (with the last patient enrolled in May 2020). Results Of 3109 patients enrolled, 88% were on chronic, 1.5% on transient OAC and 10% without OAC. Of patients on chronic OAC, 39% received rivaroxaban, 30% dabigatran, 14% apixaban and 18% vitamin K antagonists (VKA). Patients on apixaban were oldest, had worst renal function and highest both bleeding and thromboembolic risk, and more often received reduced doses. Overall, prevalence of LAT was 8.0% (7.3% on chronic OAC vs. 15% without OAC; p<0.01). In patients on VKA, prevalence of LAT was doubled compared to patients on non-VKA-OACs (NOACs) (13% vs. 6.0%; p<0.01), even after propensity score matching (13% vs. 7.5%; p<0.01) and in multivariable logistic regression (OR 1.9, 95% confidence interval 1.4-2.8). Prevalence of LAT in patients on apixaban was higher (9.8%) than in those on rivaroxaban (5.7%) and dabigatran (4.7%; p<0.01 for both comparisons). However, in propensity score matching and multivariable logistic regression, there was no difference in the risk of LAT between apixaban and other NOACs. Conclusions Prevalence of LAT in AF is non-negligible even on chronic OAC. In the real-world AF/AFl population, the risk of LAT seems higher on VKA compared to NOAC, and similar between different NOACs.

Anticoagulation and bleeding in the cancer patient.

Cancer patients have an increased risk of bleeding compared to non-cancer patients with anticoagulant therapy. A bleeding risk assessment before initiation of anticoagulation is recommended. Currently low molecular weight heparin (LMWH) and direct oral anticoagulants (DOACs) are the mainstays of treatment for cancer-associated venous thromboembolism (VTE). Since DOACs are administered orally, they offer some convenience and ease of administration; however, LMWH may be preferred in certain cancers. Given the prevalence of anticoagulant therapies in cancer patients, clinical providers must be able to recognize potentially critical bleeding sites and modalities to reverse major hemorrhage. Reversal agents or antidotes to bleeding may be required when bleeding is persistent or life-threatening. These include vitamin K, fresh frozen plasma (FFP), protamine, prothrombin complex concentrate (PCC) or andexanet alfa, and idarucizumab. Inferior vena cava (IVC) filter insertion can be also considered in those with major bleeding. Evidence for timing and need for re-initiation of anticoagulant therapy after a major bleeding remains sparse, but a multi-disciplinary approach and shared decision-making can be implemented in the interim.

Pharmacological venous thromboembolism prophylaxis in elective cranial surgery: a systematic review of time of initiation, regimen and duration

Introduction Pharmacological prophylaxis of venous thromboembolism (VTE) requires nuanced decision-making to balance the risk of VTE against haemorrhage. This problem is compounded in neurosurgical patients, in whom postoperative intracranial haemorrhage (ICH) may be catastrophic, compared to non-neuraxial bleeding in other types of surgery. Current major guidelines recommend caution when using pharmacological prophylaxis in elective cranial surgery, but incorporate low-quality evidence and lack precise guidance on timing and duration of anticoagulation. Methods We aimed to answer the following questions for patients undergoing elective cranial surgery: (1) when is the optimal time to initiate postoperative anticoagulation, and (2) how long should postoperative anticoagulation be continued for? In this systematic review, we screened randomised and non-randomised studies reporting original data on pharmacological VTE prophylaxis in elective cranial surgery. Outcomes of interest were VTE and ICH. Results Three retrospective, single-centre observational studies met eligibility criteria, with a total of 923 participants. Meta-analysis was not performed due to a high risk of bias across all studies. Through narrative synthesis, we found that patients who developed VTE were significantly more likely to receive their first postoperative dose at a later time (mean: 144 vs. 29 h, p = .04). Shorter courses of anticoagulation (<7 days) were associated with significantly lower ICH rates (p = .03) compared to longer courses (>21 days). Conclusion The limited evidence favours earlier initiation and shorter courses of thromboprophylactic anticoagulation. These findings are specific to patients undergoing surgery for meningioma or glioma and may not apply to other populations. Randomised controlled trials or robustly designed observational studies are necessary to establish a clearer evidence base.

Abstract 12: Oral Anticoagulant Prescribing For Older Adults Newly Diagnosed With Atrial Fibrillation During Hospitalization

Background: Oral anticoagulants are indicated in patients with atrial fibrillation (AF) at elevated thromboembolic risk. AF is often diagnosed during hospitalization, yet little is known about rates of anticoagulant initiation in this setting. Methods: We examined a 20% national sample of Medicare fee-for-service beneficiaries enrolled in Part D, aged &gt; 65 years, who were hospitalized in 2016, and who received a new diagnosis of AF. The primary outcome was anticoagulant claim within 7 days of discharge home. We used multivariable logistic regression and post-estimation predicted probabilities to identify predictors of discharge with an anticoagulant, hypothesizing that thromboembolic risk, bleeding risk, and frailty would independently influence anticoagulant initiation. Results: Among 31,889 patients diagnosed with AF while hospitalized (mean age, 78; 52% female; 84% white; 95% CHA 2 DS 2 -VASc ≥2; 84% HAS-BLED ≥2; 37% frail), one-quarter initiated an anticoagulant following discharge. In multivariable models, rates of anticoagulant initiation varied by primary reason for hospitalization, with the highest predicted probability of initiation among those with a primary diagnosis of AF (46.3%; 95% CI 45.1-47.5), followed by cardiac surgery (42.8%; 39.6-46.0), other cardiovascular conditions (25.1%; 24.3-26.0), non-cardiac diagnoses (18.6%; 17.3-19.9), and bleeds (3.6%; 2.3-5.0). Higher CHA 2 DS 2 -VASc score was associated with a small increase in anticoagulant initiation (predicted probability 19.8% [15.4-24.2] for CHA 2 DS 2 -VASc &lt;2 and 25.2% [24.7-25.7] for ≥4). Higher HAS-BLED score was associated with a small decrease (25.7% [24.6-26.8] for HAS-BLED &lt;2 and 23.4% [22.7-24.1] for ≥3). Increased frailty was associated with decreased likelihood of anticoagulant initiation, with robust and moderately-severely frail patients having predicted probabilities of 25.0% (23.3-26.6) and 17.6% (15.9-19.2) respectively. Discussion: Anticoagulant initiation is uncommon among older adults newly diagnosed with AF during hospitalization, even among those hospitalized primarily for AF and those with high thromboembolic risk. Providers should carefully weigh risks and benefits of anticoagulants with all inpatients found to have AF.

Susceptibility-Weighted MRI as an Imaging Marker for Reperfusion Injury in Acute Ischemic Stroke Following Mechanical Thrombectomy.

Following endovascular intervention for stroke, hyperattenuated areas are common in brain parenchyma and it is difficult to differentiate on non-contrast CT whether it is contrast staining or reperfusion hemorrhage. Differentiation between contrast staining from reperfusion hemorrhage is of paramount importance for early initiation of antiplatelets and/or anticoagulants to prevent reocclusion of vessel. This study demonstrates signal characteristics of contrast-staining and reperfusion hemorrhage on susceptibility weighted MRI and its role to differentiate between two. Between July 2017 to March 2019, 36 patients who presented with acute ischemic stroke due to large vessel occlusion underwent mechanical thrombectomy. Low-osmolar non-ionic (Iopromide 300 mg/L) iodinated contrast was used in all patients who underwent endovascular intervention. All patients underwent noncontrast CT brain and SWI on 3T MRI within 30 minutes of endovascular intervention. MRI was evaluated by two neuroradiologists. Reperfusion hemorrhage was defined as ECASS criteria II. Symptomatic ICH was defined as hemorrhagic transformation temporally related to a negative shift in NIHSS score >/=4. Out of 36 patients, 15 had hyperattenuated areas in brain on NCCT. Out of 15, 13 patients had blooming on SWI, suggestive of bleed. Two patients had no blooming on SWI, suggestive of contrast staining. Two patients didnot show any hyperdensity on NCCT but blooming on SWI, suggestive of bleed. All patients with hyperdensity on NCCT secondary to bleed showed blooming on SWI whereas those with contrast staining didnot show any signal changes on SWI. Thus, it is possible to differentiate reperfusion hemorrhage from contrast staining using SWI MRI. The significance of SWI in normal CT may be low where a small bleed maynot have any clinical significance.

Anticoagulation as secondary prevention of massive lung thromboses in hospitalized patients with COVID-19

Anticoagulation as secondary prevention of massive lung thromboses in hospitalized patients with COVID-19

Disparities in oral anticoagulation initiation in patients with schizophrenia and atrial fibrillation: A nationwide cohort study

AimsSchizophrenia is associated with poor anticoagulation control and clinical prognosis in patients with atrial fibrillation (AF). Little is known about initiation of oral anticoagulation therapy (OAC) in this patient population.MethodsIn the nationwide Danish health registries, we identified all patients with incident AF and schizophrenia with indication for OAC treatment. Patients with schizophrenia (n = 673) were matched 1:5 on sex, age, stroke risk score, and calendar‐period to incident AF patients without schizophrenia. We calculated absolute risk and risk difference (RD) of OAC initiation, adjusting for stroke and bleeding risk factors. Analyses were stratified by calendar period (2000–2011 and 2012–2018) to account for changes after the introduction of non‐vitamin K OACs (NOAC).ResultsAmong patients with schizophrenia (mean age 69.5 years, 50.3% females), 33.7% initiated OAC within the first year after AF diagnosis, compared with 54.4% of patients without schizophrenia, corresponding to an adjusted RD of −20.7 (95% confidence interval [CI]: −24.7 to −16.7). OAC initiation increased over time regardless of schizophrenia status. During 2000–2011, 18.3% of patients with schizophrenia and 42.9% without schizophrenia initiated OAC (adjusted RD −23.6%, 95% CI −28.8 to −18.6). During 2012–2018, this was 48.5% and 65.7%, respectively (adjusted RD −14.4%, 95% CI −20.4 to −8.4).ConclusionInitiation of OAC was substantially lower among patients with AF and schizophrenia compared with matched AF peers. These findings accentuate the importance of close attention to disparities in initiation of OAC treatment, and potential missed opportunities for prevention of disabling strokes in AF patients with schizophrenia.

Ultra-early therapeutic anticoagulation after craniotomy – A single institution experience

There is a paucity of information regarding the optimal timing of initiation or re-initiation of therapeutic anticoagulation after intracranial surgery. Anticoagulation that is started too soon after surgery may increase the risk of catastrophic intracranial bleeding. However, there are scenarios that necessitate the use of anticoagulation in the immediate post-operative period despite the increased risk of hemorrhage. Therefore, we sought to report our experience with ultra-early therapeutic anticoagulation after craniotomy. Retrospective chart review of patients from a single institution between 1/1/2010 and 10/1/2021 who were treated with therapeutic anticoagulation for venous thromboembolism on or before 7-days after a craniotomy or craniectomy. The primary endpoint was intracranial hemorrhage resulting in death or return to the operating room for hematoma evacuation. Secondary endpoints included extra-cranial hemorrhage, length of hospital stay, and 90-day readmission rate. Eighteen patients were included for analysis. The median time that therapeutic anticoagulation was started was post-operative day 5 (range 1–7 days). One patient (5.6%) met the primary endpoint as they experienced an intracranial hemorrhage 5 days after starting anticoagulation, which required surgical evacuation. No patients experienced an extra-cranial hemorrhage. The median length of hospitalization was 13 days (range 4–89 days). No patients were readmitted within 90 days. The 90-day survival rate was 100%. Ultra-early anticoagulation after craniotomy resulted in a 5.6% risk of intracranial hemorrhage. Thus, ultra-early anticoagulation can be performed safely but it does carry a substantial risk of intracranial bleeding that may require emergent hematoma evacuation or result in permeant neurologic deficits or death.

Outcomes in Patients with a Centrifugal Flow with Full Magnetic Levitation Left Ventricular Assist Device (CF-FML LVAD) Who Did Not Receive Bridging with a Continuous Heparin Infusion (CHI) After Implantation

PurposeCompare outcomes in CF-FML LVAD patients who received a CHI after implantation until they reached a therapeutic INR on warfarin to patients who were started on warfarin only and did not receive a CHI.MethodsA retrospective analysis using chart review and the institutional LVAD database was completed on 27 patients.Results5 of the 27 patients did not receive a CHI after implantation of CF-FML LVAD (due to a medication shortage), they were started on warfarin post-operative day 1 or 2 (POD1 or POD2) for an INR goal of 2-3. CHI was initiated on the remaining patients (DOS-POD8) and PTT reached therapeutic range POD2 (DOS-POD9). 2 patients did not reach therapeutic PTT before their INR was therapeutic. The CHI patients were started on warfarin POD4 (DOS-POD14). INR was therapeutic for patients without CHI POD6 (POD5-POD11). INR was therapeutic for patients with CHI POD10 (POD2-POD31). The no CHI patients reached therapeutic INR faster and were discharged from index hospitalization sooner. The no CHI patients had similar or less adverse events (AEs) then the CHI patients (Image 1).ConclusionIn a small cohort of patients, initiation of warfarin anticoagulation without CHI was not associated with thromboembolic complications. Further work to identify populations of LVAD supported patients who need less anticoagulation post-operatively is warranted before considering practice changes. Compare outcomes in CF-FML LVAD patients who received a CHI after implantation until they reached a therapeutic INR on warfarin to patients who were started on warfarin only and did not receive a CHI. A retrospective analysis using chart review and the institutional LVAD database was completed on 27 patients. 5 of the 27 patients did not receive a CHI after implantation of CF-FML LVAD (due to a medication shortage), they were started on warfarin post-operative day 1 or 2 (POD1 or POD2) for an INR goal of 2-3. CHI was initiated on the remaining patients (DOS-POD8) and PTT reached therapeutic range POD2 (DOS-POD9). 2 patients did not reach therapeutic PTT before their INR was therapeutic. The CHI patients were started on warfarin POD4 (DOS-POD14). INR was therapeutic for patients without CHI POD6 (POD5-POD11). INR was therapeutic for patients with CHI POD10 (POD2-POD31). The no CHI patients reached therapeutic INR faster and were discharged from index hospitalization sooner. The no CHI patients had similar or less adverse events (AEs) then the CHI patients (Image 1). In a small cohort of patients, initiation of warfarin anticoagulation without CHI was not associated with thromboembolic complications. Further work to identify populations of LVAD supported patients who need less anticoagulation post-operatively is warranted before considering practice changes.

Undertreatment of Anticoagulant Therapy in Hospitalized Acute Ischemic Stroke Patients With Atrial Fibrillation.

BackgroundThis study aimed to investigate the prevalence and factors associated with the initiation of oral anticoagulation among patients with acute ischemic stroke (AIS) and concurrent atrial fibrillation (AF) at discharge in China.MethodsWe continuously included hospitalized patients with AIS with an AF diagnosis registered in the computer-based Online Database of Acute Stroke Patients for Stroke Management Quality Evaluation (CASE II) from January 2016 to December 2020 and divided them into a and non-anticoagulant groups according to the medications at discharge. Binary logistic regression was used to determine the factors associated with the prescription of anticoagulants in patients with AF.ResultsA total of 16,162 patients were enrolled. The mean age was 77 ± 9 years, 8,596 (53.2%) were males, and the median baseline National Institute of Health Stroke Scale score was 5 (2–12). Of the 14,838 patients without contraindications of antithrombotic therapy, 6,335 (42.7%) patients were initiated with anticoagulation treatment at discharge. Prior history of hemorrhagic stroke (OR 0.647, p < 0.001) and gastrointestinal bleeding (OR 0.607, p = 0.003) were associated with a lower rate of anticoagulation at discharge. Patients with any intracranial hemorrhage (OR 0.268, p < 0.001), gastrointestinal bleeding (OR 0.353, p < 0.001), or pneumonia during hospitalization (OR 0.601, p < 0.001) were less likely to receive anticoagulants at discharge. Among 7,807 patients with previously diagnosed AF and high risk of stroke (CHA2DS2-VASc ≥2), only 1,585 (20.3%) had been receiving anticoagulation treatment prior to the onset of stroke. However, the mean international normalized ratio (INR) was 1.5 on the first test during hospitalization in patients receiving warfarin. Patients complicated with a previous history of ischemic stroke/transient ischemic attack (TIA; OR 2.303, p < 0.001) and peripheral artery disease (OR 1.456, p = 0.003) were more common to start anticoagulants.ConclusionsLess than half of patients with AIS and concurrent AF initiated guideline-recommended oral anticoagulation at discharge, while only 20% of patients with previously diagnosed AF with a high risk of stroke had been using anticoagulants prior to the onset of stroke, which highlights a large care gap in hospitalized stroke patients and the importance of AF management.

Remote Design of a Smartphone and Wearable Detected Atrial Arrhythmia in Older Adults Case Finding Study: Smart in OAC – AFNET 9

IntroductionScreening for atrial fibrillation and timely initiation of oral anticoagulation, rhythm management, and treatment of concomitant cardiovascular conditions can improve outcomes in high-risk populations. Whether wearables can facilitate screening in older adults is not known.Methods and AnalysesThe multicenter, international, investigator-initiated, single-arm case-finding Smartphone and wearable detected atrial arrhythmia in older adults case finding study (Smart in OAC – AFNET 9) evaluates the diagnostic yield of a validated, cloud-based analysis algorithm detecting atrial arrhythmias via a signal acquired by a smartphone-coupled wristband monitoring system in older adults. Unselected participants aged ≥65 years without known atrial fibrillation and not receiving oral anticoagulation are enrolled in three European countries. Participants undergo continuous pulse monitoring using a wristband with a photo plethysmography (PPG) sensor and a telecare analytic service. Participants with PPG-detected atrial arrhythmias will be offered ECG loop monitoring. The study has a virtual design with digital consent and teleconsultations, whilst including hybrid solutions. Primary outcome is the proportion of older adults with newly detected atrial arrhythmias (NCT04579159).DiscussionSmart in OAC – AFNET 9 will provide information on wearable-based screening for PPG-detected atrial arrhythmias in Europe and provide an estimate of the prevalence of atrial arrhythmias in an unselected population of older adults.

Planning neurosurgical interventions in patients with anticoagulant therapy

Clinical practice guideline on anticoagulation is intended to manage patients undergoing neurosurgical procedures for the best possible short and long-term outcomes. In the clinical office practice, anticoagulation is offered to prevent thromboembolism with Warfarin, Heparin, Novel Oral Anticoagulants. The management approach starts with the mitigation plans from a reversal of pre-procedural anticoagulants for impending neurosurgical procedures by estimating procedural bleeding risk on the patients. The haemorrhage criteria and the timing of procedures are best assessed by the proceduralist during and after the intervention, standing on ground situations. Yet, intra- and post-procedure anticoagulant therapy should induct a multidisciplinary consultation paradigm for the best outcome in any emergent scenario. Further, each anticoagulation event should be monitored closely with competence in the optimum reversal process. Different neurosurgical procedures also should be weighed for their inherent hazards along with the probabilities of the bleeding and thromboembolism. The treating team should also concur to suggest a resumption of the pre-procedure anticoagulant therapy which may have been in place for altogether different morbidities. Regarding the anticoagulant agent, there are special conditions and recommendations to bear in mind in the daily medical practice for patient management. In the clinical practice guidelines for neurosurgical procedures, decisions about initiation and continuation of anticoagulants require experience and thorough internalization of the planned procedure, to avoid the risks of inherent risks of bleeding and thromboembolism.

Prolonged Cardiac Monitoring and Stroke Recurrence: A Meta-analysis.

Prolonged poststroke cardiac rhythm monitoring (PCM) reveals a substantial proportion of patients with ischemic stroke (IS) with atrial fibrillation (AF) not detected by conventional rhythm monitoring strategies. We evaluated the association between PCM and the institution of stroke preventive strategies and stroke recurrence. We searched MEDLINE and SCOPUS databases to identify studies reporting stroke recurrence rates in patients with history of recent IS or TIA receiving PCM compared with patients receiving conventional cardiac rhythm monitoring. Pairwise meta-analyses were performed under the random effects model. To explore for differences between the monitoring strategies, we combined direct and indirect evidence for any given pair of monitoring devices assessed within a randomized controlled trial (RCT). We included 8 studies (5 RCTs, 3 observational; 2,994 patients). Patients receiving PCM after their index event had a higher rate of AF detection and anticoagulant initiation in RCTs (risk ratio [RR] 3.91, 95% CI 2.54-6.03; RR 2.16, 95% CI 1.66-2.80, respectively) and observational studies (RR 2.06, 95% CI 1.57-2.70; RR 2.01, 95% CI 1.43-2.83, respectively). PCM was associated with a lower risk of recurrent stroke during follow-up in observational studies (RR 0.29, 95% CI 0.15-0.59), but not in RCTs (RR 0.72, 95% CI 0.49-1.07). In indirect analyses of RCTs, the likelihood of AF detection and anticoagulation initiation was higher for implantable loop recorders compared with Holter monitors and external loop recorders. PCM after an IS or TIA can lead to higher rates of AF detection and anticoagulant initiation. There is no solid RCT evidence supporting that PCM may be associated with lower stroke recurrence risk.

Between Scylla and Charybdis: risks of early therapeutic anticoagulation for venous thromboembolism after acute intracranial hemorrhage

Objective To assess the risk of hematoma expansion in patients with acute intracranial hemorrhage (ICH) requiring therapeutic anticoagulation for the treatment of venous thromboembolism. Methods We retrospectively reviewed all patients at our institution between 2014 and 2019 who were therapeutically anticoagulated for venous thromboembolism within 4 weeks after ICH. We included subtypes of traumatic ICH and spontaneous intraparenchymal hemorrhage. Our main outcome was the incidence of hematoma expansion within 14 days from initiating therapeutic anticoagulation. Hematoma expansion was defined as (1) radiographically proven expansion leading to cessation of therapeutic anticoagulation or (2) death due to hematoma expansion. Secondary outcomes included mortality due to hematoma expansion and characteristics associated with hematoma expansion. Results Fifty patients met inclusion criteria (mean age: 54 years, 80% male, 76% Caucasian); 24% had undergone a neurosurgical procedure prior to therapeutic anticoagulation. Median time from ICH to therapeutic anticoagulation initiation was 9.5 days (IQR 4–17), 40% received therapeutic anticoagulation in <7 days after ICH. Six patients (12%) developed hematoma expansion, of whom two (4%) died. While not statistically significant, patients with hematoma expansion tended to be older (57.8 vs. 53.5 years), were anticoagulated sooner (4 vs. 10 days), presented with lower GCS (50% vs. 39% with GCS <8), higher hematoma volume (50% vs. 42% >30 cc), and higher SDH diameter (16 mm vs. 8.35 mm). There was a trend towards greater risk of hematoma expansion for patients undergoing endoscopic ICH evacuation (16% vs. 2%, p = 0.09); patients with hematoma expansion were more likely to present with hydrocephalus (67% vs. 16%, p = 0.02). Conclusions Our study is among the first to explore characteristics associated with hematoma expansion in patients undergoing therapeutic anticoagulation after acute ICH. Larger studies in different ICH subtypes are needed to identify determinants of hematoma expansion in this high-acuity population.

241 Is There a Role for Empirical Treatment of Orthopaedic Patients with Suspected, but Not Confirmed, VTE in the Post-Operative Period?

Abstract Introduction Major surgery, including major orthopaedic surgery, is a key risk factor for developing venous thromboembolism (VTE). This poses a challenge in the post-operative phase when considering initiation of therapeutic-dose anticoagulation for suspected VTE due to the risk of major bleeding. Method A search strategy was developed with inclusion criteria involving all studies relating to the treatment of suspected VTE in the post-operative orthopaedic patient. Journal articles predating 3rd June 2021 were searched for in Medline, Embase and PubMed. Titles and s were reviewed based on clinical relevance. Results 56 articles were generated using this search strategy. 22 results were excluded as conference papers and/or case reports. Title and review of the remaining 34 studies did not identify any relevant articles reporting outcomes. Conclusions No evidence is available to guide recommendations for the empirical treatment of suspected VTE in the post-operative orthopaedic patient prior to a confirmed VTE diagnosis. This is therefore a risk-benefit clinical decision to be undertaken based on individual patient factors. Current American College of Chest Physicians guidelines advise initiation of anticoagulation for suspected acute VTE in cases with a high clinical suspicion, or intermediate clinical suspicion with expected delay in diagnostic imaging for at least 4 hours. However, this does not apply to patients following recent surgery who are at increased risk of bleeding post-operatively. Empirical systemic treatment dose anticoagulation for VTE in the post-operative period should therefore only be initiated when timely image-based diagnosis cannot be achieved.

Factors associated with positive thrombus findings at ultrasonography in COVID-19 ward patients who underwent imaging for suspected deep vein thrombosis under prophylactic anticoagulation

ObjectiveThe incidence of deep vein thrombosis (DVT) is increased in patients with coronavirus disease 2019 (COVID-19) and its presence is associated with worse outcomes. Ultrasound examination of patients with COVID-19 with a suspected DVT is challenging owing to concerns with disease transmission; the timely initiation of therapeutic anticoagulation is essential. This study aimed to identify patient factors associated with positive thrombus findings at ultrasound examination in patients with COVID-19 who underwent imaging for suspected DVT. MethodsPatients who did not require intensive care unit treatment and who underwent ultrasound imaging for suspected DVT between March and December 2020 were included retrospectively. Patient demographics, comorbidities, modified Well’s score, and d-dimer results on the day of ultrasound examination were recorded. Parameters for a higher likelihood of a positive DVT result were determined by comparing patients with confirmed DVT on ultrasound examination and patients with negative ultrasound findings. To determine a cut-off for d-dimer levels, a receiver operating characteristic curve was constructed. The sensitivity and specificity of the determined high-risk factors in the prediction of positive ultrasound results were calculated. ResultsA positive history for DVT (25% vs 4%; P < .001), thrombophilia (9% vs 2%; P = .048), immobilization (53% vs 23%; P = .001), and a Well’s score ≥ 2 (50% vs 21%; P = .001) were more frequent in patients with DVT. The mean d-dimer levels were higher in patients with DVT (3871 ± 1805 vs 2075 ± 1543; P < .001). The presence of either thrombophilia or a d-dimer level of >2020 had a sensitivity of 93% and a specificity of 64%. The presence of either thrombophilia, a d-dimer level of >2020, or a Well’s score of ≥2 had a sensitivity of 100% and a specificity of 51%. ConclusionsPatients with COVID-19 with a d-dimer of >2020, a positive history for thrombophilia, and a Well’s score of ≥2 should undergo a timely ultrasound examination. The high risk of DVT should be remembered for all hospitalized patients with COVID-19.

Use of Prolonged Cardiac Rhythm Monitoring to Identify Atrial Fibrillation After Cryptogenic Stroke

Prolonged cardiac monitoring (PCM) improves detection of atrial fibrillation (AF) after cryptogenic stroke. We summarize current research supporting the use of PCM as part of the cryptogenic stroke evaluation, while highlighting areas that require more investigation. Despite increased AF detection with longer durations of PCM, more definitive research is needed to demonstrate how PCM improves clinical outcomes. The optimal type, timing, and length of cardiac monitoring after cryptogenic stoke remains unknown. Clinical calculators will be important to risk stratify which cryptogenic stroke patients are most likely to benefit from PCM. Currently, AF detection after cryptogenic stroke should prompt consideration of anticoagulation, but it is unclear if all durations and timing of AF after stroke should be treated the same. PCM remains an important part of the cryptogenic stroke work up, and detection of AF allows for anticoagulation initiation. Additional research is needed to further refine our application of PCM to cryptogenic stroke.

Editors' Note: Early Neurologic Deterioration in Lacunar Stroke: Clinical and Imaging Predictors and Association With Long-term Outcome

In “Early Neurologic Deterioration in Lacunar Stroke: Clinical and Imaging Predictors and Association With Long-term Outcome,” Vynckier et al. reported that of 365 prospectively identified patients with lacunar stroke; early neurologic deterioration (END; persisting increase in NIHSS score by ≥ 2 points within 24 hours of admission) was associated with lower admission NIHSS score, capsular warning syndrome, ventral pontine infarct, hypoperfusion, and lack of initiation of dual antiplatelet therapy. They also reported END was associated with 90-day mRS score 3–6. Cao and Xia commented that when considering the outcome for patients with END after lacunar stroke, it is important to evaluate the interventions performed in response to the deterioration, such as endovascular treatment or initiation of anticoagulation or a glycoprotein IIb/IIIa inhibitor. The readers were also surprised to see that although only 16.7% of patients developed END, yet 48% of patients had a follow-up MRI performed at 24 ± 12 hours after their admission MRI. Vynckier et al. clarified that follow-up MRI was performed in all patients with END in addition to patients treated with intravenous thrombolysis or with transient neurologic symptoms that did not meet criteria for END. The authors agree that additional research and recommendations on the management of patients with lacunar strokes who have END is needed but noted that there is no evidence for the use of the therapies mentioned by Cao and Xia in this patient population. In “Early Neurologic Deterioration in Lacunar Stroke: Clinical and Imaging Predictors and Association With Long-term Outcome,” Vynckier et al. reported that of 365 prospectively identified patients with lacunar stroke; early neurologic deterioration (END; persisting increase in NIHSS score by ≥ 2 points within 24 hours of admission) was associated with lower admission NIHSS score, capsular warning syndrome, ventral pontine infarct, hypoperfusion, and lack of initiation of dual antiplatelet therapy. They also reported END was associated with 90-day mRS score 3–6. Cao and Xia commented that when considering the outcome for patients with END after lacunar stroke, it is important to evaluate the interventions performed in response to the deterioration, such as endovascular treatment or initiation of anticoagulation or a glycoprotein IIb/IIIa inhibitor. The readers were also surprised to see that although only 16.7% of patients developed END, yet 48% of patients had a follow-up MRI performed at 24 ± 12 hours after their admission MRI. Vynckier et al. clarified that follow-up MRI was performed in all patients with END in addition to patients treated with intravenous thrombolysis or with transient neurologic symptoms that did not meet criteria for END. The authors agree that additional research and recommendations on the management of patients with lacunar strokes who have END is needed but noted that there is no evidence for the use of the therapies mentioned by Cao and Xia in this patient population.

Longitudinal outcomes in cryptogenic stroke patients with and without long-term cardiac monitoring for atrial fibrillation.

BackgroundGuidelines recommend a confirmed diagnosis of atrial fibrillation (AF) to initiate oral anticoagulation in cryptogenic stroke (CS) patients. However, the intermittent nature of AF can make detection challenging with intermittent short-term cardiac monitoring.ObjectiveThe purpose of this retrospective cohort study was to examine post-CS utilization of cardiac monitoring and associated clinical outcomes.MethodsAdults with incident hospitalization for CS were identified in the Optum® claims database and assessed for cardiac monitoring received poststroke. Patient were stratified into those with a long-term insertable cardiac monitor (ICM) vs external cardiac monitor (ECM) only. The timing of ICM placement poststroke was treated as a time-dependent covariate. The clinical outcomes of interest were time to AF diagnosis, oral anticoagulation usage, and all-cause mortality.ResultsA total of 12,994 patients met selection criteria for the analysis, of whom 1949 (15%) received an ICM and 11,045 (85%) received ECM only. In those who had received an ECM as their first monitoring modality, only 4.4% moved on to receive an ICM for longer-term monitoring. Use of ECM before ICM was associated with a longer time to AF diagnosis (median 336 vs 194 days). Compared to those with ECM only, ICM patients had a significantly lower rate of death (hazard ratio [HR] 0.70; P = .004), and faster time to AF diagnosis (HR 1.50; P <.0001) and anticoagulation initiation (HR 1.57; P <.0001) during follow-up of up to 5 years after CS.ConclusionIn a real-world study of CS patients, prolonged cardiac monitoring was associated with higher rates of AF detection and treatment, and higher odds of survival.

Anticoagulation practices and venous thromboembolism in COVID-19 patients in a Philippine tertiary hospital

Funding AcknowledgementsType of funding sources: None.INTRODUCTIONCOVID-19 poses an increased risk for thrombosis and initiation of prophylactic anticoagulation has been shown to have mortality benefit in earlier studies. However, the use of full dose anticoagulation as prophylaxis and evidence of the efficacy and safety of anticoagulation on COVID-19 patients remains to be a topic of interest. This study aimed to explore the aspects of anticoagulation applied in a tertiary hospital in the Philippines and to further elucidate on its outcomes and development of complications among COVID-19 patients.METHODSIn this retrospective, observational study, we collected data from the case record forms of 945 patients with COVID-19 from two tertiary centers. Patients given anticoagulant therapy were classified as treated with standard, intermediate and therapeutic dose anticoagulation. The incidence of mortality and venous thromboembolism (VTE) among the three groups were compared as well as the risk for bleeding complications. Categorical variables were analyzed using the Chi-squared test and logistic regression analysis was done to quantify odds for mortality and complications among the treatment groups.RESULTSAmong available agents, Enoxaparin was the anticoagulant of choice in 96.1% of cases. The percentage of patients given anticoagulation was noted to increase with increasing severity. Overall, there were 168 (17.8%) inpatient deaths wherein 128 received anticoagulation. 51.3% of those who received therapeutic anticoagulation were intubated at any time during their hospital stay (p value 0.00). In-hospital survival for patients given prophylactic anticoagulation was 78.3% with the highest mortality among patients given therapeutic anticoagulation at 53.8%. Using binary logistic regression, there was increasing odds of mortality as anticoagulant dosage increased with an odds ratio of 2.818 for therapeutic anticoagulation (p = 0.00, b = 1.036). There was significantly lower incidence of pulmonary embolism and among patients given standard prophylactic therapy. The odds of incurring VTE (OR = 3.38, p = 0.001) and PE (OR = 4.315, p = 0.000) were found to increase as dosage increased. Major bleeding after given anticoagulant therapy was recorded in 4.7% of patients. Although half of the patients who presented with bleeding were given standard dose prophylaxis, the incidence of bleeding was highest within the intermediate dose category at 9.2%.CONCLUSIONTherapeutic dose anticoagulation was associated with higher odds of mortality. The incidence of recorded venous thromboembolism was low but still showed increasing odds as dosage of anticoagulation increased. In lieu of these findings, we recommend that therapeutic dose anticoagulation be given with caution to patients diagnosed with COVID-19, especially among those with severe to critical disease. Patients with the highest risks for VTE and requiring higher anticoagulant dosages should be monitored closely due to higher odds of bleeding. Figure. Figure.