Anticoagulation In Patients Research Articles

Abstract TP200: Anticoagulation Use and Endovascular Thrombectomy in Patients With Large Core Stroke - A Secondary Analysis of SELECT2 Trial

Introduction: Anticoagulation (AC) use is common in patients presenting with acute ischemic stroke and is known to pose challenges to acute reperfusion therapy. However, evidence about association of AC use prior to stroke with endovascular thrombectomy outcomes and post-procedure hemorrhages, especially in those with large strokes is limited. Methods: From SELECT2, patients were stratified based on AC medication use and prior to stroke. Functional outcomes at 90day follow-up and hemorrhagic transformation on follow-up imaging were compared between patients with and without AC in adjusted regression models. Results: Of 352 patients, 29/180 (16%, VKA - 15, DOACs 14) EVT patients and 18/172 (10%, VKA - 3, DOACs 15) MM patients were receiving anticoagulants at baseline. AC patients were older (72 (62-79) y vs 66 (58-75) y), with higher cardiac morbidity (Congestive Heart Failure: 28% vs 10%, Atrial Fibrillation: 70% vs 17%), but had similar NIHSS [20 (16-24) vs 18 (15-23)], time to randomization [511 (350-909) vs 586 (326-920) minutes], CT ASPECTS [4 (3-5) vs 4 (3-5)] and ischemic core estimates [91 (71 -110) vs 103 (71-139) ml, AC vs nonAC respectively]. Within AC patients, EVT did not improve outcomes (Shift: 6 (4-6) vs 5 (4-6), aGenOR: 0.89 (0.53-1.50), mRS 0-3: 11% vs 14%, aRR: 1.27 (0.40-4.05), mRS 5-6: 69% vs 67%, aRR: 1.05 (0.73-1.50)]. Furthermore, EVT patients on AC reported numerically higher rates of any intracerebral hemorrhage [85.7% vs 70.2%, aRR: 1.18, 95% CI: 0.98-1.43], but no sICH or parenchymal hemorrhage and demonstrated worse outcome [median mRS: 6 (4-6) vs 4 (3-6), aGenOR: 0.49(0.32-0.74)], mRS 0-3: 14% vs 43%, aRR: 0.36 (0.15-0.86)], and mRS 5-6: 69% vs 43%, aRR: at 90 day follow-up and numerically lower functional independence (mRS 0-2) [3.4% vs 23.3%, aRR: 0.18(0.03-1.21)], AC vs nonAC respectively. Consistent results were observed in patients achieving successful reperfusion. Conclusion: Almost 1/7 th of patients presenting with large stroke in SELECT2 trial demonstrated AC use at baseline, with higher cardiac morbidity. These patients were more likely to have hemorrhagic outcomes and worse clinical outcomes after EVT and successful reperfusion. Clinicaltrials.gov registration: NCT03876457

Effectiveness of Peripheral Nerve Block in Terms of Search for a Standardized Treatment Protocol in Diabetic Foot Patients Using Anticoagulants: A Double-Center Study.

Lower-extremity amputation for a diabetic foot is mainly performed under general or central neuraxial anesthesia. Ultrasound-guided peripheral nerve block (PNB) can be a good alternative, especially for patients who require continuous anticoagulation treatment and patients with additional comorbidities. We evaluated bleeding due to PNB application in patients with diabetic foot receiving antiplatelet or anticoagulant therapy. Perioperative morbidity and mortality and the need for intensive care hospitalization were analyzed. This study included 105 patients with diabetic foot or debridement who underwent distal foot amputation or debridement between February and October 2020. Popliteal nerve block (17 mL of 5% bupivacaine and 3 mL of saline) and saphenous nerve block (5 mL of 2% lidocaine) were applied to the patients. Postoperative pain scores (at 4, 8, 12, and 24 hours) and complications due to PNB were evaluated. Intensive care admission and 1-month mortality were recorded. The most common diseases accompanying diabetes were hypertension and peripheral artery disease. No complications due to PNB were observed. Mean ± SD postoperative first analgesic need was determined to be 14.1 ± 4.1 hours. Except for one patient, this group was followed up without the need for postoperative intensive care. In 16 patients, bleeding occurred as leakage from the surgical area, and it was stopped with repeated pressure dressing. Mean ± SD patient satisfaction score was 8.36 ± 1.59. Perioperative mortality was not observed. Ultrasound-guided PNB can be an effective and safe anesthetic technique for diabetic patients undergoing distal foot amputation, especially those receiving antiplatelet or anticoagulant therapy and considered high risk.

Chronic Anticoagulation is Associated With Increased Risk for Postoperative Complications Following Aseptic Revision Total Hip Arthroplasty

BackgroundWith an aging global population, the incidence of revision total hip arthroplasty (rTHA) is expected to increase markedly. While patients undergoing primary total hip arthroplasty who require chronic anticoagulation (AC) have been associated with increased postoperative complications, less is known about the impact of chronic AC status on postoperative complications in the rTHA setting. This study sought to compare complication rates following aseptic rTHA between patients who were on chronic AC and those who were not. MethodsA large national database was utilized to retrospectively identify 9,421 patients who underwent aseptic rTHA between 2014 and 2019. Patients were divided into 2 cohorts: 1,790 patients (19.0%) were in the chronic AC cohort (ie, having an AC prescription filled within 6 months prior to and following rTHA), and 7,631 patients (81.0%) were not on chronic AC. Postoperative complications at 90-days and 2-years were compared between cohorts utilizing univariate and multivariate analyses, controlling for sex, age, and comorbidities. ResultsAt 90-days, chronic AC patients had increased odds of prosthetic joint infections (PJIs) (odds ratio [OR] 3.2, P < .001), surgical site infections (OR 3.6, P < .001), and mechanical prosthetic complications (OR 3.5, P < .001), which included any aseptic loosening, implant dislocation, or broken prosthetic. At 2-years, chronic AC patients had increased odds of PJI (OR 3.3, P < .001) as well as mechanical prosthetic complications (OR 3.2, P < .001). Chronic AC patients were also at increased risk for reoperation within 2 years after initial aseptic rTHA (OR 1.9, P < .001). ConclusionsPatients on chronic AC have significantly higher odds of 90-day and 2-year complications after aseptic rTHA. This includes increased odds of PJI, surgical site infection, and mechanical prosthetic complications. Patients receiving chronic AC who undergo rTHA should be counseled on the risk-benefit ratio of their chronic AC status in a multidisciplinary setting to optimize their postoperative outcomes.

Systematic Review and Meta-Analysis of the Effect of Anticoagulation on Outcomes After Endovascular Aneurysm Repair.

Our objective was to investigate whether patients who receive anticoagulation therapy have different outcomes after endovascular aneurysm repair (EVAR) from those who do not. We conducted a systematic review of studies that compared outcomes of EVAR in patients who were on therapeutic anticoagulation vs those who were not. We developed and reported the review in accordance with the PRISMA guidelines with a registered protocol (CRD42022375894). The Ovid interface was used to search Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (EMBASE), and Cochrane Central Register of Controlled Trials (CENTRAL) up to November 2022. The quality of studies was assessed with the Newcastle-Ottawa Scale (NOS) (maximum score=9), and the evidence was appraised with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework. The hazard ratio (HR) and 95% confidence interval (CI) was the effect estimate in time-to-event meta-analyses, calculated using the inverse-variance statistical method and random-effects models. Sixteen studies qualified for inclusion reporting a total of 35 739 individuals. Anticoagulated patients had a statistically significantly higher hazard of death (HR=1.93, 95% CI=1.03-3.63), endoleak (HR=2.13, 95% CI=1.55-2.93), reintervention (HR=1.79, 95% CI=1.27-2.52), and aneurysm sac expansion (HR=2.72, 95% CI=1.57-4.72) than patients not receiving anticoagulation therapy. The median score on the NOS was 7 (range=4-9). The certainty of evidence was very low for mortality and reintervention and low for endoleak and sac expansion. Anticoagulation is a poor prognostic factor after standard EVAR and should be considered in decision-making, consent processes, and surveillance strategies. The number of individuals who take anticoagulation treatment has been rapidly increasing over the recent years. We aimed to investigate the effect of such treatment on outcomes after endovascular aneurysm repair (EVAR). Anticoagulated patients were found to have increased mortality, endoleak, and reintervention rates after EVAR compared to their non-anticoagulated counterparts. Anticoagulation therapy has a prognostic role in EVAR and should be considered in decision making and EVAR surveillance. Anticoagulated patients need to be informed of the higher failure rates of EVAR, and intensified surveillance strategies may need to be implemented in this patient cohort.

Efficacy of Direct Oral Anticoagulants Vs Warfarin Vs Low Molecular Weight Heparin in the Treatment of Acute Splanchnic Vein Thrombosis in Patients with Underlying Myeloproliferative Disorder

Introduction: Myeloproliferative neoplasms (MPNs) are hematopoietic stem cell disorders characterized by clonal proliferation of myeloid-lineage cells. Venous thrombosis poses a significant morbidity risk for MPN patients. The current recommended treatments for acute splanchnic vein thrombosis (SVT) are warfarin and low molecular weight heparin (LMWH). Direct oral anticoagulants (DOACs) are potential alternatives due to their predictable dose response and oral administration, but limited data exists for their use in acute SVTs. This retrospective study aims to assess the efficacy and outcomes of DOACs, LMWH, and warfarin in treating acute SVTs in patients with underlying MPN. Methods: We included patients of all ages with underlying myeloproliferative neoplasms and splanchnic vein thrombosis, with no underlying liver diseases, from Henry Ford Hospital Clinics in metropolitan Detroit, Michigan between 2013 and 2023. Patient data, which included age, gender, race, and BMI were recorded. The primary outcome was complete radiographic resolution (CRR) of the SVT, and secondary outcomes included recanalization, thrombosis progression, recurrent thrombosis, major bleeding, thrombocytopenia, and skin necrosis. The outcomes were compared between the three anticoagulant groups and patients using aspirin. Results: Among the 34 MPN patients with SVT, warfarin was prescribed most frequently (n=19), followed by enoxaparin (n=5) and DOACs (n=5). Although no significant differences were observed, warfarin showed the highest CRR rates (41.2%), while enoxaparin and DOACs had equal CRR rates (25%). DOACs showed recanalization rates similar to warfarin and higher than enoxaparin (44.4% and 47.1% vs. 20.0%, respectively). LMWH was associated with increased recurrent thrombosis rates (50.0%), while DOACs had a higher risk of major bleeding. All three anticoagulants had similar effects on thrombocytopenia and SVT progression. Aspirin use was linked to a higher risk of major bleeding (42.9%), but not using aspirin correlated with complete SVT resolution (30.8%), SVT progression (20.8%), recurrent thrombosis (29.2%), and thrombocytopenia (28.6%). Conclusions: Although limited by a small sample size, our study found no significant differences among the three anticoagulant groups. This contributes to establishing the role of DOACs in treating SVTs in patients with underlying MPN. Further studies with larger sample sizes are needed to explore the efficacy of DOACs compared to warfarin. Additionally, investigating the potential benefits of early thrombolysis in conjunction with anticoagulation for SVT patients with underlying MPN should be pursued, as the rates of complete resolution in these patients were low.

Developing the Form and Content of Implementation Strategies to Prevent Venous Thromboembolism for Ambulatory Patients with Cancer

Introduction To prevent venous thromboembolism (VTE) in people with cancer, guidelines recommend risk-assessment for those receiving systemic therapy and anticoagulation (AC) prophylaxis for those at high risk of VTE. However, these recommendations are significantly underused in clinical practice. Our prior work demonstrated barriers and facilitators contributing to this underuse and identified potential implementation strategies to address these barriers. The objective of this study was to develop the form and content of targeted implementation strategies promoting the uptake in clinical practice of guideline-recommendations for VTE prevention for ambulatory patients with cancer. Methods We conducted multidisciplinary stakeholder focus group discussions and semi-structured patient interviews to iteratively design the form and content of five implementation strategies (Table 1): (1) Conduct clinician education and training on risk-assessment models and anticoagulation thromboprophylaxis; (2) Adapt electronic health records (EHR) to provide interactive assistance; (3) Develop and distribute educational materials for clinicians about the Khorana score, VTE risk, and AC counseling; (4) Develop and distribute educational materials for patients; and (5) Audit and feedback. Stakeholders included oncologists, classical hematologists, an oncology clinical pharmacist, oncology advanced practice providers, and oncology patients, in academic and community-based settings within a single health care system. We conducted the clinician focus groups iteratively: in the first session we reviewed guidelines and evidence to support the use of risk assessment and AC prophylaxis in patients with cancer and shared barriers and facilitators identified in our earlier work. During subsequent sessions, we iteratively designed the form and content of the implementation strategies. In the final session, clinicians were presented a finalized prototype of the implementation strategies and asked to perform exploratory usability testing through simulated patient care encounters. Individual semi-structured interviews were conducted with patients to obtain feedback on the design of the implementation strategies and patient-education resources. Results A workflow for integration of risk-assessment and relevant prophylaxis in clinical practice was created based on participant feedback. Details for selected implementation strategies are shown in Table 1. For EHR support, stakeholders recommended the risk-assessment component be integrated within chemotherapy order sets. In addition, they recommended incorporating aid for AC management within the EHR, including a method to assess bleeding risk, pre-populated options for AC thromboprophylaxis, provision of easily accessible links to resources for peri-operative/procedure AC management, and a list of interactions between anticoagulants and common drugs used in oncology practice. Clinician stakeholders also recommended - and subsequently approved - standard phrases available to incorporate into the EHR documentation, both to guide decision-making and to serve as a reminder to re-assess in future visits. For education resources (clinician and patient), clinicians wanted education resources to be concise, and for the patient-facing resource, to be provided to patients both in existing “chemotherapy education” booklets and sent in after-visit appointment instructions. Regarding audit and feedback, clinicians recommended a personalized report card comparing their use of appropriate VTE prevention to their peers. After reviewing the patient-facing education documents, patients recommended simpler, straightforward language and clarifications for the VTE and AC patient education resources based on their past experiences. Conclusions With multidisciplinary stakeholder input from clinicians and patients, we developed a set of implementation strategies designed to address barriers to uptake of VTE prevention recommendations in oncology clinics. Next steps are to test the implementation strategies in clinical practice to measure impact on increasing these evidence-based interventions.

Efficacy and safety of under-dose non-vitamin K antagonist oral anticoagulant with atrial fibrillation undergoing PCI: Insights from a nationwide population-based cohort study

Abstract Background The under-dose non-vitamin K antagonist oral anticoagulants (NOACs) are required according to clinical conditions for patients with atrial fibrillation (AF). We aimed to assess the comparative effectiveness and safety of standard-dose and under-dose NOACs undergoing PCI. Methods We studied the retrospective nonrandomized observational cohort of oral anticoagulant native nonvalvular patients with atrial fibrillation treated NOACs (rivaroxaban, dabigatran, apixaban, or edoxaban) from January 2013 to December 2017, based on the Korean Health Insurance Review and Assessment database. We performed head-to-head comparisons of standard-dose and under-dose NOACs. Results We studied standard-dose and under-dose NOACs were 1,095 and 2,136, respectively (Rivaroxaban, 500 vs 782; Dabigatran, 233 vs 709; Apixaban, 244 vs 430; Edoxaban, 118 vs 214). Compared with standard-dose NOACs, low-dose NOACs were associated with lower risk of major bleeding in AF patients with PCI(Rivaroxaban, HR=0.72[0.58∼0.85]; Dabigatran, HR=0.73[0.60-0.86]; Apixaban, HR=0.82[0.69-0.95]; Edoxaban, HR=0.85[0.72-0.98]. Also, the ischemic stroke was significantly different for standard-dose and under-dose NOACs in AF patients with PCI (Rivaroxaban, HR=0.67[0.54-0.80]; Dabigatran, HR=0.68[0.55-0.81]; Apixaban, HR=0.69[0.56-0.82]; Edoxaban, HR=0.70[0.57-0.83]). Conclusions In this nonrandomized Asian cohort study, NOACs(rivaroxaban, dabigatran, apixaban, or edoxaban) were associated with lower risk of major bleeding and ischemic stroke for standard-dose and under-dose NOACs in AF patients with PCI.Table 1.Clinical outcomes

Development and validation of the DOAC Score: a novel bleeding risk prediction tool for patients with atrial fibrillation

Abstract Background Clinicians and patients must balance the ischemic benefits and bleeding risks when deciding to anticoagulate patients with atrial fibrillation (AF). Current clinical decision tools for assessing bleeding risk have limited performance and were developed for individuals anticoagulated with warfarin. Purpose This study develops and validates a clinical risk score to personalize estimates of bleeding risk for individuals with AF taking direct-acting oral anticoagulants (DOACs). Methods Among individuals taking dabigatran 150mg twice per day from 44 countries and 951 centers in this secondary analysis of the RE-LY trial, a risk score was developed to determine the probability for bleeding, based on covariates derived in a Cox proportional hazards model. The risk prediction model was internally validated with bootstrapping. We then refined the model in the GARFIELD-AF registry, with individuals taking dabigatran, edoxaban, rivaroxaban, and apixaban. To determine generalizability in external cohorts and among individuals on different DOACS, the risk prediction model was validated in the COMBINE-AF pooled clinical trial cohort and the RAMQ administrative database. The primary outcome was major bleeding. The risk score, termed the DOAC Score, was compared to the HAS-BLED score. Results Of the 5684 patients in RE-LY, 386 experienced a major bleeding event, within a median follow-up of 1.74-years. The prediction model was well-calibrated (goodness-of-fit P = 0.57) and had an optimism-corrected C statistic of 0.73 after internal validation with bootstrapping. The DOAC Score assigned points for age, creatinine clearance/glomerular filtration rate, underweight status, stroke/transient ischemic attack/embolism history, diabetes, hypertension, antiplatelet use, non-steroidal anti-inflammatory use, liver disease, and bleeding history, with each additional point scored associated with a 48.7% (95% CI: 38.9%-59.3%, P&amp;lt;0.001) increase in major bleeding in RE-LY. The score had superior performance to the HAS-BLED score in RE-LY (C Statistic: 0.73 vs 0.60, P for difference &amp;lt;0.001) and among 12,296 individuals in GARFIELD-AF (C statistic: 0.71 vs 0.66, P for Difference = 0.025). The DOAC Score had stronger predictive performance than the HAS-BLED score in both validation cohorts, including 25,586 individuals in COMBINE-AF (C statistic: 0.67 vs 0.63, P for Difference &amp;lt;0.001) and 11,945 individuals in RAMQ (C statistic: 0.65 vs 0.58, P for Difference &amp;lt;0.001). Conclusion In individuals with AF on DOAC therapy, the DOAC Score can help stratify patients based on expected bleeding risk.

Abstract 15632: Warfarin Dose Management Using Offline Deep Reinforcement Learning

Introduction: Warfarin is a commonly prescribed anticoagulant for treating atrial fibrillation, mechanical valves, and venous thromboembolism. Warfarin dose management remains challenging due to dosing variability between patients and warfarin’s narrow therapeutic window. Time in therapeutic range (TTR) is critical to warfarin’s safety and efficacy, but TTR typically remains low (40-50%) in community practices. Specialized anticoagulation clinics and protocolized approaches can increase TTR but have great administrative burdens and health care costs. Aim: To develop standardized optimal warfarin dose decision support using a machine learning model based on time series anticoagulation data and patient demographic characteristics Methods: The dataset included 12,497 warfarin patients monitored in the anticoagulation tracker of electronic medical records across the Mayo Clinic Enterprise. The dataset contained time series anticoagulation data (warfarin dose, INR, INR target range) and patient demographic characteristics. We implemented an offline deep reinforcement learning model (DRL) to predict the cumulative warfarin dose for the days until the next INR test based on a patient’s historical anticoagulation data. Prior approaches utilized traditional supervised learning methods such as regression or Long Short Term Memory (LSTM) neural networks to approximate a function mimicking the behavior of the training data. On the other hand, DRL learned an optimal dosing policy through continuous interaction and feedback from the training data. The key advantage of DRL is the model can learn to behave differently (and potentially better) for suboptimal clinical states in the data such as overdosing or underdosing. To evaluate the DRL model we compared the predicted warfarin doses with the physician-prescribed doses Results: DRL model’s prediction accuracy was 96.96%, outperforming our implementation of a baseline LSTM model with a prediction accuracy of 70.58%. Further evaluation of the DRL model indicated that the model correctly adjusted the warfarin dose at time steps when patients had out-of-range INRs. Conclusions: Offline deep reinforcement learning demonstrates potential in supporting warfarin dose management to maximize TTR.

PB0411 Platelet Glycoprotein IIb- and IIIa Levels are Altered in Persistently Lupus Anticoagulant Positive Patients with a History of Thrombosis

PB0411 Platelet Glycoprotein IIb- and IIIa Levels are Altered in Persistently Lupus Anticoagulant Positive Patients with a History of Thrombosis

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.

The Prevalence of Gastrointestinal Bleeding in COVID-19 Patients: A Systematic Review and Meta-Analysis.

Introduction: Severe acute respiratory syndrome coronavirus 2 caused the coronavirus disease of 2019 (COVID-19), which rapidly became a pandemic, claiming millions of lives. Apart from the main manifestations of this infection concerning the respiratory tract, such as pneumonia, there are also many manifestations from the gastrointestinal tract. Of these, bleeding from the gastrointestinal tract is a significant complication quite dangerous for life. This bleeding is divided into upper and lower, and the primary pathophysiological mechanism is the entering of the virus into the host cells through the Angiotensin-converting enzyme 2 receptors. Also, other comorbidities and the medication of corticosteroids and anticoagulants are considered to favor the occurrence of gastrointestinal bleeding (GIB). Methods: This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and the studies were searched in two different databases (Scopus and PubMed) from November 2019 until February 2023. All studies that reported GIB events among COVID-19 patients were included. Results: 33 studies were selected and reviewed to estimate the prevalence of GIB. A total of 134,905 patients with COVID-19 were included in these studies, and there were 1458 episodes of GIB. The prevalence of GIB, in these 33 studies, ranges from 0.47% to 19%. This range of prevalence is justified by the characteristics of the COVID-19 patients. These characteristics are the severity of COVID-19, anticoagulant and other drug treatments, the selection of only patients with gastrointestinal manifestations, etc. The pooled prevalence of gastrointestinal bleeding was estimated to be 3.05%, rising to 6.2% when only anticoagulant patients were included. Conclusions: GIB in COVID-19 patients is not a rare finding, and its appropriate and immediate treatment is necessary as it can be life-threatening. The most common clinical findings are melena and hematemesis, which characterize upper GIB. Treatment can be conservative; however, endoscopic management of bleeding with embolization is deemed necessary in some cases.

Stem cell mobilizating effect of heparin in patients undergoing autologous stem cell transplantation.

Adequate stem cell collection is essential for successful stem cell transplantation. Heparin enhances stem cell mobilization by competing with heparin sulfate proteoglycans. Heparin is also used as an anticoagulant before leukapheresis. Here, we evaluated the effects of heparin on stem cell mobilization in patients who underwent autologous stem cell transplantation (ASCT). We evaluated patients who underwent ASCT. Patients were divided into two groups: those who received heparin plus citrate (heparinized patients) and those who received citrate only (nonheparinized patients) for anticoagulation. Univariate and multivariate analyses were also performed. The collection efficiency 2 (CE2) for CD34+ cells was calculated and compared between heparinized and nonheparinized patients. This study included 1017 patients. There were 478 (47%) heparinized and 539 (53%) nonheparinized patients. The number of collected CD34+ cells was significantly higher in heparinized patients (P < .00001). The multivariate analyses showed that using heparin was an independent positive factor for collected CD34+ cells (adj-R2 = 0.744; F = 369.331, P < .00001). CE2 was significantly higher in heparinized patients than in nonheparinized patients (66.8% vs 52.1%; P < .00001). The rate of collecting at least 2 × 106 /kg CD34+ cells was 3.3 times higher for heparinized patients in poor mobilizers (P < .00001). Heparinized patients had significantly higher total nucleated and mononuclear cell counts (P < .00001 and <.00001, respectively). Heparin enhances stem cell collection and increases CE2. The use of heparin may reduce the need for other strategies to increase stem cell mobilization.

Timing of venous thromboemboli in patients with acetabular and pelvic ring fractures.

To determine the timing of symptomatic venous thromboemboli (VTE) in patients sustaining a pelvic and/or acetabular fracture. Secondly, to evaluate for any factors that may influence this timing. A retrospective cohort of 47 patients with acetabular and/or pelvic ring injuries who developed VTEs at a single academic level I trauma center were identified from 2012 to 2018. The chronology of VTE diagnosis in relation to date of injury, initial surgery, final surgery, and date of discharge was evaluated. Patients who developed VTEs were then evaluated based on known risk factors for VTE to determine if any of these affected timing. Symptomatic VTEs were diagnosed in 3.8% of patients with pelvic and/or acetabular fractures. In patients who developed a thromboembolism, diagnosis occurred on average 21.5 (± 19.2), 20.7 (± 19.9), 9.8 (± 23.4), and 4.3 (± 27.6) days after injury, index procedure, final procedure, and date of discharge. 25% of patients developed VTE more than 4weeks after their initial injury. No known risk factors effected the timing of VTE. The 2015 OTA expert panel recommends 4weeks of anticoagulation for orthopedic trauma patients at high risk of VTE, which may be too short a duration. In our cohort, 25% of VTEs occurred greater than 4weeks after injury. Additional research is needed to clarify the exact duration of anticoagulation after pelvic and acetabular fractures; however, surgeons may want to consider anticoagulating patients for greater than 4weeks. Level III-retrospective cohort.

P.063 Physician approaches to the initial management of an intraluminal thrombus in recently symptomatic carotid artery stenosis: results from the Hot Carotid Study

Background: The presence of intraluminal thrombi (ILT) in acutely symptomatic carotid stenosis (“hot carotid”) represents a therapeutic dilemma for physicians. With little evidence to guide treatment, current ILT management approaches rely on individual or institutional preferences. Methods: This mixed methods study analyzed themes from semi-structured interviews with 22 stroke physicians from 16 centers, paired with a worldwide case-based survey of 628 stroke physicians conducted through the “Practice Current” section of Neurology: Clinical Practice. Results: In the thematic analysis of the interviews and quantitative analysis of the survey, participants favoured using anticoagulation with or without antiplatelet agents in patients with ILT (463/628, 74%). Despite a preference for anticoagulation, uncertainty regarding optimal antithrombotic management was noted in the thematic analysis. Additional themes identified included a preference for re-imaging patients in 3-5 days after initiating treatment to look for complete or partial clot resolution, at which point most experts would then be comfortable proceeding with revascularization if indicated, though uncertainty regarding the optimal timing of revascularization was noted. Conclusions: In cases of ILT in the “hot carotid” practice patterns of global experts show a preference for using anticoagulation and reimaging patients in 3-5 days, though there is considerable equipoise regarding the most appropriate management of these patients.

(128) Complication Rates in Patients Using Intracavernosal Injection Therapy for Erectile Dysfunction With or Without Concurrent Anticoagulant Use—A Single-Center, Retrospective Pilot Study

Abstract Introduction Intracavernosal injection therapy (ICI) is an effective intervention used to treat erectile dysfunction (ED). It has been proposed that caution should be exercised when prescribing ICI to patients currently taking anticoagulants (AC) due to the theoretical increased risk of bleeding, however, there is limited literature describing complication rates of actively anticoagulated patients utilizing ICI. Objective We sought to determine whether there was a difference in bleeding and other complications in a cohort of patients using ICI therapy with or without concurrent AC use. Methods We reviewed our institutional electronic health record and identified 168 patients who were seen in our clinic from January to August 2020 who had either currently or previously utilized ICI therapy for ED treatment. These patients were surveyed regarding their ICI therapy as well as given the Erectile Dysfunction Inventory for Treatment Satisfaction (EDITS) questionnaire. Data from 85 patients was obtained; 43 concurrently using AC during ICI therapy and 42 with no AC use. Documented bleeding events (e.g. bruising, hematoma), complications, and mean EDITS scores were compared between the two groups. Fisher’s exact test for categorical variables and a two-tailed t-test were used with p&amp;lt;0.05 considered to be significant. Results There were more absolute bleeding complications in the AC group versus the no AC group, with 3/43 AC patients (7%, 95% CI: 2.4-18.6) and 0/42 no AC patients (0%, 95% CI: 0-8.4) experiencing some type of bleeding complication on ICI. However, there was no statistically significant difference found in overall or stratified documented bleeding events and complications between the two groups. Conclusions Findings from a single-center cohort of patients suggest that ICI therapy may be a safe and effective treatment modality for ED in patients with concurrent anticoagulant usage, however, given the higher rate of absolute bleeding events in our AC cohort, future assessment in a higher-powered study is warranted in determining a more accurate estimation of risk or propensity for bleeding complications in patients on AC using ICI therapy. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Run Wang, MD, FACS is a consultant for Boston Scientific and Teleflex.

How effective are PPIs at reducing the risk of GI bleeds in patients on anticoagulation therapy versus patients not taking PPIs?

Tripler Family Medicine Residency, Honolulu, HI The corresponding author is Sarah Kinkennon, MD; [email protected]. The authors declare no conflicts of interest.

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An algorithm helps reverse anticoagulation for intracranial hemorrhageFigure: An Algorithm for Reversing Anticoagulation for Intracranial HemorrhageA 65-year-old man with a history of hypertension, diabetes mellitus, and atrial fibrillation presented with a posterior scalp hematoma and altered mental status after a mechanical fall. The patient's family reported that he was taking apixaban, and his last dose had been four hours before arrival. A physical examination revealed a GCS of 13, a blood pressure of 175/99 mm Hg, and asymmetric pupils. The patient was taken to CT, where head imaging revealed a left-sided subdural hematoma with a midline shift and developing uncal herniation. A nicardipine infusion was initiated and the head of the bed was elevated. Andexanet alfa was not available, so an infusion of 4-factor prothrombin complex concentrate was initiated. The patient was taken emergently to the operating room by neurosurgery for a craniotomy and hematoma evacuation. Discontinue Anticoagulation Patients may require blood pressure control including antihypertensive infusions (goal SBP <140). Avoid reversal for intracranial hemorrhage associated with cerebral venous thrombosis. Use cautiously in patients with concomitant life-threatening ischemia, thrombosis, or severe DIC. Vitamin K Antagonists (Ex. Warfarin) Initial Dose: A fixed dose of 4F-PCC 1500 to 2000 units can be given as an initial dose with repeat dosing based on INR measurement 15 minutes after completion of the infusion. Follow local institution guidelines if available. Monitoring and Repeat Dosing: Give vitamin K if the INR is ≥1.4 at 12 hours (Chest. 2008;133[6 Suppl]:160S.) Consider repeat PCC dosing based on INR, though with increased DIC and thrombotic risk, it is recommended to correct further with FFP if INR remains ≥1.4. (J Thromb Haemost. 2008;6[4]:622; https://bit.ly/3ZDvpdU.) Direct Factor Xa Inhibitors (Ex. Rivaroxaban, Apixaban) Activated charcoal may be effective for up to six hours for apixaban (https://bit.ly/41PvXPJ) and eight hours for rivaroxaban (https://bit.ly/3L2mQFm). Andexanet Alfa Regimens (Stroke. 2021;52[6]:2096; https://bit.ly/3STy01c; J Am Coll Emerg Physicians Open. 2022;3[2]:e12655; https://bit.ly/3IYilZH.) Low-dose: rivaroxaban <10 mg, apixaban <5 mg, edoxaban <30 mg or eight or more hours since last dose High-dose: If greater than the thresholds above or dose/timing unknown Pentasaccharides (Ex. Fondaparinux) Use high-dose Andexanet alfa regimen (Nat Med. 2013;19[4]:446). Direct Thrombin Inhibitors (Ex. Dabigatran) Monitoring and Repeat Dosing: If the patient has ongoing significant bleeding after treatment, consider redosing idarucizumab or hemodialysis. Alternative Regimens: If idarucizumab is not available, aPCC (50-80 units/kg), 4F-PCC, or 3F-PCC (50 units/kg) can be used in order of preference. Unfractionated Heparin Dosing: Heparin units are based on estimated active agent (half-life 1-2 hours). Protamine sulfate 1 mg/100 units IV, maximum dose 50 mg Alternatively, give fixed dose of 25 to 50 mg. Monitoring and Repeat Dosing: If aPTT is persistently elevated, repeat 0.5 mg/100 units. Low-Molecular Weight Heparin (Clin Pharmacokinet. 2003;42[12]:1043.) Reversal is not indicated if more than three to five half-lives have passed since administration: Enoxaparin mean half-life: Four to five hours Dalteparin mean half-life: 2.8 hours Nadroparin mean half-life: 3.7 hours If bleeding persists or the patient has or renal insufficiency, repeat dose 0.5 mg/1 mg enoxaparin or 0.5 mg/100 anti-Xa units. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website: www.EM-News.com. Comments? Write to us at [email protected].

A retrospective study to identify the compliance with SDCEP guidelines of exodontia patients taking oral anticoagulant and antiplatelet medication

AbstractIntroductionExodontia treatment plans for oral anticoagulant and antiplatelet patients should consider Scottish Dental Clinical Effectiveness Programme (SDCEP) management guidelines. No previous literature has identified SDCEP guidelines compliance. The aim of this study was to determine how Oral Surgery staff manage exodontia patients who take antithrombotic medication, and the extent to which management principles consider SDCEP guidelines.Materials and MethodsAll clinical records were retrospectively analysed to identify patients who matched our criteria and had an exodontia procedure undertaken at Birmingham Dental Hospital over a 3‐month period.ResultsInitial records (n = 2961) of exodontia patients identified that 7.8% (n = 231) of patients were taking oral antithrombotic medication; 163 patients on Antiplatelet medication, 42 on Novel Oral Anticoagulants (NOAC) and 24 on Warfarin. No Antiplatelet or Warfarin patient had their medication regime interrupted. All Warfarin patients had their INR performed and recorded within 72 h of the procedure. A notable difference was found between managing high and low‐risk bleeding procedures for NOAC patients, although this was not statistically significant. Local intra‐operative haemostatic measures applied were significantly different between each of the drug groups (p &lt; 0.001). No local haemostatic measures were recorded in 45% of Antiplatelet patients, compared to 4.8% of NOAC and 12.5% of Warfarin cases. Self‐referrals are presented more commonly on a Thursday or Friday (p = 0.037).ConclusionsEach treatment plan should be considered on an individual basis, combining clinician expertise and clinical guidelines to optimise patient care. Areas of poor compliance were identified with further research being required to comprehend how compliance with the literature alters post‐operative haemostatic complications.

SCREENING FOR THROMBOPHILIA IN STROKE: ARE WE OKAY?

Stroke is now a global epidemic. It is on the rise, especially among the young population. The mechanism of stroke needs to be determined for appropriate management. Unfortunately, 40 percent of young strokes have an unknown aetiology. So, we should not leave any stone unturned to nd a possibility to treat. Thrombophilia in stroke is one such condition and is still a neglected entity in many parts of the world. Clinicians need to remember the appropriate time to test, the methodology, standard laboratory values, and the selection of patients for lifelong anticoagulation. In the absence of denitive data, it should be practised to obtain testing for hypercoagulable conditions in patients who have a personal or family history of systemic thromboses, no clear aetiology for ischemic stroke or transient ischemic attack (TIA), and clinical ndings that suggest systemic lupus erythematosus or the antiphospholipid antibody syndrome