Recommendations For Anticoagulation Research Articles

Early vs late anticoagulation in acute ischemic stroke with indications outside atrial fibrillation

BackgroundCurrent literature lacks guidance on the safety of administering anticoagulation in acute ischemic stroke with emergent indications that require anticoagulation other than atrial fibrillation. Therefore, we tend to rely on studies investigating acute ischemic stroke in atrial fibrillation for anticoagulation recommendations. MethodsWe retrospectively reviewed data for patients with acute ischemic stroke who had a non-atrial fibrillation emergent indication for anticoagulation (e.g., intra-arterial thrombus, intracardiac thrombus, acute coronary syndrome, acute limb ischemia, deep vein thrombosis and pulmonary embolism) diagnosed within 3 days of acute ischemic stroke. Patients who received anticoagulation ≤ 3 days of stroke onset (Group A) were compared to those who either received it afterwards or did not receive it at all (Group B). ResultsOut of the 558 patients, only 88 patients met our inclusion criteria. Of the total cohort, 55.7 % patients were males, and basic demographics were similar in both groups except for milder strokes in Group A (national institute of health stroke scale 6 vs. 12.5, p = 0.03). Only 2 patients in Group A and 1 patient in Group B developed intracranial hemorrhage, which was not statistically significant. Group A patients had a lower incidence of both new diagnosis (2 % vs. 34.2 % %, p < 0.001) and propagation of an established venous thromboembolism. They also had a lower rate of any thromboembolic complication (2 % vs. 42 %, p < 0.001). ConclusionEarly anticoagulation (i.e., ≤ 3 days) in non-atrial fibrillation ischemic stroke patients with an emergent indication may be safe and carry a lower risk of thromboembolic complications than later anticoagulation.

431 The Role of Stroke Prophylaxis in Traumatic Vertebral Artery Injury: A Literature-Based Cohort Study

INTRODUCTION: Vertebral artery injury (VAI) can precipitate posterior circulation strokes acutely following blunt trauma. VAI severity is conventionally classified by the Denver grading system, but at present, there remain no guidelines that translate Denver injury grade to antiplatelet or anticoagulant recommendations. METHODS: Four databases (Ovid MEDLINE, Ovid Embase, Cochrane Central, and Scopus) were queried to identify all studies evaluating stroke risk following blunt VAI. Stroke rates following VAI were compared for patients managed with observation only or antiplatelets. Sub-analyses stratifying outcomes by injury severity (Denver grade) were performed. Effectiveness of antiplatelet use was summarized by the number needed to prevent (NNP) post-VAI stroke. RESULTS: Of 2,256 unique studies identified, 34 comprising 1,138 patients were incluced. Overall VAI-related stroke risk was 1.75% before admission and 3.40% after admission. Grades I and II had a cumulative stroke risk of 2.43% (95% CI: 0.98-4.94), which differed significantly (p &lt; 0.01) from Grade IV-associated risk (10.10%; 95% CI: 4.95-17.79). Overall stroke risk in patients without prophylactic treatment was 10.00% (95% CI: 9.07-10.9), and 0.43% (95% CI: 0.01-1.06) in their counterparts who received antiplatelets (NNP = 10). Patients with grade I-II VAI receiving no treatment had 5.19% (95% CI: 1.43-12.77) stroke risk compared to 0.55% (95% CI: 0.01-3.02) treated with antiplatelet agents (NNP = 22). Among grade IV VAI, the stroke risk among patients that received no treatment was 21.21% (95% CI: 8.98-38.91), while none of the patients that received antiplatelet therapy developed stroke (NNP = 5). CONCLUSIONS: The majority of VAI-related stroke occurs after initial presentation, suggesting a potential for prevention of post-VAI stroke. Antiplatelet treatment was associated with significantly lower odds of post-VAI stroke among patients with Grade I, II, or IV injury, with the impact increasing within injury grade. The results suggest the positive impact of antiplatelet therapy with increasing VAI injury severity.

Abstract WP98: Variability of Perioperative Anticoagulation Strategies in Patients With Atrial Fibrillation

Introduction: In patients with atrial fibrillation (AFib) whose anticoagulation (AC) requires being held prior to non-emergent surgery, ischemic stroke is an unfortunately familiar event. Current practices in the holding of anticoagulation pre-op and the use of bridging therapy are heterogeneous, the guidelines for which are often underutilized. Methodology: We surveyed cardiologists, general practitioners and surgical specialists across a single large academic-based healthcare institution regarding periprocedural AC practices in patients with AFib. Data were organized by provider type and experience. Chi-square, Fisher exact, and Student's t-tests were used to analyze differences in anticoagulation practices. Results: Of 2,604 surveys emailed, 14 cardiologist, 53 general practitioners and 70 procedural/surgical specialists participated. Average number of days surgical specialists required holding AC were 2.6 (SD = 1.2) for direct oral anticoagulant (DOAC) and 4.6 (SD=1.6) for warfarin. INR goal averaged 1.6 (SD 0.3). Surgical specialists required bridging therapy for DOAC significantly less often than they did for warfarin, 15.5% vs 44.3%, X 2 = 14.0, p &lt; 0.001. Timing of DOAC held and warfarin held did not differ between attendings and trainees, nor did threshold goal INR. In contrast, practices between non-surgical specialists widely differed. Cardiologists trended roughly 4 times less likely than general practitioners to prescribe bridging therapy while DOAC was held, X 2 = 3.3, p = 0.06, yet they also trended toward prescribing bridging therapy more often for patients who had history of ischemic stroke. Significantly, attendings were 5 times less likely than residents to prescribe bridging therapy for DOACs and 3x times less likely to do so for warfarin, X 2 = 14.9, p = 0.0001 and X 2 = 5.5, p = 0.01, respectively. Conclusion: Our data indicate that significant differences exist in pre-op anticoagulation recommendations across provider type as well as training level. These differences are most stark in the use of bridging therapy while anticoagulation is held. Surgeons demonstrated more consistency in their anticoagulation strategies than did non-surgical providers.

Management after flap failure: a narrative review

Autologous free tissue transfer for breast reconstruction is a well-established and reliable form of reconstruction for women undergoing mastectomies. These surgeries are performed with high rates of success; however, the consequences of flap failure can be devastating to patients and surgeons. Breast reconstruction decision making following flap loss is a uniquely individualized process, based on considerations of safety, patient goals and preferences, as well as the surgeon’s skillset. The first priority following flap failure is to provide thoughtful patient counseling and support through this difficult time. The aims of reconstruction salvage after flap loss are to excise unhealthy tissue and restore a breast mound of normal anatomical shape. We present an algorithm as a possible approach to managing flap failures. We also review the management of breast reconstruction following free flap failure, including the role of hematologic investigation, anticoagulation recommendations and secondary or tertiary reconstruction with both prosthetic and autologous techniques.

Risk Assessment Model for Postpartum Venous Thromboembolism Prevention in Patients with Systemic Lupus Erythematosus

Background Patients with Systemic Lupus Erythematosus (SLE) may be at increased risk for developing a venous thromboembolism (VTE), particularly in the postpartum period. The Royal College of Obstetricians and Gynaecologists (RCOG) guideline for postpartum VTE prophylaxis is often used to triage which patients should get VTE prophylaxis. In this RCOG guideline, a score ≥ 3 drives a formal recommendation for postpartum anticoagulation. RCOG is unique in its inclusion of “active SLE” as an actionable VTE risk factor (adding 3 points). We sought to determine if a cohort of postpartum patients with a known history of SLE a) qualify as having “active” SLE by standard rheumatologic criteria b) have other risk factors for VTE c) received the recommended prophylaxis based on RCOG VTE risk assessment scoring and d) had a postpartum VTE. Objective To assess the application of the RCOG venous thromboembolism (VTE) risk model on a cohort of postpartum patients with a history of Systemic Lupus Erythematosus (SLE). Study Design This is a secondary analysis of an ongoing patient registry of women with SLE from 2016-2022. There were 49 SLE patients with 55 pregnancies using Definitions of Remission in SLE (DORIS) criteria to determine SLE disease activity. RCOG risk assessment model scoring was calculated for each patient prior to and after delivery. The primary outcome was the qualification of “active SLE” by standard rheumatologic criteria and assessment of recommendations for VTE prophylaxis based on RCOG VTE risk assessment scoring. Data were analyzed using Fisher’s Exact test, chi-square test, and Mann-Whitney U test with significance defined as p&lt;0.05. Results In the study cohort, 34 pregnancies (61.8%) were in DORIS remission at delivery. Twenty-one pregnancies (38.2%) were not and scored 3 points on the RCOG VTE risk model. Of these pregnancies, only 19% (n=4) were recommended for VTE prophylaxis by the obstetrical provider despite RCOG score ≥ 3. Only 35.7% (n=5) of pregnancies in DORIS remission, but with 3 points for non-SLE related VTE risk factors (n=14), were recommended for VTE prophylaxis. Of the 20 pregnancies in remission with an RCOG score &lt; 3 after assessing all risk factors, 15% (n=3) were nevertheless recommended for VTE prophylaxis. No patients had a postpartum VTE regardless of therapy. Conclusion These data reveal a need to improve upon providing postpartum VTE prophylaxis to SLE patients not in remission while also recognizing a diagnosis of SLE alone should not equate with active disease. Moreover, SLE patients in remission may still warrant VTE prophylaxis if other non-SLE-related risk factors are present.

Outcomes in high-risk pulmonary embolism patients undergoing FlowTriever mechanical thrombectomy: the FLAME study in perspective.

Pulmonary embolism (PE) is a common and life-threatening acute cardiovascular problem. In some patients, an abrupt increase in right ventricular (RV) afterload and impaired gas exchange result in acute RV failure, hypoperfusion, and severe hypoxemia due to V/Q mismatch. State-of-the-art management of acute PE includes early detection, risk stratification based on clinical, imaging, and biomarker criteria, and multidisciplinary decision-making regarding therapy.1,2 The European Society of Cardiology guidelines for management of PE recommend selection of therapy based on clinical severity of the presentation with class I recommendations for anticoagulation and systemic thrombolysis in patients with high-risk PE and for surgical thrombectomy in such patients in whom thrombolysis is contraindicated or has failed.3 Catheter-directed interventions for acute PE are aimed at increasing the cross-sectional area of patent pulmonary vasculature, thereby lowering resistance and alleviating V/Q mismatch.1,2 Percutaneous catheter-directed treatments are recommended as a reasonable alternative (Class IIa) in patients for whom thrombolysis is contraindicated or has failed.

Outcome of antithrombotic therapy in cancer patients with catheter-related thrombosis: a systematic review.

The guidelines' recommendations for anticoagulation in cancer patients with catheter-related thrombosis are unclear. The aim of this systematic review was to assess anticoagulation management in cancer patients with catheter-related thrombosis (CRT) based on previously published studies. As of June 10, 2023,we searched databases including PubMed, Embase, and Cochrane and included 11 observational studies that met the criteria. We evaluated 770 adults with active cancer and objectively confirmed patients with CRT who were using drugs including warfarin, LMWH, and new oral anticoagulants as antithrombotic therapy. We extracted outcome data, including thrombosis recurrence, catheter dysfunction, major bleeding, and death, and performed a meta-analysis. In this study we found that the risk of VTE recurrence was higher with rivaroxaban, the risk of bleeding and death appeared to be greater with warfarin, and although the risk of catheter dysfunction due to LMWH is a concern, it is still a more reasonable option for cancer patients with catheter-related thrombosis. http://www.clinicaltrials.gov, identifier (CRD42022367979).

Oral Anticoagulant Use in Patients With Atrial Fibrillation and Chronic Kidney Disease: A Review of the Evidence With Recommendations for Australian Clinical Practice.

Chronic kidney disease is common in patients with atrial fibrillation (AF) and is associated with heightened risks of stroke/systemic embolisation and bleeding. In this review we outline the evidence for AF stroke prevention in kidney disease, identify current knowledge gaps, and give recommendations for anticoagulation at various stages of chronic kidney disease. Overall, anticoagulation is underused. Warfarin use becomes increasingly difficult with advancing kidney disease, with difficulty maintaining international normalised ratio (INR) in therapeutic range, increased risk of intracranial and fatal bleeding compared to non-vitamin K oral anticoagulants (NOACs), and high rates of discontinuation. Similarly, the direct thrombin inhibitor dabigatran is not recommended as it is predominantly renally excreted with consequent increased plasma levels and bleeding risk with advanced kidney disease. The Factor Xa inhibitors apixaban and rivaroxaban have less renal excretion (25-35%), modest increases in plasma levels with advancing kidney disease, and are the preferred first line choice for anticoagulation in moderate kidney disease based on strong evidence from randomised clinical trials (RCTs). In severe kidney disease there is a paucity of RCT data, but extrapolation of the pharmacokinetic and RCT data for moderate kidney disease, and observational studies, support the considered use of dose-adjusted Factor Xa inhibitors unless the bleeding risk is prohibitive. In Australia, apixaban is approved for creatinine clearance down to 25 mL/min, and rivaroxaban down to 15 mL/min. For end-stage kidney disease warfarin is the only agent approved, but we recommend against anticoagulation (except in selected cases) due to high bleeding risk, multiple co-morbidities, and questionable benefit.

Natural history of ‘silent’ atrial fibrillation from subclinical to asymptomatic: State of the art and need for research

In the last 30 years clinical research in the atrial fibrillation (AF) field has seen a great advance both in terms of productivity and heterogeneity of areas that developed significant new knowledge and evidence. Indeed, it is very easy to verify how in the last 3 decades the number of articles regarding AF registered in MEDLINE has increased exponentially overtime. This large amount of evidence led to significant changes in the guidelines, with an improvement of the overall quality of recommendations and an increase in the high-quality recommendations (despite being still generally low) [ [1] Boriani G. Vitolo M. Lane D.A. Potpara T.S. Lip G.Y. Beyond the 2020 guidelines on atrial fibrillation of the European society of cardiology. Eur J Intern Med. 2021; 86: 1-11https://doi.org/10.1016/j.ejim.2021.01.006 Google Scholar , [2] Barnett A.S. Lewis W.R. Field M.E. Fonarow G.C. Gersh B.J. Page R.L. et al. Quality of evidence underlying the American Heart Association/American College of Cardiology/Heart Rhythm Society Guidelines on the management of atrial fibrillation. JAMA Cardiol. 2017; 2: 319https://doi.org/10.1001/jamacardio.2016.4936 Google Scholar ]. Several areas about AF clinical management are now largely assessed and established, as the need for oral anticoagulant (OAC) prescription, the preference of the non-vitamin K antagonist oral anticoagulants over vitamin k antagonist ones, as well as the assessment of thromboembolic and bleeding risks [ [3] Imberti J.F. Mei D.A. Vitolo M. Bonini N. Proietti M. Potpara T. et al. Comparing atrial fibrillation guidelines: focus on stroke prevention, bleeding risk assessment and oral anticoagulant recommendations. Eur J Intern Med. 2022; 101: 1-7https://doi.org/10.1016/j.ejim.2022.04.023 Google Scholar , [4] Hindricks G. Potpara T. Dagres N. Arbelo E. Bax J.J. Blomström-Lundqvist C. et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2021; 42: 373-498https://doi.org/10.1093/eurheartj/ehaa612 Google Scholar ]. Also, the need for implementation of integrated care, emerged as the main AF management strategy in the last guidelines, is now largely assessed and evidence based [ 4 Hindricks G. Potpara T. Dagres N. Arbelo E. Bax J.J. Blomström-Lundqvist C. et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2021; 42: 373-498https://doi.org/10.1093/eurheartj/ehaa612 Google Scholar , 5 Romiti G.F. Pastori D. Rivera-Caravaca J.M. Ding W.Y. Gue Y.X. Menichelli D. et al. Adherence to the “atrial fibrillation better care” pathway in patients with atrial fibrillation: impact on clinical outcomes-a systematic review and meta-analysis of 285,000 patients. Thromb Haemost. 2022; 122: 406-414https://doi.org/10.1055/a-1515-9630 Google Scholar , 6 Romiti G.F. Proietti M. Vitolo M. Bonini N. Fawzy A.M. Ding W.Y. et al. Clinical complexity and impact of the ABC (Atrial fibrillation Better Care) pathway in patients with atrial fibrillation: a report from the ESC-EHRA EURObservational Research Programme in AF General Long-Term Registry. BMC Med. 2022; 20: 326https://doi.org/10.1186/s12916-022-02526-7 Google Scholar ].

Thrombophilia Testing Patterns, Result Interpretation, and Clinical Outcomes in a Retrospective Cohort of Patients with Retinal Vascular Occlusion

Background Low quality evidence exists to support an association between retinal vascular occlusion and thrombophilia. However, testing may be complicated by the impact of anticoagulants, hormone use and other factors on the results. Even when test results are interpretable, the implications for clinical decision-making are not established. We performed a retrospective chart review to assess patterns of test selection, result interpretation, and clinical outcomes in a cohort of patients who received thrombophilia testing after presenting to a tertiary care center for retinal vascular occlusion. Methods Eligible patients were >18 years with retinal vein occlusion (RVO) or retinal artery occlusion (RAO) and referred for thrombophilia testing by an ophthalmologist between 3/16/2011 and 3/22/2021 at the University of Washington. Electronic medical records were extracted for relevant clinical characteristics, test results, use of antithrombotic therapy, and recurrent arterial or venous events. Continuous variables are summarized by means and standard deviations or medians and range, as applicable. Categorical variables are described by proportions. Differences between groups were assessed using Student's t-tests and Fisher's exact tests for continuous and categorical variables, respectively. Analyses were conducted in R. Results A cohort of 57 patients were identified, with median age of 44 years at diagnosis (Table 1). 38 (66.7%) presented with RVO and 23 (40.4%) presented with RAO, including 4 patients with concurrent RVO and RAO at diagnosis. Baseline characteristics were not significantly different between patients presenting RAO versus RVO, apart from a trend toward higher prevalence of stroke history in the RAO group (4/23 vs 1/38, p = 0.06). Thrombophilia test selection varied: protein C activity was most commonly tested (80.7%) while activated protein C resistance (40.4%) was least commonly ordered (Figure 1). Among the 50 patients who received some combination of antiphospholipid antibody (aPL) testing, only 44% had all Sydney criteria aPL assays performed. The underlying prevalence of thrombophilia was 3.5% (2/57). One patient was found to be homozygous for the factor V Leiden mutation (FVL) after presenting with a central RVO and 1 was diagnosed with antiphospholipid syndrome (APS) in the context of a branch RAO plus persistent positivity of anti-beta-2 glycoprotein I (IgM) and anticardiolipin (IgM) antibodies. Another 5 patients had abnormal test results that were not diagnostic of an underlying thrombophilia (1 heterozygous FVL, 1 heterozygous prothrombin gene mutation, and 3 positive aPL). In total, 15 patients were initiated on low-dose aspirin following diagnosis, including the patient diagnosed with APS. Four patients were treated with anticoagulation, including the heterozygous FVL and heterozygous prothrombin gene mutation patients, who were placed on indefinite anticoagulation. The patient found to be homozygous for FVL briefly received prophylactic dosing of rivaroxaban before switching to low-dose aspirin due to side effects. After a median follow-up of 3.1 years, 3 patients had recurrent events (1 RVO, 2 strokes). One developed recurrent stroke while taking rivaroxaban for atrial fibrillation, while the other 2 were not receiving antithrombotic therapy at the time of thrombosis recurrence. Conclusion A low prevalence of thrombophilia was observed in a young cohort of patients presenting with retinal vascular occlusion. Incomplete testing was common, including for antiphospholipid syndrome, which is associated with 2-fold increased risk of retinal vascular occlusion. Thrombophilia testing did not clearly aid in clinical decision making; the tests ordered and the actions taken based on the test result were inconsistent. Both patients identified to have underlying thrombophilia lacked other history of venous or arterial thromboembolism and ultimately opted against long-term anticoagulation. An additional 14 patients opted for antithrombotic therapy with low-dose aspirin after an entirely negative thrombophilia workup. Misinterpretation of test results likely led to inappropriate recommendations for indefinite anticoagulation in at least 2 patients. The utility of thrombophilia testing in retinal vascular occlusion is poorly studied. In this cohort, we found no evidence that such testing should influence clinical decision-making. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

COVID-19 Associated 60-Day Acute VTE Events in Hospitalized Patients Can be Predicted By D-Dimer and Prior VTE but Not By Reticulated Platelets

Introduction: COVID-19 is associated with venous thromboembolic (VTE) events, which are predictors for poor outcomes. Beyond d-dimer, there is a dearth of robust studies evaluating the association between VTE and clinical biomarkers. Our prior study established an association between immature platelet fraction (IPF%) and outcomes in COVID-19, specifically mortality and ICU admission. We expand on this by investigating the relationship between IPF% and acute 60-day VTE events in COVID-19 with a larger cohort. Methods: 1238 patients admitted with COVID-19 were analyzed. Various demographic factors and laboratory values, including IPF%, d-dimer, and platelet count were extracted. Charts were reviewed for 60-day VTE events. We assessed the relationship between 60-day VTE events and peak IPF% (IPF% max), lowest value of platelet counts (min platelet count), peak values of immature platelet counts (IPC max). In addition, the study also assessed the relationship between acute 60-day VTE events and average IPF% values (mean IPF%), average platelet counts (mean platelet count), maximum d-dimer (d-dimer max), and average d-dimer (mean d-dimer). Kaplan-Meir curves, Cox proportional hazard, and Cox time-varying covariate models were used to conduct time-to-event analyses to test associations between the selected inflammatory biomarker measures and increased risk of 60-day acute VTE events in our cohort. Results: 110 (9%) patients had an acute VTE event within 60 days of COVID-19 diagnosis. Maximum d-dimer is predictive of acute 60-day VTE events in the Cox proportional hazard model (HR 1.04, 95% CI 1.02-1.06, p<0.01). Additionally, prior VTE event is predictive of acute 60-day VTE event in COVID-19 in the Cox proportional hazard model (HR 2.1, 95% CI 1.4-3.8, p<0.01). However, elevated mean IPF% and IPF% max were higher in patients with VTE (IPF% max 6.4±4.7 vs. 5.1±3.3, p=0.0478; mean IPF% 5.1±3.4 vs.4.7±3.8, p=0.0025) (table 1). In the Cox proportional hazard model, neither mean IPF% nor IPF% max are predictive of VTE. Discussion: Predictive biomarkers for thromboembolism in COVID-19 is an unmet need. This study demonstrates that prior VTE events and maximum d-dimer are predictive of 60-day VTE events but not reticulated (immature) platelets in hospitalized COVID-19 patients. Current prophylactic anticoagulation recommendations in COVID-19 hospitalized patients are broadly based on the patient's clinical acuity, and there is a need for more personalized anticoagulation measures. Use of patient VTE history, clinical scenario, and biomarkers, in conjunction, would provide a more patient-centered approach to anticoagulation practice in hospitalized COVID-19 patients. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

In a large dataset of primary care patients, use of CHA2DS2-VA score leads to almost universal recommendation for anticoagulation in those aged 65 years and over with atrial fibrillation

Abstract Background Treatment with oral anticoagulants (OAC) for high-risk atrial fibrillation (AF) patients can reduce stroke risk by two-thirds. From 2012–14, the OAC treatment recommendation threshold in international guidelines moved from CHADS2 ≥2 to CHA2DS2-VASc ≥2 (men) or ≥3 (women), equivalent to a “sexless” CHA2DS2-VA≥2. This move aimed to identify truly low risk patients who did not need OAC treatment. General practitioners (GPs) report barriers about assessing patient suitability for OAC. Objectives To compare the proportion of AF patients for whom OAC treatment is recommended under CHADS2 ≥2 and CHA2DS2-VA ≥2, and to look at the drivers of any differences, using an existing dataset. Methods Analyses were conducted on a large Australian general practice dataset collated during previous studies (2011–2019), with deidentified data extracted from the clinical records system at a single timepoint for regularly-attending adult patients from 164 practices. CHADS2 and CHA2DS2-VA scores were calculated for AF patients with sufficient data available and the proportion with CHADS2 and CHA2DS2-VA ≥2 was compared using chi-square tests. Results There were records for 340,463 patients, of which 285,635 (8,294 with AF) had sufficient data to calculate CHADS2 and CHA2DS2-VA scores. Among AF patients of all ages, the CHA2DS2-VA ≥2 threshold captured a significantly higher proportion than CHADS2≥2 (85% vs 68%, p&amp;lt;0.0001). In AF patients aged ≥65 years, the CHA2DS2-VA ≥2 threshold also captured a significantly higher proportion than CHADS2 ≥2 (96% vs 76%, p&amp;lt;0.0001). Almost all older patients (≥65 years) who were captured by CHA2DS2-VA ≥2 but not CHADS2 ≥2 (n=1395) qualified on the basis of age, with only 1.4% eligible because of age 65–74 years and vascular disease history. Conclusions The change from CHAD2 to CHA2DS2-VA has resulted in a significantly higher proportion of patients with AF being recommended OAC treatment under the guidelines, driven almost entirely by the revised scoring for age. Among AF patients aged ≥65 years, almost all (96%) were recommended OAC treatment under CHA2DS2-VA, demonstrating that AF is strongly associated with other vascular pathology. These findings support the Canadian guidelines, which recommend OAC treatment for all AF cases aged ≥65 years. The findings also reinforce the argument that AF screening in those aged ≥65 years is justified, as almost all patients with prevalent AF in that age group are eligible for OAC treatment. These results suggest could be an argument for simplifying the treatment message for GPs, which may reduce barriers and further improve treatment rates. High rates of associated vascular pathology in AF patients suggest that additional management strategies are also justified, including promotion of exercise, smoking cessation, and treatment of associated conditions such as hypertension and diabetes. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): RACGP Foundation / HCF Research Foundation GrantUniversity of Notre Dame Australia Research Grant

Annals for Educators - September 2022

Annals for Educators - September 2022

Venous thromboembolism and adverse outcomes in highest thromboembolism risk patients compared with those at lower risk

A risk-based institutional protocol for inpatient heparin-based venous thromboembolism prophylaxis in a general obstetrical population previously demonstrated a greater than 2-fold increase in wound hematomas with no change in the frequency of thromboembolism. We sought to compare the rates of thromboembolism and bleeding outcomes in patients at the highest risk for thromboembolism (eg, those with a history of thromboembolism or thrombophilia who require anticoagulation prophylaxis or therapy throughout pregnancy) than low-risk patients. We performed a retrospective cohort study of all deliveries >20 weeks at a single center from 2013-2018. Patients were categorized as high-risk (received outpatient heparin-based prophylaxis or treatment) or low-risk (no outpatient anticoagulation). The primary outcome was newly diagnosed postpartum thromboembolism; the main secondary outcome was wound/perineal hematoma. The outcomes were compared between the high- and low-risk cohorts. Adjusted odds ratios (with 95% confidence intervals) were calculated with the low-risk group as reference. Of 24,303 total deliveries, 395 (1.7%) were high-risk and 23,905 (98.3%) were low-risk. Among the low-risk patients, 8.6% received anticoagulation prophylaxis in accordance with our risk-based inpatient thromboembolism prophylaxis protocol. High-risk patients were more likely to be older and have a higher body mass index, earlier delivery gestational age, medical comorbidities, and pregnancy complications, eg, preeclampsia. Despite outpatient antepartum anticoagulation, high-risk patients had an 11-fold increased risk of thromboembolism (adjusted odds ratio, 11.1 [4.7-26.2]) than low-risk patients. High-risk patients also had significantly more wound/perineal hematomas (adjusted odds ratio, 4.8 [2.7-8.4]), overall wound complications (adjusted odds ratio, 3.0 [2.0-4.4]), blood transfusions, intensive care unit admissions, maternal deaths, and longer maternal lengths of stay. Patients at the highest risk of obstetrical thromboembolism had an 11-fold increased risk of thromboembolism with a more moderate increase (∼5-fold) in postpartum wound and bleeding complications than low-risk patients. This more favorable risk or benefit profile supports current anticoagulation recommendations in high-risk patients.

A Novel Orderset Driven Emergency Department Atrial Fibrillation Algorithm to Increase Discharge and Risk-appropriate Anticoagulation.

Patients with atrial fibrillation (AF) are frequently admitted from the emergency department (ED), and when discharged, are not reliably prescribed indicated anticoagulation. We report the impact of a novel computerized ED AF pathway orderset on discharge rate and risk-appropriate anticoagulation in patients with primary AF. The orderset included options for rate and rhythm control of primary AF, structured risk assessment for thrombotic complications, recommendations for anticoagulation as appropriate, and follow up with an electrophysiologist. All patients discharged from the ED in whom the AF orderset was utilized over an 18-month period comprised the primary study population. The primary outcome was the rate of appropriate anticoagulation or not according to confirmed CHADS-VASC and HASBLED scores. Additionally, the percentage of primary AF patients discharged directly from the ED was compared in the 18-month periods before and after introduction of the orderset. A total of 56 patients, average age 57.8 years and average initial heart rate 126 beats/minute, were included in the primary analysis. All 56 (100%; 95% confidence interval, 94-100) received guideline-concordant anticoagulation. The discharge rates in the pre- and postorderset implementation periods were 29% and 41%, respectively (95% confidence interval for 12% difference, 5-18). Our novel AF pathway orderset was associated with 100% guideline-concordant anticoagulation in patients discharged from the ED. Availability of the orderset was associated with a significant increase in the proportion of ED AF patients discharged.

Implementing a Clinical Decision Tool to Improve Oncologic Venous Thromboembolism Management.

Background:Cancer patients with venous thromboembolic (VTE) disease are complex, and many factors must be considered when initiating anticoagulation management. Clinical decision support systems can aid in decision-making by utilizing guidelines at the point of care.Objectives:The purpose of our project was to develop, implement, and evaluate an electronic clinical decision tool (CDT) utilizing evidence-based guidelines to aid in decision-making for adult oncologic patients who present with new VTE to symptom care clinics.Methods:We compared a pre-intervention group of patients who were prescribed anticoagulation (n = 98) with two post-intervention groups: CDT applied (n = 96) and not applied (n = 46). Outcomes included whether the CDT anticoagulation recommendations were followed and if the tool was perceived to be helpful or improve confidence in initiating management for new VTE by the SCC advanced practitioners and physicians.Results:There was no significant difference between the pre- and post-intervention groups in how many of the CDT anticoagulation recommendations were followed (68.8% pre-intervention, 60.8% post-intervention tool applied, and 63.5% post-intervention tool not applied; χ2 [2, N = 161] = .921, p = .631). However, the tool was found to be helpful and improved confidence of the providers in initiating management for new VTE (pre median = 3, interquartile range [IQR] = 2, 3.5; post median = 3, IQR 3, 4; p = .033).Conclusion:This CDT provided evidence-based anticoagulation recommendations for cancer-associated VTE and enhanced familiarity with the standard of care. Further development of the CDT will be required to account for situations that resulted in deviation from the recommendations.

Time trends in adherence to guideline recommendations for anticoagulation therapy in patients with atrial fibrillation and myocardial infarction

BackgroundPoor adherence to guideline recommendations for anticoagulation in patients with acute myocardial infarction (MI) and atrial fibrillation (AF) is previously reported. The aim of the present cohort study was to...

Anticoagulation for Left Ventricular Thrombosis Post-Myocardial Infarction – Current Recommendations and Future Perspectives

Abstract Left ventricular thrombosis (LVT) is one of the most severe complications of acute myocardial infarction (AMI). LVT is commonly associated with an increased risk of cerebral or systemic embolization, which furthermore increases the morbidity and mortality of these patients. Management of LVT implies the administration of anticoagulants to achieve thrombus resolution and reduce the embolic risk. However, in the setting of an AMI, anticoagulants are added to already existing antiplatelet therapy, which increases the bleeding risk for this category of patients. Vitamin K antagonist (VKA) represents the main guideline recommendation for anticoagulation, but its multiple interactions are associated with an increased number of patients who are outside the therapeutic range and low compliance. Early studies that evaluate direct oral anticoagulants (DOAC) as an alternative for VKA show promising results, with reduced strokes and bleeding rates and faster thrombus resolution. Thus, in the near future, DOAC may represent a therapeutic option for treating LVT, but larger studies are needed to validate this approach.

Resolution of acute pulmonary embolism using anticoagulation therapy alone in coronavirus disease 2019

ObjectiveTo investigate the radiographic resolution of acute pulmonary embolism (PE) using contrast-enhanced computed tomography (CECT) examinations in patients diagnosed with acute PE while hospitalized with coronavirus disease 2019 (COVID-19) and to understand the mid-term and long-term implications of anticoagulation therapy. MethodsWe identified patients with acute PE per CECT and at least one follow-up CECT from March 11, 2020, to May 27, 2021, using a prospective registry of all hospitalized patients with COVID-19 infection receiving care within a multicenter Health System. Initial and follow-up CECT examinations were reviewed independently by two radiologists to evaluate for PE resolution. The Modified Miller Score was used to assess for thrombus burden at diagnosis and on follow-up. ResultsOf the 6070 hospitalized patients with COVID-19 infection, 5.7% (348/6070) were diagnosed with acute PE and 13.5% (47/348) had a follow-up CECT examination. The mean ± standard deviation time to follow-up imaging was 44 ± 48 days (range, 3-161 days). Of 47 patients, 47 (72.3%) had radiographic resolution of PE, with a mean time to follow-up of 48 ± 43 days (range, 6-239 days). All patients received anticoagulation monotherapy for a mean of 149 ± 95 days and this included apixaban (63.8%), warfarin (12.8%), and rivaroxaban (8.5%), among others. The mean Modified Miller Score at PE diagnosis and follow-up was 4.8 ± 4.2 (range, 1-14) and 1.4 ± 3.3 (range, 0-16; P < .0001), respectively. Nine patients (19%) died at a mean of 13 ± 8 days after follow-up CECT (range, 1-27 days) and at a mean of 28 ± 16 days after admission (range, 11-68 days). Seen of the nine deaths (78%) deaths were associated with progression of COVID-19 pneumonia. ConclusionsHospitalized patients with COVID-19 have a clinically apparent 5.7% rate of developing PE. In patients with follow-up imaging, 72.3% had radiographic thrombus resolution at a mean of 44 days while on anticoagulation. Prospective studies of the natural history of PEs with COVID-19 that include systematic follow-up imaging are warranted to help guide anticoagulation recommendations.

Stroke risk and anticoagulation in the setting of post-cardiac surgery atrial fibrillation: a systematic review of the literature

Postoperative atrial fibrillation (POAF) affects up to 50% of patients undergoing cardiac surgery. It remains unclear to what extent POAF increases the stroke risk and whether anticoagulation is warranted in this setting. The primary objective of this review was to conduct a systematic review of the evidence for a correlation between POAF and stroke. Further, we sought to evaluate the published evidence on anticoagulation in the setting of POAF to prevent stroke. To this end, we performed a comprehensive literature search to identify studies on POAF in patients undergoing cardiac surgery with stroke as an outcome. To date, eight meta-analyses providing pooled estimates of the stroke risk associated with POAF in patients undergoing cardiac surgery have been published. The reported pooled odds ratios range from 1.36 to 4.09 for unadjusted estimates. Additionally, five studies were identified that evaluated the impact of anticoagulation on stroke in the setting of POAF. Of these, three supported the use of anticoagulants, and two studies were inconclusive. This systematic review did not find strong supporting evidence that POAF is causally related to stroke, despite a strong correlation with comorbidities and all-cause mortality in the literature. Available evidence to date suggests an elevated risk of bleeding with no clear reduction in stroke or other thromboembolic events when anticoagulation is initiated in the setting of POAF. An upcoming randomized clinical trial by the Cardiothoracic Surgery Network group will hopefully provide clarification on the recommendations for anticoagulation in the setting of POAF after cardiac surgery.