Antithrombotic Medication Research Articles

Pharmacotherapy of acute ST-elevation myocardial infarction and the pharmacist's role, part 1: Patient presentation through revascularization.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Key pharmacotherapeutic modalities and considerations for the patient with ST-elevation myocardial infarction (STEMI) across the critical initial phases of care are reviewed. Despite established value in the emergency department (ED), cardiac care, and intensive care settings, there is currently little published literature describing or supporting clinical pharmacist roles in the acute management of STEMI. The high-risk period from hospital presentation through revascularization and stabilization involves complex pharmacotherapeutic decision points, many operational medication needs, and multiple layers of quality oversight. While rife with opportunities for pharmacists to optimize care, this timeframe appears inconsistently targeted by clinical pharmacy services, which may halt after ED evaluation and then resume upon postcatheterization cardiac unit admission. Herein we review the key pharmacotherapeutic modalities and considerations for the patient with STEMI across the critical initial phases of care. These include supportive therapies prior to revascularization, the host of antithrombotics involved in revascularization by percutaneous coronary intervention and/or fibrinolysis, and other periprocedural medications. Important practice guidelines and clinical resources are summarized from the clinical pharmacist perspective, and roles and responsibilities of the responding pharmacist are suggested. A companion article will extend the review to periprocedural adverse event management, key early decision-making regarding long-term risk reduction, and pharmacist involvement in institutional quality improvement efforts. We aim to support inpatient pharmacy departments in advancing clinical services for this critical patient population, and we call for further research delineating pharmacist impact on patient and institutional STEMI outcomes. Patients presenting with STEMI rapidly traverse multiple phases of care and receive a host of antithrombotic and supportive medications during acute management, presenting many important pharmacotherapeutic decision points and roles for pharmacists.

Perioperative management of antithrombotic therapy in elderly patients undergoing lumbar discectomy: a retrospective study on 163 patients.

The prevalence of lumbar disc herniation (LDH) has risen alongside the aging population, often necessitating neurosurgical intervention. However, managing antithrombotic medications in elderly patients with a history of major cardiovascular events (MACE) presents challenges, as treatment may require modification or cessation. This study aims to compare surgical outcomes among elderly patients receiving antithrombotic drugs and assess their impact and potential complications. The findings aim to inform the management of elderly patients with cardiovascular and spinal conditions undergoing neurosurgery. This retrospective, observational study was conducted at a single center. A total of 163 patients aged 60 or above who underwent lumbar discectomy for LDH were included. Patients were categorized into three groups based on their antithrombotic drug management: Group A (46 patients) replaced antiplatelet agents with low-dose aspirin for secondary prevention, Group B (54 patients) discontinued antiplatelet agents for primary prevention one week preoperatively and replaced them with LMWH, and Group C (63 patients) did not receive antithrombotic medication. Intraoperative blood loss, surgical time, and postoperative hospitalization were analyzed across all three groups. Continuous variables were compared between groups using the two-tailed Mann-Whitney test, with significance set at p < 0.05. No significant differences were found in intraoperative blood loss or surgical time among groups A, B, and C. Similarly, no significant differences were observed between groups B and C across all analyzed variables. No early or delayed hemorrhagic complications occurred perioperatively or during the 3-month postoperative follow-up period. The study suggests that elective discectomy surgery in patients receiving anticoagulant and antiplatelet therapies may proceed without early complications and can be safely continued perioperatively. These findings have implications for the management of elderly patients requiring neurosurgical intervention in the context of cardiovascular comorbidities.

Real-world antithrombotic strategies in patients with atrial fibrillation and recently developed acute coronary syndrome

BackgroundThe antithrombotic strategy for patients with atrial fibrillation (AF) and coronary artery disease following percutaneous coronary intervention is shifting towards less intensive. Nevertheless, for patients with AF and acute coronary syndrome (ACS), an optimal antithrombotic strategy is yet to be established. Methods and resultsWe conducted a multi-center cohort study involving 146 Japanese centers that had prospectively registered 460 patients with AF and ACS followed for 2 years. Primary endpoint was the composite of thrombotic and bleeding events, and secondary endpoints included heart failure hospitalization. At the time of study registration, 86% of participants had received direct oral anticoagulants (DOACs) and 75% had received aspirin-based triple antithrombotic therapy (TAT) between March 2017 and August 2019. Apixaban was the most frequently used DOAC (29%). While the proportion of anticoagulants did not change according to the time course, the intensity of antiplatelets significantly attenuated over time (dual antiplatelet at baseline: 75%, and at 2-years: 7%). The cumulative incidence of the primary outcome measure was similar in patients with warfarin and DOACs. However, the risk of heart failure hospitalization was significantly higher in those with warfarin compared to DOACs (Hazard ratio: 2.8, 95% confidence interval: 1.1-5.8, p=0.022). ConclusionsThe present findings suggest the appropriate optimization of antithrombotic medication balancing in patients with AF and ACS in Japan by reducing the intensity of antiplatelets during the study period.

Adherence to Secondary Preventative Medications One Year Post Stroke

Abstract Background Adherence to secondary preventative medications is critical to reduce subsequent vascular events after ischaemic stroke. Many stroke risk factors are modifiable, but adherence is poor in up to 40% of stroke survivors. Guidelines recommend the use of antithrombotic, lipid lowering and antihypertensive medication. We examined adherence to these medications one year post stroke. Methods This was a retrospective cohort study of patients admitted to an Irish level 3 hospital with an acute stroke between July 2022 and June 2023. Stroke survivors were interviewed a year after stroke onset, either in clinic or in their home, and asked to show the interviewer all current medications. Adherence to three categories of secondary prevention medications and knowledge of their indication was assessed. Results 172 stroke patients were contacted and 64% agreed to participate. The cohort included 62% males and average age was 69.9 years. The majority (72/110, 65%) had a modified Rankin score (mRS) of 0-2. The proportion of participants reporting full adherence to all prescribed medications was 81% (89/110) with adherence rates of 81% for lipid lowering agents and 88% for both antithrombotics and antihypertensives. Adherence was higher in participants who had an involved caregiver (85.9% vs 73.9%) and in those with mRS &amp;gt;2 (94.9% vs 73.2%). There was no significant difference between age or gender subgroups. Knowledge of the indication was 62% for antithrombotics and 55% for lipid-lowering drugs. Conclusion Self-reported adherence to secondary preventative medications was high in this cohort but one in five stroke survivors reported poor adherence increasing their risk for recurrent stroke. Adherence was highest for antithrombotics and lowest for lipid-lowering drugs. Adherence is higher in more dependent individuals and helped by an involved caregiver. We observed a deficit in patient understanding of secondary prevention medications. Improving this knowledge gap could increase adherence to secondary prevention post stroke.

Postoperative Bleeding Complications are Common among Patients Undergoing Transcarotid Artery Revascularization

Current practice guidelines recommend dual antiplatelet therapy for at least 30 days postoperatively after transcarotid artery revascularization (TCAR) to promote stent patency. However, many patients are already taking other antithrombotic medications. The optimal pharmacologic regimen in this patient population remains unclear, especially as it pertains to postoperative bleeding complications. All TCAR procedures performed at a large academic medical center from January 1, 2017 to April 30, 2023 were identified via current procedural terminology codes and retrospectively reviewed via electronic medical records. Data were collected on patient demographics, procedural details, postoperative complications, and antithrombotic regimen. Bleeding complications were categorized as surgical and non-surgical, which included any bleeding diatheses that were not related to the neck incision, such as epistaxis, hematuria, melena, or non-cervical hematoma. A total of 116 TCAR procedures were performed. The 30-day incidence of bleeding complications was 12.1% (n=14), which included 8 (6.9%) symptomatic neck hematomas and 6 (5.2%) non-surgical site bleeding complications. Aside from patient age (median 72 y [66-79] vs 79 y [70.5-88], p=0.03), demographics, medical comorbidities, surgical indication, risk-related indication for TCAR, and inpatient/outpatient status were similar between patients who experienced bleeding versus no bleeding complications. Patients who developed bleeding complications experienced higher thirty-day hospital readmission (42.9% vs 9.8%, p<0.001) and reintervention rates (21.4% vs 2.0%, p<0.001) and trended towards longer postoperative length of stay (1.5 d [1-3] vs 1 [1-2] d, p=0.07). Reasons for readmission (n=16) included: epistaxis (1), hematuria (1), headache and melena (1), melena and myocardial infarction (1), fall (1), headache (1), dyspnea (5), delirium (1), diarrhea (1), atrial fibrillation (1), and neck hematoma (1); one patient did not have a readmission reason documented. Reinterventions (n=6) included: neck hematoma evacuation (2), epistaxis cauterization (1), emergent cricothyroidotomy (1), and repeat carotid stenting (1). The management of antithrombotic medications during bleeding events were highly variable amongst providers (11 patients with nothing held, one apixaban held, one aspirin held, one clopidogrel held), however, no patients suffered carotid stent thrombosis. Bleeding complications are common within 30 days of TCAR and frequently result in unplanned hospital readmission and reintervention. There is significant provider-level variability in management of antithrombotic medications during these events. These data highlight need for evidence-based guidelines for the optimal pharmacologic strategy for patients post-TCAR who develop bleeding complications.

Postoperative bleeding complications in breast conserving surgery and the role of antithrombotic medications: retrospective analysis of 4712 operations

BackgroundThis study aimed to evaluate the risk and timing of postoperative bleeding complications following breast-conserving surgery (BCS), with or without axillary surgery, especially in relation to perioperative management of antithrombotic medications.MethodsData from all patients who underwent BCS for breast cancer between 2010 and 2022 at a single university hospital were collected. Medical records were reviewed for reoperations, unplanned admissions, and patient characteristics.ResultsIn total, 4712 breast-conserving surgeries and 3631 axillary surgeries were performed on 3838 patients. The risk of any bleeding complication was 1.1% (40/3571) in breast-conserving surgery, 0.3% (9/2847) in sentinel lymph node biopsy, and 0.5% (4/779) in axillary lymph node dissection. Upon arrival for treatment, 645 (17%) patients were taking antithrombotic medications. The risk of bleeding complications was not elevated in patients whose medication was discontinued at least a day before the surgery (OR 0.84, p = 0.76); but it was almost four-fold (OR 3.61, p = 0.026) in patients whose antithrombotic medication was continued. However, the absolute risk for bleeding complication was low in these patients as well (2.0%, 15/751). The majority of bleeding complications (85%, 47/55) occurred within 24 h after the surgery.ConclusionThe risk for bleeding complications was elevated, but still low, after BCS with or without axillary surgery, when antithrombotic medications were continued through the surgical period. Discontinuing antithrombotic medications is not obligatory in these patients.

The Use of Clips to Prevent Post-Polypectomy Bleeding: A Clinical Review.

The goal of this clinical review is to provide an overview of the current literature regarding the utility of prophylactic clips in reducing postpolypectomy bleeding and to provide an expert statement regarding their appropriateness in clinical practice. Colonoscopy enables the identification and removal of premalignant and malignant lesions through polypectomy, yet complications including postpolypectomy bleeding (PPB) can arise. While various studies have explored applying clips prophylactically to prevent PPB, their effectiveness remains uncertain. A literature search conducted in PubMed and Embase identified 671 publications discussing clip use postpolypectomy; 67 were found to be relevant after screening, reporting outcomes related to PPB. Data related to clip utilization, polyp characteristics, and adverse events were extracted and discussed. The current literature suggests that prophylactic clipping is most beneficial for nonpedunculated polyps ≥20mm, especially those in the proximal colon. The utility of clipping smaller polyps and those in the distal colon remains less clear. Antithrombotic medication usage, particularly anticoagulants, has been linked to an increased risk of bleeding, prompting consideration for clip placement in this patient subgroup. While cost-effectiveness analyses may indicate potential savings, the decision to clip should be tailored to individual patient factors and polyp characteristics. Current research suggests that the application of prophylactic clips can be particularly beneficial in preventing delayed bleeding after removal of large nonpedunculated polyps, especially for those in the proximal colon and in patients on antithrombotic medications. In addition, for large pedunculated polyps prophylactic clipping is most effective at controlling immediate bleeding.

Anticoagulation Alone vs Anticoagulation Plus Aspirin or DAPT Following Left Atrial Appendage Occlusion

BackgroundThe prevalence of and outcomes associated with different antithrombotic strategies after left atrial appendage occlusion (LAAO) are not well described. ObjectivesThis study sought to evaluate patterns of antithrombotic medication strategies at discharge following LAAO with the Watchman FLX device in real-world practice and to compare the risk of adverse events among the different antithrombotic regimens. MethodsThe authors evaluated patients in the NCDR (National Cardiovascular Data Registry) LAAO Registry who underwent LAAO with the second-generation LAA closure device between 2020 and 2022. They grouped patients by mutually exclusive discharge antithrombotic strategies and compared the rates of adverse events at 45 days and 6 months using multivariable Cox proportional hazards regression. ResultsAmong 53,878 patients undergoing successful LAAO with the second-generation LAA closure device, the most common antithrombotic discharge regimens were direct oral anticoagulant (DOAC) plus aspirin (48.3%), DOAC alone (22.6%), dual antiplatelet therapy (8.1%), warfarin plus aspirin (7.7%), and DOAC plus P2Y12 inhibitor (4.9%). In multivariate analysis, DOAC alone had a lower rate of major adverse events and major bleeding at 45 days of follow-up compared with DOAC plus aspirin (major adverse events: HR: 0.78; 95% CI: 0.68-0.91; major bleeding: HR: 0.69; 95% CI: 0.60-0.80). These differences persisted at 6 months. Warfarin without aspirin also showed lower rates of major bleeding at both time points. No differences were seen in stroke/transient ischemic attack or device-related thrombus. ConclusionsIn real-world U.S. practice, discharge on DOAC alone or warfarin alone was associated with a lower rate of adverse events compared with DOAC plus aspirin.

Microporous polysaccharide hemospheres for reducing pocket hematomas after cardiac device implantation in patients on antithrombotic therapy.

Various surgical procedures have employed microporous polysaccharide hemosphere (MPH) hemostatic agents. However, data regarding their effectiveness in preventing pocket hematomas (PHs) during the implantation of cardiac implantable electronic devices (CIED) among the Asian population are limited. Therefore, this study aimed to investigate the potential benefits of using MPH hemostatic agents during CIED implantations as a preventive measure against post-procedural PHs. We conducted a retrospective, single-center, observational study involving 255 consecutive Japanese patients who underwent CIED implantation between November 2017 and April 2021. We compared PH occurrences within 28 days after CIED implantation between patients who received MPH hemostatic agents (n = 145) and those who did not (n = 110). PH development was observed in nine (6.2%) patients who received MPH hemostatic agents and in 13 (11.8%) patients without MPH hemostatic (p = .111). Kaplan-Meier analysis of PH development revealed no significant difference between the two groups (log-rank p = .102). However, utilizing MPH hemostatic agents among patients taking antithrombotic drugs, including antiplatelet medications, direct oral anticoagulants, and warfarin, significantly reduced PH incidence (log-rank p = .03). The multivariate Cox proportional hazards model demonstrated that MPH hemostatic agent utilization independently correlated with a decreased PH risk (hazard ratio 0.22, 95% confidence interval 0.08-0.63, p = .004). The findings of this study suggest that the incorporation of MPH hemostatic agents into standard practice may benefit to mitigate PH risk during CIED implantations in patients on antithrombotic therapy. This simple and practical measure may be valuable, especially in high-risk patients, such as those taking antithrombotic medications.

Perioperative antithrombotic medication: An approach for the primary care clinician.

The primary care clinician faces many challenges and is often left to manage complex pathology because of resource constraints at higher levels of care. One of these complex conditions is the perioperative management of antithrombotic medication. This narrative review is focused on helping the clinician navigate the complex path and multiple guidelines related to the perioperative use of antithrombotic medication. Perioperative antithrombotic guidelines (American College of Chest Physicians, European Society of Regional Anaesthesia, and American Society of Regional Anesthesia) and relevant publications were identified by a PubMed search using the terms perioperative AND anticoagulants OR antithrombotics AND guideline. Issues relevant to clinical practice were identified, and attempts were made to explain any ambiguity that arose. Adhering to basic pharmacological principles and evidence-based guidelines allows for the safe usage of antithrombotics. Knowing when to stop, continue, bridge and restart antithrombotic medication prevents perioperative morbidity and mortality. Stopping antithrombotic medication too early can lead to thromboembolic complications associated with their primary disease process. Not stopping antithrombotic medication or stopping it too late can potentially cause life-threatening bleeding, haematomas and increased transfusion requirements.

Effects of Angiotensin-Converting Enzyme Inhibition on the Recurrence and Internal Structure of Chronic Subdural Hematomas.

Background/Objectives: Chronic subdural hematoma (cSDH) is a common disease of growing significance due to the increasing use of antithrombotic drugs and population aging. There exists conflicting observational evidence that previous treatment with angiotensin-converting enzyme (ACE) inhibitors reduces the rate of cSDH recurrence. This study assesses the hypothesis that ACE inhibitors may affect recurrence rates by altering hematoma membrane formation. Methods: All patients with chronic subdural hematoma who were operated upon in a single university hospital between 2015 and 2020 were considered for inclusion. Hematomas were classified according to their structural appearance in computed tomography (CT) imaging into one of eight subtypes. Patients' own medication, prior to hospitalization for cSDH treatment, was noted, and the use of ACI-inhibitors was identified. Results: Of the included 398 patients, 142 (35.9%) were treated with ACE inhibitors before admission for cSDH treatment. Of these, 115 patients (81.0%) received ramipril, 13 received patients lisinopril (11.3%), and 11 patients (9.6%) received enalapril. Reflecting cardiovascular comorbidity, patients on ACE inhibitors were more often simultaneously treated with antithrombotics (63.4% vs. 42.6%; p ≤ 0.001). Hematomas with homogenous hypodense (OR 11.739, 95%CI 2.570 to 53.612; p = 0.001), homogenous isodense (OR 12.204, 95%CI 2.669 to 55.798; p < 0.001), and homogenous hyperdense (OR 9.472, 95%CI 1.718 to 52.217; p < 0.001) architectures, as well as the prior use of ACE inhibitors (OR 2.026, 95%CI 1.214 to 3.384; p = 0.007), were independently associated with cSDH recurrence. Conclusions: Once corrected for hematoma architecture, type of surgery, and use of antithrombotic medication, preoperative use of ACE inhibitors was associated with a twofold increase in the likelihood of hematoma recurrence.

Structural, Biochemical Characterization and Molecular Mechanism of Cerastokunin: A New Kunitz-Type Peptide with Potential Inhibition of Thrombin, Factor Xa and Platelets.

The current investigation focused on separating Cerastes cerastes venom to produce the first Kunitz-type peptide. Based on its anti-trypsin effect, Cerastokunin, a 7.75kDa peptide, was purified until homogenity by three steps of chromatography. Cerastokunin was found to include 67 amino acid residues that were obtained by de novo sequencing using LC-MALDI-MSMS. Upon alignment with Kunitz-type peptides, there was a high degree of similarity. Cerastokunin's 3D structure had 12% α-helices and 21% β-strands with pI 8.48. Cerastokunin showed a potent anticoagulant effect by inhibiting the protease activity of thrombin and trypsin as well as blocking the intrinsic and extrinsic coagulation pathways. In both PT and aPPT, Cerastokunin increased the blood clotting time in a dose-dependent way. Using Lys48 and Gln192 for direct binding, Cerastokunin inhibited thrombin, Factor Xa and trypsin as shown by molecular docking. Cerastokunin exhibited a dose-response blockade of PARs-dependent pathway platelet once stimulated by thrombin. An increased concentration of Cerastokunin resulted in a larger decrease of tail thrombus in the mice-carrageenan model in an in vivo investigation when compared to the effects of antithrombotic medications. At all Cerastokunin doses up to 6mg/kg, no in vivo toxicity was seen in challenged mice over the trial's duration.

Incidence, surgical eligibility and outcome of spontaneous intracerebral haemorrhage in Southwest Finland – A retrospective study

IntroductionSpontaneous intracerebral haemorrhage (sICH) is a major cause of morbidity and mortality. Large-scale trials have shown neutral outcomes for surgical interventions. The recent trial suggested functional benefits from surgical intervention. Surgical treatment for sICH is likely increasing. Research questionTo determine the incidence of sICH in Southwest Finland, standardized to the European population, and to identify the proportion of large sICH patients eligible for surgery based on previously published trial criteria. We also examined factors associated with outcomes, including the effects of anticoagulant and antithrombotic medications. Material and methodsA retrospective clinical study identified 596 ICH cases treated at Turku University Hospital (2018–2019), of which 286 were supratentorial sICHs. Variables were analysed using a t-test, chi-squared or Fisher's exact test. A multivariate logistic modelling was performed to evaluate outcome differences. ResultsThe sICH incidence was 29.9/100,000 persons per year, with the highest European population age and sex standardized rates in individuals over 80 years old (110/100,000 males, 142/100,000 females). The incidence of sICH patients meeting surgical criteria was 2.7/100,000 persons per year. Out of 286 patients, 26 were eligible for surgery and had unfavourable outcomes (p = 0.0049). Multivariate analysis indicated a significant decrease in favourable outcomes with warfarin (p = 0.016, OR 0.42) and direct-acting anticoagulants (DOACs) (p = 0.034, OR 0.38), while antithrombotic medications showed no significant effect. Discussion and conclusionWe identified comparable incidence of sICH as European average. A small proportion of sICH cases were identified to be candidates for surgical intervention. Anticoagulants were associated with increased risk of unfavourable outcomes.

Hydroxychloroquine and Cardiovascular Events in Patients With Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) predisposes individuals to early cardiovascular (CV) events. While hydroxychloroquine is thought to mitigate CV risk factors, its protective role against CV events, particularly arterial ones, remains to be confirmed. To evaluate the association between hydroxychloroquine and the risk of myocardial infarction (MI), stroke, and other thromboembolic events (OTEs) in patients with SLE. This cohort study using a nested case-control design was conducted within the National French Healthcare Database (SNDS), which represents 99% of the French population, from 2010 to 2020. Participants were the cohort of all patients with SLE recorded in the SNDS. Patients with SLE experiencing CV events during the study period were the case group; those without CV events were controls. The analysis period was from February 2022 to September 2023. Hydroxychloroquine use within 365 days prior to the index date, defined as current (within 90 days), remote (91-365 days), or no exposure within the previous 365 days. Outcomes of interest were MI, stroke, and OTE, analyzed individually and as a composite outcome (primary analysis). Controls were matched to patients with CV events by age, sex, time since SLE onset and entry into the SNDS database, index date, prior antithrombotic and CV medication, chronic kidney disease, and hospitalization. Multivariable conditional logistic regression was performed using hydroxychloroquine exposure as the main independent variable. The SLE cohort included 52 883 patients (mean [SD] age, 44.23 [16.09] years; 45 255 [86.6%] female; mean [SD] follow-up, 9.01 [2.51] years), including 1981 patients with eligible CV events and 16 892 matched control patients. There were 669 MI events, 916 stroke events, and 696 OTEs in the individual outcome studies. For current exposure to hydroxychloroquine, the adjusted odds were lower for composite CV events (odds ratio [OR], 0.63; 95% CI, 0.57-0.69) as well as for MI (OR, 0.72; 95% CI, 0.60-0.85), stroke (OR, 0.69; 95% CI, 0.60-0.81), and OTEs (OR, 0.58; 95% CI, 0.49-0.69) individually compared with no hydroxychloroquine exposure within 365 days. In this nationwide cohort study of patients with SLE, a protective association was found between the current use of hydroxychloroquine and the occurrence of CV events, but not between remote use of hydroxychloroquine and CV outcomes, highlighting the value of continuous hydroxychloroquine treatment in patients with SLE.

Management of complications associated with percutaneous left atrial appendage closure with or without ablation: experience from 512 cases over a 4-year period.

Percutaneous left atrial appendage closure (LAAC) serves as an alternative prophylactic strategy for patients with non-valvular atrial fibrillation (AF) who cannot undergo anti-coagulation therapy. Proper management of associated complications is crucial to enhancing the procedure's success rate and mitigating perioperative risks and adverse events during follow-up. This study aims to summarize our center's experience and strategies in managing procedural-related complications encountered in 512 cases of LAAC with or without ablation for AF conducted from January 2020 to December 2023. We identified 11 significant intervention-requiring complications associated with LAAC with or without Ablation procedure. These included three cases of intraoperative thrombosis, three instances of pericardial effusion or tamponade, one case of device-related thrombosis, one peri-device leak, one systemic embolism, one bleeding episode, and one additional device-related complication. The categorization of intraoperative thrombosis was as follows: one patient exhibited heparin resistance; one experienced thrombosis due to prolonged device implantation during the LAAC with ablation procedure; and one had unexplained intraoperative thrombosis. The pericardial effusion or tamponade likely resulted from damage to the atrial appendage during LAAC device insertion. Two patients encountered device-related thrombosis and systemic embolism events possibly caused by non-standard postoperative antithrombotic medication use; one patient's peri-device leak may have resulted from incomplete endothelialization of the occluder post-surgery; one patient experienced postoperative bladder bleeding; and one patient's device-related complications occurred due to a dislodged strut frame that damaged the left atrial appendage, leading to pericardial effusion. Our proactive interventions enabled all patients with these surgical-related complications to be safely discharged, with subsequent follow-ups showing no adverse events. Implementing targeted interventions for immediate procedural-related complications during the LAAC with or without ablation procedures enhances procedural success rates, diminishes postoperative mortality and patient disability, and bolsters stroke prevention efforts. This approach underscores the importance of a strategic response to complications, affirming the procedure's viability and safety in managing non-valvular AF in patients contraindicated for anticoagulation.

Antithrombotics alter intracerebral hemorrhage presentation without affecting minimally invasive endoscopic evacuation

ObjectivesIntracerebral hemorrhages are associated with significant morbidity and mortality. While the ENRICH trial supports the efficacy of surgical evacuation for lobar hemorrhages, the impact of antithrombotic therapies on minimally invasive surgery outcomes remains unexplored. This study evaluates the effects of chronic anticoagulants and antiplatelets on the technical and longterm outcomes of minimally invasive intracerebral hemorrhage evacuation. Materials and MethodsA prospectively collected registry of patients undergoing minimally invasive surgery for intracerebral hemorrhage from a single institution was analyzed (December 2015-September 2022). Data included key demographics, comorbidities, antithrombotic/reversal status, presenting clinical/radiographic characteristics, procedural metrics, and clinical outcomes. Patients were divided into control (neither therapy), antiplatelet-only, and anticoagulant-only groups, with antiplatelet/anticoagulant reversals conducted per current American Heart Association/American Stroke Association guidelines. Variables significant in univariate analyses (p<0.05) were advanced to multivariable regression models. ResultsAmong 226 intracerebral hemorrhage patients treated with minimally invasive surgery, 41% (N=93) had antithrombotic medication history; 28% (N=64) received antiplatelets, and 9% (N=21) received anticoagulants. Patients on both therapies (N=6) were excluded. The antiplatelet group presented more frequently with lobar hemorrhages (56% vs. 37%; p=0.022), while patients on anticoagulants showed increased rates of intraventricular hemorrhage co-presentation (62% vs. 46%; p=0.011) compared to controls. Despite univariate analyses showing a higher postoperative hematoma volume (3.9 vs. 2.9 milliliters; p=0.020) and lower evacuation percentage (88% vs. 92%; p=0.019) for the antiplatelet group, and longer procedures for patients on anticoagulants (2.3 vs. 1.7 hours; p=0.042) compared to control, multivariable analyses indicated that antiplatelets and anticoagulants had no significant impact on these technical outcomes. Longitudinally, antithrombotics were not associated with increased rebleeding, less frequent discharge to home, lower 30-day mortality, or worse, 6-month Modified Rankin Scale scores. ConclusionsPatients on chronic antiplatelets and anticoagulants exhibited characteristic intracerebral hemorrhage phenotypes without worse technical or long-term outcomes after minimally invasive intracerebral hemorrhage evacuation, suggesting the procedure's safety for these patients.

Epidemiology of maxillofacial trauma in elderly patients receiving oral anticoagulant or antithrombotic medication; a Swiss retrospective study

BackgroundThe percentage of elderly trauma patients under anticoagulation and antiplatelet agents has been rising lately. As newer agents are introduced, each comes with its own advantages and precautions. Our study covered elderly patients admitted to the ED with maxillofacial trauma while on anticoagulation (AC) or antiplatelet therapy (APT). We aimed to investigate the demographic characteristics, causes, and types of maxillofacial trauma, along with concomitant injuries, duration of hospitalisation, haemorrhagic complications, and the overall costs of care in the emergency department (ED).MethodsData were gathered from the ED of Bern University Hospital. In this retrospective analysis, patients over 65 of age were included, who presented at our ED with maxillofacial trauma between 2013 and 2019 while undergoing treatment with therapeutic AC/APT.ResultsThe study involved 188 patients with a median age of 81 years (IQR: 81 [74; 87]), of whom 55.3% (n=104) were male. More than half (54.8%, n=103) were aged 80 years or older. Cardiovascular diseases were present in 69.7% (n=131) of the patients, with the most common indications for AC/APT use being previous thromboembolic events (41.5%, n=78) and atrial fibrillation (25.5%, n=48). The predominant cause of facial injury was falls, accounting for 83.5% (n=157) of cases, followed by bicycle accidents (6.9%, n=13) and road-traffic accidents (5.3%, n=10). The most common primary injuries were fractures of the orbital floor and/or medial/lateral wall (60.1%, n=113), zygomatic bone (30.3%, n=57), followed by isolated orbital floor fractures (23.4%, n=44) and nasal bone fractures (19.1%, n=36). Fractures of the mandible occurred in 14.9% (n=28). Facial hematomas occurred in 68.6% of patients (129 cases), primarily in the midface area. Relevant facial bleeding complications were intracerebral haemorrhage being the most frequent (28.2%, n=53), followed by epistaxis (12.2%, n=23) and retrobulbar/intraorbital hematoma (9%, n=17). Sixteen patients (8.5%) experienced heavy bleeding that required emergency treatment. The in-hospital mortality rate was 2.1% (4 cases).ConclusionsThis study indicates that falls are the leading cause of maxillofacial trauma in the elderly, with the most common diagnoses being orbital, zygomatic, and nasal fractures. Haemorrhagic complications primarily involve facial hematomas, especially in the middle third of the face, with intracerebral haemorrhage being the second most frequent. Surgical intervention for bleeding was required in 8.5% of cases. Given the aging population, it is essential to improve prevention strategies and update safety protocols, particularly for patients on anticoagulant/antiplatelet therapy (AC/APT). This can ensure rapid diagnostic imaging and prompt treatment in emergencies.

Ascertaining accurate exposure to aspirin and other antithrombotic medications using structured electronic health record data

BackgroundAscertaining accurately the exposure to antithrombotic medications for both research and quality initiatives has been challenging due to a multitude of reasons: aspirin, the most commonly used antithrombotic, is available over the counter in the United States. Additionally, antithrombotic medications are frequently interrupted for bleeding and procedures. ObjectivesWe aimed to develop and validate an algorithm to capture accurately the longitudinal exposure to antithrombotic medications including aspirin using the electronic health record. MethodsWe used the Medical Inpatient Thrombosis and Hemostasis cohort, which consists of primary care patients at a university medical center followed for a median of 6.2 years. Exposure to antithrombotic medications was captured using the medication reconciliation data linked to each ambulatory encounter. We developed an algorithm that used the taking “yes” or “no” tab as well as start and stop dates to define the duration of exposure for each medication. Eighty charts were reviewed and compared with results of the algorithm for validation. We estimated the sensitivity, specificity, and positive and negative predictive values. ResultsThe algorithm was 97% (95% CI, 94%-100%) sensitive and 95% (95% CI, 90%-100%) specific in identifying exposure to any antithrombotic medication. This translated to a 93% (95% CI, 85%-100%) positive predictive value and 98% (95% CI, 96%-100%) negative predictive value. When looking at aspirin alone, the sensitivity and the positive predictive value were 95% (95% CI, 88%-100%) and 87% (95% CI, 71%-100%). ConclusionThis current algorithm provides a new and easily adaptable strategy to capture accurately exposure to aspirin and other antithrombotic medications.

Additional treatment after primary conservative treatment in patients with chronic subdural hematoma-A retrospective study.

Chronic subdural hematoma (CSDH) is a common neurological condition and is typically treated with burr hole craniostomy. Nevertheless, conservative treatment may lead to spontaneous hematoma resolution in some patients. This study aims to describe the characteristics of patients who were treated conservatively without the eventual need for additional treatment. Data were retrospectively collected from patients who were primarily treated conservatively in three hospitals in the Netherlands from 2008 to 2018. The Primary outcome was the nonnecessity of additional treatment within 3 months after the initial CSDH diagnosis. We used univariable and multivariable logistic regression analyses to identify factors associated with not receiving additional treatment. In this study, 83 patients were included and 61 patients (73%) did not receive additional treatment within 3 months. Upon first presentation, the patients had a Markwalder Grading Scale score (MGS) of 0 (n=5, 6%), 1 (n=43, 52%), and 2 (n=35, 42%). Additional treatment was less often received by patients with smaller hematoma volumes (adjusted odds ratio [aOR] 0.78 per 10mL; 95% confidence interval [CI] 0.64-0.92). Patients using antithrombotic medication also received less additional treatment, but this association was not significant (aOR 2.02; 95% CI 0.61-6.69). Three quarters of the initially conservatively treated CSDH patients do not receive additional management. Typically, these patients have smaller hematoma volumes. Further, prospective research is needed to distinguish which patients require surgical intervention and in whom primary conservative treatment suffices.

The effect of Mycobacterium tuberculosis treatment on thrombelastography-assessed haemostasis: a prospective cohort study

Background and objectiveTuberculosis disease (TB) and tuberculosis infection (TBI) have been associated with increased risk of cardiovascular disease which may be connected to infection-related haemostatic changes. It is unknown if treatment of Mycobacterium tuberculosis influences haemostasis. Here, we assessed if TB or TBI treatment affects thrombelastography (TEG)-assessed haemostasis.MethodsIndividuals with TB or TBI were included from a TB outpatient clinic in Copenhagen, Denmark. Patients treated with antithrombotic medication or systemic immunosuppressants were excluded. TEG analysis was performed before and after TB/TBI treatment using the TEG®6s analyser to provide data on the reaction time of clot initiation (R) (min), the speed of clot formation (K) (min) and clot build-up (Angle) (°), maximum clot strength (MA) (mm), and clot breakdown/fibrinolysis (LY30) (%). Differences in TEG were assessed using paired t tests.ResultsWe included eleven individuals with TB with median [interquartile range] [IQR] age 52 (Liu et al. in Medicine (United States) 95, 2016) years and mean (standard deviation) (SD) body mass index (BMI) 24.7 (6.3) kg/m2 as well as 15 individuals with TBI with median [IQR] age 49 (Wells et al. in Am J Respir Crit Care Med 204:583, 2021) years and BMI 26.0 (3.2) kg/m2. Treatment reduced MA for both TB (64.0 (6.3) vs. 57.9 (5.2) mm, p = 0.016) and TBI (61.3 (4.1) vs. 58.6 (5.0) mm, p = 0.023) whereas R, K, Angle and LY30 were unaffected.ConclusionTEG analysis showed that treatments of TB and TBI were associated with reduced MA which may indicate the existence of cardiovascular benefits from therapy.Trial registrationRegistered at ClinicalTrials.gov 05 April 2021 with registration number NCT04830462.