Early Anticoagulant Treatment Research Articles

Identifying risk factors for cerebral venous thrombosis in an intensive care unit: Interest in early anticoagulant treatment

Thrombosis of the dural venous sinus or cerebral veins (CVT) of particular anatomical location of venous thrombosis with a complete or partial occlusion. Treatment of CVT with Heparin followed by VKA is recommended by current guidelines. Material and methods: We conducted a descriptive cohort study, of CVT recorded at the University Hospital Centre Lamine Debaghine Bab El Oued (Algeria) from April 2020 to December 2023. Results: We reported 16 cases of cerebral venous thrombosis (CVT) that were admitted to the intensive care ward from April 2020 to December 2023. It represents 7.4% of neurologic deficiency consultation in the emergency department in the studied period. The mean age of our population is 37.38. we found a preponderance in the female population. The aim of our study is to highlight the importance of early anticoagulation. Discussion: We found that early administration of anticoagulant therapy within the first 24 hours reduced mortality and outcomes in the study population. Our results were consistent with most studies reported in the literature. Conclusion: the introduction of the precocial anticoagulation impacts the mortality and outcomes in CVT however, more studies on the exact timing of introduction are required to define the right timing.

Anticoagulant therapy likely increases risk of bleeding in Gynura segetum-induced hepatic sinus obstruction syndrome.

This study aimed to analyze the clinical characteristics of Gynura segetum (Tusanqi)-induced hepatic sinusoidal obstruction syndrome (HSOS) and the benefits and risks of anticoagulant therapy for Tusanqi-induced HSOS. This was a retrospective analysis of 49 patients with Tusanqi-induced HSOS who were treated with anticoagulation or standard therapy between July 2006 and December 2022. Clinical manifestations included abdominal pain (n = 47) and peritoneal or pleural effusion (n = 46); 2 patients died. Nineteen patients requested standard medical treatment, while 30 were treated with anticoagulants. HSOS resolved within 6 months in 22 patients but did not resolve in 27 patients. The resolution rate was higher in the anticoagulant than standard treatment group (P = .037). Logistic regression analysis revealed that a history of chronic liver disease or treatment increased the risk of poor outcomes. Bleeding complications occurred in 6 patients in the anticoagulant treatment group. Early diagnosis and anticoagulant treatment are beneficial for rapid recovery after Tusanqi-induced HSOS. However, anticoagulant treatment is associated with the risk of multisite bleeding.

Abstract 074: Early Versus Late Anticoagulation In AF‐related Ischemic Stroke: A Systematic Review and Meta‐analysis of RCTs

Introduction In AF‐associated ischemic stroke, there is increased risk of early stroke recurrence, making anticoagulation treatment is highly recommended for secondary stroke prevention [1‐2]. On the other hand, high rates of ICH were also reported in this population, making it very challenging for physicians to decide when to start anticoagulation treatment [3]. We aim to investigate safety and efficacy of early versus late anticoagulation in AF patients with AIS. Methods This meta‐analysis followed the Preferred Reporting Items for Systematic reviews and Meta‐Analysis (PRISMA) guidelines. We searched PubMed, Cochrane Library, WOS, and Scopus up to June 30, 2023, to collect randomized controlled trials comparing early versus late anticoagulation for acute ischemic stroke in AF patients. The primary outcome assessed in this study was the composite efficacy outcome (as defined by individual studies). Secondary outcomes included recurrent ischemic stroke, all‐cause mortality, ICH, and mRS 0‐2 at 90 days. Using the R statistical programming language, risk ratios (RRs) with 95% confidence intervals (95% CIs) were calculated using a common‐effect model for each outcome [4]. Results Four RCTs were included, involving 3050 patients (with 1527 patients in the early group). In the pooled analysis, early treatment group showed a significantly lower risk of composite efficacy outcome (RR: 0.71, 95% CI: 0.53‐0.96, p‐value: 0.02) compared to late treatment group. Early treatment group demonstrated a lower risk in terms of recurrent ischemic stroke (RR: 0.75, 95% CI: 0.52‐1.08), intracranial hemorrhage (RR: 0.93, 95% CI: 0.59‐1.46), and all‐cause mortality (RR: 0.88, 95% CI: 0.64‐1.22), however these results were not statistically significant. Moreover, the pooled analysis of two studies that reported mRS 0‐2 outcome at 3 months, both treatment groups were found to have similar rates but statistically insignificant. Conclusion This meta‐analysis, which pooled data from 3050 ischemic stroke patients with AF, early initiation of anticoagulation treatment was associated with lower risk of composite efficacy outcome. However, no statistically significant differences were found between the two groups regarding ischemic stroke, all‐cause mortality, ICH, and mRS 0‐2 at 90 days. Early anticoagulation treatment in AF patients with AIS may be as safe and effective as late anticoagulation treatment and might provide more benefit. However, more RCTs need to be conducted.

Urgenţe în reumatologia pediatrică (II): sindromul antifosfolipidic

Sometimes, child’s rheumatic diseases are generating emergency type complications which, if not diagnosed in time, are life-threatening. Antiphospholipid syndrome in its severe form can induce coagulation disorders and acute organ failure, depending on location and extent. Systemic lupus erythematosus is frequently associated with this pathology and must be carefully investigated and monitored in the evolution of the patient, in order to benefit from early specific anticoagulant treatment, associated with chronic background immunosuppressive treatment.

Usefulness of contrast echocardiography for detection of left ventricular thrombus in a real-world population with acute anterior myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction The treatment of ST-elevation myocardial infarction (STEMI) has considerably changed in recent years, with early, mainly transcatheter reperfusion therapy improving survival. However, left ventricular thrombus (LVT) is still reported as a relatively common complication especially in anterior STEMI. Two-dimensional transthoracic echocardiography (TTE) is the most commonly used diagnostic modality in this setting due to its wide availability and low cost but can lead to misdiagnoses. The use of ultrasound contrast agents has dramatically improved the visualization of cardiac chambers and thus detection of LVT. Purpose The purpose of this study was to assess the value of contrast echocardiography (CE) for the detection of apical LVT in a real-world population of patients with acute anterior myocardial infarction (MI) in the modern era. Methods The population of this prospective study consisted of consecutive patients presenting within a year with acute anterior MI in a tertiary hospital with capability of primary percutaneous coronary intervention (PCI). Patients with confirmed COVID-19 infection and/or current use of anticoagulant medication were excluded from the study. All patients underwent TTE without and with contrast within 7 days post-MI by an experienced cardiologist. CE was considered the reference standard. Results A total of 102 patients (mean age 61±13 years, 19% female) with anterior STEMI were prospectively recruited in our study. Ninety-eight patients underwent primary PCI, 3 patients underwent rescue PCI after unsuccessful thrombolysis, 1 patient underwent surgical revascularization. Two patients did not receive contrast agent (1 due to known hypersensitivity to contrast agent and 1 due to cardiogenic shock). Mean ejection fraction (EF) was 46% ± 10% in total population and was significantly lower in patients with LVT (42% ± 7% vs 47% ± 10%, p = 0.025). The incidence of confirmed LVT by CE was 28% (28/100) within 7 days post-MI. In total, 8 out of 28 LVT cases (28.5%) would have been missed using TTE without contrast within 7 days post-MI (sensitivity 71%, specificity 100%, positive predictive value 100% and negative predictive value 90%). Example of missed LVT on TTE without and with contrast (left and right panel respectively) is shown in Figure 1. Conclusions LVT is not uncommon after anterior STEMI in the modern era of primary PCI. LVT would have been missed in a significant proportion of patients with anterior STEMI if CE was not used, depriving these patients from the option of early anticoagulation treatment.

Monitoring hypertensive disorders in pregnancy to prevent preeclampsia in pregnant women of advanced maternal age: Trial mimicking with retrospective data.

This study investigated the implication of monitoring hypertensive disorders in pregnancy (HDP) to prevent preeclampsia (PE) in pregnant women of advanced maternal age. Between January 2016 and April 2021, 262 consecutive pregnant women aged ≥40 years were recruited. Extensive monitoring of hypertensive disorders in pregnancy, including blood hypercoagulability screening and subsequent interventions, was performed in 129 pregnant women in our university hospital. The remaining 133 patients from other centres, who did not receive antenatal maternal pregnancy screening and preventive intervention during the same period, constituted the non-intervention group enabling comparison to mimic a trial. The incidences of hypertensive disorders, mild and severe PE, eclampsia, and chronic hypertension complicated by PE in the intervention group were significantly lower than in the non-intervention group (10.08 versus 20.30%, 8.52 versus 18.80%, 7.75 versus 21.05%, 0 versus 3.01%, and 3.86 versus 15.04%, respectively; P < 0.05). Premature birth, low birth weight, and foetal loss were significantly rarer in the intervention group than in the non-intervention group (6.98 versus 24.81%, 7.75 versus 21.80%, and 0.78 versus 14.29% respectively; P < 0.001). The comparison of MP with routine blood coagulation biochemical examination found that the MP detection system of Beijing Yes Medical Devices Co., Ltd., had similar sensitivity as thromboelastogram. Still, it was significantly better than the routine biochemical indicators (P < 0.01). Based on MP parameters, early anticoagulant treatment with low-molecular-weight heparin or low-dose aspirin in pregnant women with hypercoagulability can effectively prevent the occurrence of PE and significantly improve the prognosis of both mothers and infants.

Therapeutic dilemma: When to start anticoagulation for cardiac thrombi in acute ischemic stroke? Lessons from cases

Ischemic stroke has been one of the major reason for morbidity and mortality all over the world. Anticoagulation treatment in patients with cerebral ischemic events caused by cardiac emboli is no longer a matter of debate. The problem is when to start. Because of a recurrence rate of 15 to 20% in the first few weeks after the initial event, direct anticoagulation by means of intravenous heparin followed by oral anticoagulants seems to be indicated. We are presenting 2 cases of patients who suffered cardio-embolic stroke due to cardiac thrombosis and had a therapeutic dilemma on when to start the anticoagulation treatment. Early anticoagulation treatment was associated with good clinical and neurological outcome. Keywords: anticoagulation; stroke; cardiac thrombus; cardio-embolic stroke; hemorrhagic stroke; warfarin.

Prophylaxis and treatment of pulmonary thromboembolism in COVID-19 patients

In 2019, a completely unique pneumonia, called coronavirus disease 2019 (COVID-19), spread rapidly throughout the planet. This novel global pandemic severely threatened public respiratory health and medical services. To date, apart from the common respiratory symptoms, coagulation disorders, especially Pulmonary Thromboembolism (PTE), has been proven as a crucial complication in severe COVID-19 patients, and therefore the incidence of PTE causes poor clinical outcome and increased fatality. Therefore, it’s important that healthcare providers, including respiratory physicians, medicine specialists, hematologists, cardiologists, communicable disease specialists, and other specialists, recognize that patients with COVID-19 are at increased risk of PTE, and make sure that appropriate prophylaxis is run to the acceptable patients, which they effectively manage PTE when it does occur. The mechanism of PTE in patients with coronavirus pneumonia consists of endothelial injury, activated platelet, cytokine storm, and a suppressed fibrinolytic system. Early prophylaxis, antiviral therapy, anticoagulation, and supportive treatment are beneficial to COVID-19 patients. In this review, we summarize the harm that coronavirus pneumonia wreaks and highlight the clinical relationship between PTE and coronavirus infection. The potential mechanism and therefore the prophylaxis and therapeutic measures also are discussed to involve more effort and research to research the strategies for PTE in COVID-19.

Early Initiation of Anticoagulation Improves the Long-Term Prognosis in Patients With Antiphospholipid Syndrome Associated Portal Vein Thrombosis.

Objectives: Portal vein thrombosis (PVT) is a rare and severe clinical phenotype of antiphospholipid syndrome (APS) with a poor prognosis. Anticoagulation therapy is efficient but is associated with potentially severe bleeding episodes, especially for those patients with thrombocytopenia. We conducted this case-control study to explore the clinical features and associated factors of PVT in APS patients, the re-canalization rate of the PVT after anticoagulation and investigate the beneficial effects of early initiation of anticoagulation in patients with APS associated PVT.Methods: We enrolled patients with APS associated PVT as the case group, and age-, and entry-time-matched APS patients without PVT (1:2) as the control group. We explored the associated factors of PVT in APS patients using multivariate logistic regression analysis. The re-canalization rate of the PVT after anticoagulation was analyzed using the survival analysis.Results: A total of 34 patients (8 males and 26 females) with APS-PVT were enrolled, with a median follow-up time of 3 years (1.5, 7 years). Multivariate logistic regression analysis showed that thrombocytopenia (OR 6.4, 95%CI 1.561–26.218, P = 0.01), hypersensitive c-reactive protein >3 mg/L (OR 4.57, 95%CI 1.426–14.666, P = 0.011), anti β2GPI positive (OR 5, 95%CI 1.816–13.772, P = 0.002) and aPL double-positive (OR 4.08, 95%CI 1.312–12.429, P = 0.013) were independent associated factors for PVT in APS. Survival analysis revealed that effective anticoagulation could increase re-canalization rate significantly (log-rank p = 0.001), with better prognosis (lower mortality rate, log-rank p = 0.045).Conclusions: PVT could be the first presentation of APS with insidious onset and atypical clinical symptoms and easily be misdiagnosed. For patients with APS, double aPLs positive, thrombocytopenia, and inflammation could be the associated factors of PVT. Early diagnosis and anticoagulation treatment can bring thrombus re-canalization thereby significantly improving the prognosis.

Commentary: COVID-19 disease is more than just a respiratory infection

The coronavirus disease (COVID-19), caused by the novel, highly contagious severe acute respiratory syndrome coronavirus 2, has quickly become a global health emergency. It started with an outbreak of pneumonia causing fever, cough, and shortness of breath. However, the virus has been noted to involve multiple organs and systems. The global research community has made an impressive effort in compiling the various manifestations of the disease in a short time.[1] The infected individuals are predisposed to arterial and venous thromboembolic complications like deep vein thrombosis, pulmonary embolism, myocardial infarction, and stroke. The proposed mechanisms responsible for these thromboembolic events include a transient hypercoagulable state due to systemic inflammation and cytokine storm, postinfectious immune-mediated responses, and direct viral-induced endothelitis.[2] The incidence of thrombotic complications in COVID-19 patients admitted to intensive care unit ranges between 16 to 49%.[1] Acute cardiovascular accident has been reported in 0.5–6.0% of COVID-19 patients.[3] Acharya et al.[4] first reported a central retinal artery occlusion (CRAO) in a case of severe COVID-19 disease. However, recent evidence suggests that arterial thromboembolism can occur in patients with mild disease also. Currently, the incidence is unknown due to possible underreporting of symptoms. Turedi et al. first reported CRAO within a case of moderate COVID-19 disease.[5] Early anticoagulant treatment has been reported to improve the clinical outcome of COVID-19 patients and reduce the risk of thromboembolic events.[1] Interestingly, all the patients that have been reported to develop RAO secondary to COVID-19 were already being treated with anticoagulant therapy. The occurrence of RAO in COVID-19 patients is limited to only case reports. Further studies should be planned to evaluate out the incidence of vascular occlusions in patients suffering and recovered from COVID-19. Such studies can give us insight related to the association of the ocular diseases with the stage and severity of the COVID-19 infection. Our knowledge regarding the pathophysiology and treatment of this disease is still in its preliminary stage. The fast-paced ongoing research will hopefully provide better algorithms for management of this disease and prevention of its complications. Physicians treating COVID-19 patients must be sensitized to seek an urgent retina consultation for patients complaining of symptoms like blurry vision, sudden painless visual loss, or scotomas. We congratulate the authors for reporting the first case of an isolated cilioretinal artery occlusion (CLRAO) associated with paracentral acute middle maculopathy (PAMM) in a patient with moderate COVID-19 disease and no other predisposing diseases. PAMM is reported to be present in 100% of isolated CLRAO due to hypoperfusion of the involved cilioretinal artery.[6] The authors started treating the patient 48 h after the episode and gave 20 sessions (40 h) of hyperbaric oxygen (HBO), which led to resolution of retinal edema after 3 weeks. HBO involves the inhalation of 100% oxygen at pressures greater than 1 atm. The inspired oxygen partial pressure is nearly 203 kPa, which is almost 10 times that of breathing air at normal atmospheric pressure. It is postulated that oxygen at higher pressures diffuses from the choroidal circulation to reach the ischaemic retina and increase the oxygen delivery to the ischemic tissue until spontaneous or assisted reperfusion occurs.[7] However, isolated CLRAO is associated with good prognosis and does not usually require treatment. Retinal edema usually resolves spontaneously within few weeks. The central field defect improves in nearly half of the eyes and remains stable in the other half.[8] HBO is usually reserved for patients presenting with poor vision due to CRAO and BRAO. Also, the maximum benefit of the treatment is expected in case it is started within 6–8 h of the occlusion.[7] The risk-benefit for the application of multiple sessions to gain <1 line of vision during the COVID-19 pandemic should be carefully calculated. Role of corticosteroids in COVID-19 has been evaluated by several studies. The RECOVERY trial was a prospective study where 2104 patients were randomized to dexamethasone 6 mg per day (oral or intravenous) for 10 days and compared to the 4321 patients receiving usual care. They concluded that in patients hospitalized with COVID-19, dexamethasone reduced the 28-day mortality among those receiving invasive mechanical ventilation or oxygen at randomization, but not among patients with mild to moderate COVID-19 disease.[9]

The effectiveness of early anticoagulant treatment in Covid-19 patients.

Coronavirus disease 2019 (Covid-19) is an emerging, fast-spreading and worldwide infectious disease that would be deteriorated with the precipitation of systemic or local thrombosis. The aim of current study was evaluating the effects of early anticoagulant treatment in hospitalized Covid-19 patients. The present retrospective and comparative cohort study investigated 413 hospitalized Covid-19 patients treated with or without Low Molecular Weight Heparin (LMWH) (n = 187 and 226, respectively) in the Covid Clinics of Gulhane Education and Research Hospital in Ankara, Turkey, between March 18 and May 03, 2020. The treatment groups were consisted of the patients evaluated before and after The Covid-19 Treatment Guide update on April 12, 2020 that included the anticoagulant treatment thereafter. The mean age of all 413 patients (204 male and 209 female) at disease onset was 50.6 ± 16.7 years. The LMWH-treated patients had significantly higher coagulation markers such as d-dimer and platelet count than LMWH-untreated patients (p values < 0.05). The inflammatory markers, ferritin, interleukin-6 and procalcitonin were significantly increased in LMWH-untreated patients (p values < 0.05). The presence of any comorbidity was significantly more common in LMWH-treated patients compared to LMWH-untreated group (39.6% vs 19.9%, respectively; p < 0.001). Hypertension and diabetes mellitus were the most frequent comorbidities in both groups. The number of intensive care unit (ICU) transfer and longer length of hospital stay were more commonly observed in LMWH-untreated patients (p values <0.05). Early anticoagulant treatment with relatively higher doses of LMWH may improve the clinical outcome of Covid-19 patients and shorten the length of hospital stay.

Silent atrial fibrillation detected by home-monitoring: Cardiovascular disease and stroke prevention in patients with diabetes

ObjectivePatients with silent and undiagnosed paroxysmal atrial fibrillation and flutter (AF) have increased risk of ischemic stroke. Patients with diabetes have a higher risk of both AF and ischemic stroke compared to patients without diabetes. Our aim was to investigate the prevalence of silent AF in patients with diabetes in an outpatient cohort and to identify the possible risk factors associated with AF. Research design and methodsThis prospective observational study was performed in the outpatient diabetes clinic at a single University Hospital. We included 217 patients with type 1 or type 2 diabetes with at least one additional risk factor from the CHA2DS2VASc Score for Stroke Risk Assessment in Atrial Fibrillation. The primary outcome was prevalence of AF, with a duration of at least 30 s, recorded by a seven-day home-monitor, external loop recorder (ELR) in comparison to a standard resting ECG. Seventeen patients were excluded due to premature removal of the device. ResultsIn the final cohort of 200 patients the majority were male (58.5%) with a mean age of 66 ± 0.7 years. The mean BMI was 29 ± 6 and patients had a mean diabetes history of 23 ± 14 years with the majority diagnosed with type 2 diabetes (59%). Comorbidity was common with hypertension in 86%, and dyslipidemia in 80%. The total prevalence of silent AF [n = 20 (10%)] or flutter [n = 1 (0.5%)] was 10.5% using the ELR compared to a 0.0% detection-rate in the standard ECG method (p < 0.001). Higher age, male gender, albuminuria, and elevated systolic blood pressure were associated with AF in univariate analyses, but only age [OR 1.14 (95% CI = 1.00–2.04) (p = 0.048)], male gender [OR 4.9 (95% CI = 1.30–18.65) (p = 0.019)] and albuminuria [OR 2.7 (95% CI =1.08–6.98) (p = 0.034) were independently associated with AF. Mean CHA2DS2VASc Score was ≥2 (4.1, SD ± 1.6), and patients with AF were referred to further cardiac evaluation. ConclusionUndiagnosed, silent AF is common in high-risk cohort with a long history of diabetes followed in a University Hospital outpatient clinic. Non-invasive monitoring with ELR enhances detection of AF and identifies candidates for early anticoagulation treatment with the possible effect of stroke prevention.

Covid-19 as a Cause of Pneumonia and Diffuse Peripheral Pulmonary Embolism. Early Anticoagulant Treatment to Prevent Thrombi Formation

Covid-19 as a Cause of Pneumonia and Diffuse Peripheral Pulmonary Embolism. Early Anticoagulant Treatment to Prevent Thrombi Formation

A descriptive monocentric study in Algeria of adults with cerebral venous thrombosis

IntroductionPatients with cerebral venous thrombosis (CVT) often present with slowly progressive symptoms, leading to delay in diagnosis. The aim of our single-center study was to highlight the clinical patterns and etiological features of CVT, and to show the impact of diagnostic delay on prognosis in Algerian adults. MethodsRetrospective and prospective data of patients with radiologically confirmed CVT were collected over a 10-year period at the neurovascular emergency unit of the Salim Zemirli hospital in Algiers. Manifestations were classified by clinical syndrome. All patients received immediate unfractionated heparin at a hypocoagulant dose. Systematic targeted etiological research for CVT was performed with identification of acquired and genetic risks. ResultsThe study included 28 patients, median age 32 years. Median time to diagnosis was 11 days. The most common clinical features were headache (79%), focal neurological deficit (48%), seizures (33%), and mental status changes (26%). The superior sagittal and transverse sinuses were most commonly involved. Important predisposing factors included local infection (31%), puerperium (14%), oral contraceptive pill use (11%), Behçet disease (11%) and thrombophilia (18%). Short-term outcome was favorable in a majority of patients, but vision lost was noted in three because of delayed diagnosis. ConclusionsIn a single center in Algiers, CVT occurred essentially in young women. Most patients presented acute intracranial hypertension with headache as the cardinal sign. The most common sites of thrombosis were the transverse and the superior sagittal sinuses. Predominantly, acquired causes were infection, puerperium and oral contraceptives. Protein S deficiency was notable. Outcome was favorable in most patients, without sequelae. The prognosis of CVT is decisively dependent on early diagnosis and immediate anticoagulant treatment with heparin.

Coronavirus Pneumonia and Pulmonary Thromboembolism

Abstract In 2019, a novel pneumonia, called coronavirus disease 2019 (COVID-19), spread rapidly throughout the world. This novel global pandemic severely threatened public respiratory health and medical services. To date, except for the common respiratory symptoms, coagulation disorders, especially pulmonary thromboembolism (PTE), has been proven as an important complication in severe COVID-19 patients, and the incidence of PTE causes poor clinical outcome and increased fatality. Therefore, it is important that healthcare providers, including respiratory physicians, emergency medicine specialists, hematologists, cardiologists, infectious disease specialists, and other specialists, recognize that patients with COVID-19 are at increased risk of PTE, and ensure that appropriate prophylaxis is administered to the appropriate patients, and that they effectively manage PTE when it does occur. The mechanism of PTE in patients with coronavirus pneumonia consists of endothelial injury, activated platelet, cytokine storm, and a suppressed fibrinolytic system. Early prophylaxis, antiviral therapy, anticoagulation, and supportive treatment are beneficial to COVID-19 patients. In this review, we summarize the harm that coronavirus pneumonia wreaks and highlight the clinical relationship between PTE and coronavirus infection. The potential mechanism and the prophylaxis and therapeutic measures are also discussed to call for more effort and research to investigate the strategies for PTE in COVID-19.

P3769Rapid referral to a one-stop AF clinic following possible AF detection by community pharmacists leads to early diagnosis and appropriate anticoagulant treatment

Abstract Background Atrial fibrillation is the most common cardiac arrhythmia globally, responsible for one third of ischaemic strokes, often resulting in death or incapacity. This condition, frequently asymptomatic is estimated to be up to 50% undiagnosed. Reducing this risk with appropriate detection and management strategies offers substantial economic and patient benefits. Community pharmacists have been shown to be an accessible healthcare professional capable of detecting atrial fibrillation. Concerns raised utilising community pharmacists is the additional workload for primary care physicians, and lack of a clear pathway to ensure patients are adequate followed with assurance of initiation of anticoagulation therapy. Purpose To assess the feasibility of screening by community pharmacists with onward referral to an innovative one-stop AF clinic to enable identification of new cases of AF and subsequent initiation of anticoagulation within 2 weeks. Methods 21 pharmacies were recruited and trained on pathophysiology of AF and demonstration of pulse taking using pulse check and Kardia mobile device. Any person walking into a community pharmacy aged ≥65 years was offered a free pulse check. For any irregularity detected, individualised counselling was offered with a referral made to a one-stop AF clinic for confirmation and initiation of anticoagulation. Written patient consent was obtained. Results 672 people were recruited with an average age of 69±3.5 years and 58% female (n=389). There was a history of hypertension in 618 (92%) and diabetes in 242 (36%), the most common co-morbidities. 45 people were referred following an irregular pulse or abnormal ECG rhythm strip, of whom 11 (1.6% of total population) had a confirmed AF diagnosis within 30 day follow up. An additional 8 cases with known AF not receiving anticoagulation termed (actionable AF) were also referred. All 19 cases of new or untreated AF were prescribed anticoagulation by the one stop clinic in accordance with guideline recommendations Conclusions ESC guidance recommends opportunistic screening for AF by pulse taking or ECG rhythm strip in patients ≥65 years of age. The 1.6% incidence of new AF was in accordance with meta-analyses identifying 1.4% of those aged ≥65 on a single time point check for presence of AF. Our model utilises the un-tapped skills of community pharmacy to deliver pulse checks of ECG rhythm recordings in an accessible primary care location with a clear referral pathway that is effective in early review and ensuring suitable patients receive anticoagulation. The innovative pathway could provide remote triage at scale and help address the missing people with undiagnosed and actionable AF by opening new channels for identification by healthcare professionals managing long term conditions who like pharmacists have not been considered suitable healthcare professionals due to lack of an established pathway for confirming the potential diagnosis of AF. Acknowledgement/Funding NHS England Test Bed Programme

P5588Early versus delayed oral anticoagulation in patients with acute pulmonary embolism: determinants and outcome

Abstract Background Whether early oral anticoagulant treatment is appropriate for patients with acute pulmonary embolism (PE) regardless of PE severity is undefined. The aim of this study in patients with acute PE at intermediate risk of death were: I) to assess the determinants for the use of early vs delayed vs no oral anticoagulants in patients with acute PE and II) to assess the association between timing of oral anticoagulation and in-hospital mortality. Methods Prospective cohorts of patients with acute PE at intermediate risk of death according to the European Society of Cardiology Guidelines 2014 were merged in a collaborative database. The initiation of oral anticoagulation was classified as early (≤3 days) or delayed (between day 3 and 10 from diagnosis). Patients treated with parenteral anticoagulants for longer than 10 days were also included. In-hospital death was the primary study outcome. Results Overall, 557 patients were included in the study, 23 received thrombolytic treatment during the hospital stay. The mean duration of parenteral anticoagulation was 7±8 days (5 median), 348 patients were initiated on a direct oral anticoagulant and 79 on a vitamin K antagonist during the hospital stay. Initiation of oral anticoagulants occurred early or delayed in 209 (37%) and 218 (39%) patients, respectively and never occurred during the first 30 days in 130 (23%). Intermediate-low risk patients more commonly received early and intermediate high delayed oral anticoagulation. Simplified PESI score of zero (OR 1.9, 95% CI 1.3–2.7) was independently associated with early oral anticoagulation; among sPESI components absence of cancer (OR 5.9, 95% CI 3.3–10) and heart rate &lt;110 (OR 1.8, 95% CI 1.01–3.16) were independent predictors of early initiation of oral anticoagulants. The presence of both right ventricle dysfunction and injury was associated with delayed initiation of oral anticoagulants. The incidence of death was 5.5%. Death occurred in 32 patients and was not related to the duration of parenteral anticoagulation (OR 1.01 per day, 95% CI 0.98–1.06) nor to right ventricle dysfunction but to sPESI 1 (OR 3.32, 95% CI 1.14–9.66). These results were partially confirmed in the 435 intermediate risk patients without cancer (OR 1.03, 95% CI 0.99–1.08 for days of parenteral treatment; OR 4.17, 95% CI 0.95–18 for sPESI 1). Conclusion The clinical severity of PE and not the timing of initiation of oral anticoagulants are associated with in-hospital death in patients with intermediate risk PE. Randomized studies are needed to definitively assess the role of heparin lead-in in patients with PE at intermediate risk for death.

New criteria for sepsis-induced coagulopathy. Review

In 2017 a new criteria for sepsis-induced coagulopathy (SIC) were issued following the revised sepsis definition in 2016. They aimed to the earliest detection of the sepsis-specific thrombotic phenotype of disseminated intravascular coagulation (DIC) in order to improve outcomes with early anticoagulant treatment in critically ill patients with sepsis. The following validation of SIC score demonstrated higher forecast value of that and revealed higher correlation with mortality compared to DIC score by the International Society on Thrombosis and Haemostasis (ISTH). In the future the ISTH plans to offer a simplified two-step scoring system for early DIC syndrome revealing in which SIC scale is as the first step, and the next step is the assessing of overt-DIC in patients who meet the criteria of SIC. The main goal of that should become the opportunity of timely therapeutic effects to the hemocoagulation in order to improve the treatment effectiveness of a sepsis.

Effects of neutrophil extracellular traps in severe pneumonia anticoagulant therapy

Severe pneumonia is the leading cause of death in children.With the cognition of coagulation disorders in serious infection, the immunothrombosis mediated by the reciprocity in neutrophil extracellular traps and coagulation factors are significant factors in early innate immune response against bacterial spreading, facilitating the recognition and destruction of pathogens.But it may lead to microvascular thrombosis and hypoxia, contributing to organ dysfunction, if uncontrolled.Therefore, whether patients with severe pneumonia need early anticoagulation treatment and the clinical effect of anticoagulation therapy are worthy of further study and exploration.This article reviewed the research progress of neutrophil extracellular traps in severe pneumonia anticoagulant therapy. Key words: Severe pneumonia; Coagulation disorders; Anticoagulant therapy; Neutrophil extracellular traps

Early anticoagulation therapy for severe burns complicated by inhalation injury in a rabbit model.

The aim of the present study was to determine the effects of early anticoagulation treatment on severe burns complicated by inhalation injury in a rabbit model. Under anesthetization, an electrical burns instrument (100°C) was used to scald the backs of rabbits for 15 sec, which established a 30% III severe burns model. Treatment of the rabbits with early anticoagulation effectively improved the severe burns complicated by inhalation injury-induced lung injury, reduced PaO2, PaCO2 and SPO2 levels, suppressed the expression of tumor necrosis factor-α, interleukin (IL)-1β and IL-6, and increased the activity of IL-10. In addition, it was found that early anticoagulation treatment effectively suppressed the activities of caspase-3 and caspase-9, upregulated the protein expression of vascular endothelial growth factor (VEGF) and decreased the protein expression of protease-activated receptor 1 (PAR1) in the severe burns model. It was concluded that early anticoagulation treatment affected the severe burns complicated by inhalation injury in a rabbit model through the upregulation of VEGF and downregulation of PAR1 signaling pathways. Thus, early anticoagulation is a potential therapeutic option for severe burns complicated by inhalation injury.