Early Initiation Of Anticoagulation Research Articles

Early Initiation of Anticoagulation Is Safe After Ischemic Stroke with Atrial Fibrillation: Meta-analysis and Systematic Review (P3-5.032)

Early Initiation of Anticoagulation Is Safe After Ischemic Stroke with Atrial Fibrillation: Meta-analysis and Systematic Review (P3-5.032)

Abstract WP144: Early Initiation of Anticoagulation is Safe After Ischemic Stroke With Atrial Fibrillation, Meta-Analysis and Systemic Review

Background: Large randomized clinical trials have established the superiority of Direct oral anticoagulants (DOACs) over Vitamin-K antagonists in atrial fibrillation (AF) related to Acute Ischemic stroke (AIS). However, the data regarding outcomes of early versus late administration of DOACs is limited, but few recent studies & clinical trials provided some evidence. Methodology: The Preferred Reporting Items for Systematic Reviews & Meta-Analyses (PRISMA) standards were followed for this systematic review & meta-analysis". Our search strategy used the Population (AF-related AIS patients taking DOACs), Intervention (early anticoagulation; before 3-4 days), Comparison (late anticoagulation; after 3-4 days), Outcomes & Study type (PICOS) question format. The outcomes of interest were Intracranial hemorrhage (ICH), ischemic stroke & all-cause mortality. The data was pooled using Mantel-Haenszel random effect model & the Higgins I 2 test was used to determine the heterogeneity in each analysis. Results: After the database search & study screening, we included 3 prospective cohorts & 1 RCT in our review. All four eligible studies were of good quality (the Newcastle Ottawa Scale & Cochrane Risk of Bias tool 2). Of the 1831 patients who received DOACs in A-F related AIS, 966 were given before 3-4 days & 865 people received them after 3-4 days. The adverse event of ICH (RR 0.65 [95% CI: 0.41 - 1.01] p = 0.68, I 2 = 0%) was similar in both early & late groups. No significant difference in Risk of Ischemic stroke (RR 0.67 [95% CI: 0.36 - 1.24] p = 0.28, I 2 = 22%) & all-cause mortality (RR 0.72 [95% CI: 0.45 - 1.17] p = 0.52, I 2 = 0%) was noted between the two groups. Conclusion: Our meta-analysis found that initiating DOACs within 3-4 days of AF-associated stroke is safe & does not affect outcomes such as ICH incidence, stroke recurrence, or all-cause mortality.

Abstract 14464: Meta-Analysis Comparing Early vs Delayed Anticoagulation After Stroke in Patients With Atrial Fibrillation

Introduction: Secondary prevention with anticoagulants is recommended for patients with acute ischemic stroke and atrial fibrillation (AF), but the timing of initiation of anticoagulation is debated. We performed a meta-analysis of the available studies. Methods: Studies comparing early (≤ 7 days) vs delayed (> 7 days) start of anticoagulation after acute stroke in patients with AF were searched from online databases. The primary endpoints of interest were recurrent ischemic stroke, intracranial haemorrhage (ICH), and mortality at the longest available follow up. Random-effects model was used to estimate risk ratios (RR) with 95% confidence intervals (CI). Results: Four studies (2 randomized trials and 2 observational studies), with a total of 5,606 patients - 2,918 in the early group and 2,688 in the delayed group were included. The mean age was 79 years and 55% of patients were men. The follow up duration varied from 30 days to 6 months. No significant differences were found between the early and delayed anticoagulation groups with regards to risk of recurrent ischemic stroke (RR 0.80, 95% CI 0.51-1.27, p = 0.35) (Figure 1), ICH (RR 0.62, 95% CI 0.17-2.24, p = 0.47) or mortality (RR 0.88, 95% CI 0.64-1.22, p = 0.45) (Figure 2). Conclusions: In patients with acute ischemic stroke and AF, early initiation of anticoagulation has similar risk of recurrent stroke, ICH, and mortality, when compared with delayed initiation.

Venous Thromboembolism in Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis of 4,170,027 Patients

BackgroundData on the association between atrial fibrillation (AF) and venous thromboembolism (VTE) are controversial. ObjectivesThe purpose of this study was to investigate the risk of VTE in patients with AF according to the time from AF diagnosis. MethodsSystematic review of MEDLINE (PubMed), Embase, Cumulative Index to Nursing and Allied Health Literature (EBSCO host), Cochrane Central Register of Controlled Trials (2020) in the Cochrane Library, and World Health Organization Global Index Medicus databases and meta-analysis of observational studies. The risk of VTE, deep vein thrombosis (DVT) and pulmonary embolism (PE) was analyzed according to the time of AF onset: 1) short (≤3 months); 2) medium (≤6 months); and 3) long (>6 months) time groups. ResultsEight studies were included with 4,170,027 patients, of whom 650,828 with AF. In the short-term group, AF was associated with the highest risk of either PE (HR: 9.62; 95% CI: 7.07-13.09; I2 = 0%) or DVT (HR: 6.18; 95% CI: 4.51-8.49, I2 = 0%). Even if to a lesser extent, AF was associated with a higher risk of VTE (HR: 3.69; 95% CI: 1.65-8.27; I2 = 79%), DVT (HR: 1.75; 95% CI: 1.43-2.14; I2 = 0%), and PE (HR: 4.3; 95% CI: 1.61-11.47; I2 = 68%) in the up to 6 months and long-term risk group >6 months groups (HR: 1.39; 95% CI: 1.00-1.92; I2 = 72%) and PE (HR: 1.08; 95% CI: 1.00-1.16; I2 = 0%). ConclusionsThe risk of VTE is highest in the first 3 to 6 months after AF diagnosis and decreases over time. The early initiation of anticoagulation in patients with AF may reduce the risk of VTE.

A Multidisciplinary Approach for the Management of Portal Vein Thrombosis.

Portal venous thrombosis (PVT) is an uncommon disease associated with highly morbid conditions such as intestinal ischemia and portal hypertension. Patients at higher risk of developing PVT include those with cirrhosis, malignancy, or prothrombotic states. The mainstay of treatment is early initiation of anticoagulation. The first case is a 49-year-old female diagnosed with a cecal mass and PVT. She was started on anticoagulation and underwent a right hemicolectomy with several small bowel resections. She developed portal hypertension that required TIPS and mechanical thrombectomy. The second patient is a 65-year-old female found to have PVT. She was anticoagulated with heparin and given systemic TPA. She developed intestinal ischemia and portal hypertension requiring small bowel resection, TIPS, and mechanical thrombectomy. These cases give insight into the impact of a multidisciplinary team approach to PVT. The role and timing of endovascular treatment is not well established and needs to be further investigated.

Timing of anticoagulation for venous thromboembolism after recent traumatic and vascular brain Injury.

Currently, there is no consensus guideline for initiating anticoagulation in patients with a traumatic or vascular brain injury. Initiating anticoagulation for management of venous thromboembolism (VTE) can vary significantly from 72hours to 30 weeks due to the risk of hemorrhagic complications. The purpose of this study is to compare clinical outcomes using modified Rankin Score (mRS) in a patient population with early (≤ 3 days) versus late (> 3 days) initiation of therapeutic anticoagulation from the time VTE was diagnosed. This retrospective study included patients with a traumatic or vascular brain injury who developed either deep vein thrombosis (DVT) or pulmonary embolism (PE). Use of anticoagulation prior to admission, diagnosis with VTE on admission, or patients with a non-brain injury were exclusion criteria. Secondary outcomes measured were all-cause mortality, length of stay, and reasons for early interruption of anticoagulation. Therapeutic anticoagulation was started early in 76 (74%) patients compared to late initiation in 27 (26%) patients. Baseline characteristics were similar between the two groups. The mRS score 0-3 versus 4-6 was similar in patients who received early anticoagulation versus those who received it later. However, there was a trend favoring better outcomes in the early group [mRS 4-6; 78% vs. 93%; p = 0.085] and in subgroup analysis of patients with VTE diagnosed 4-7 days [mRS 4-6; 26% vs. 56%; p = 0.006] compared to the late group. In univariate and multivariable logistic regression, only age was associated with a significant worse outcome (median, IQR) 36 years (24-50) vs. 58 years (44-65) OR 1.07 (1.03-1.12); p < 0.001. In this study, early initiation of anticoagulation did not worsen clinical outcomes.

Timing and choice of systemic anticoagulation in the setting of extremity arterial injury repair.

The role of perioperative anticoagulation in the setting of peripheral arterial injury remains unclear. We hypothesized that early initiation of anticoagulation is associated with a reduced amputation rate without increasing bleeding complications. Using the 2016-2019 ACS-TQIP database, adult patients with upper and lower extremity vascular injuries who underwent open arterial repair and received anticoagulation were included. Patients were divided into two groups: (1) early venous thromboembolism prophylaxis (≤ 24h) and (2) late prophylaxis (> 24h) following arterial repair. The primary outcomes were the rates of limb amputation and bleeding complications. Multivariable logistic regression was used to estimate the impact of timing and type of anticoagulation on the rates of limb amputation and bleeding complications. 4379 patients were included, and 83.9% were males. 68.1% of patients received early anticoagulation, whereas 31.9% received late thromboprophylaxis. Low-molecular-weight heparin (LMWH) was used in 62.0% of patients, and unfractionated heparin (UFH) was administered in 34.3% of patients. Multivariable analysis showed that late initiation of thromboprophylaxis (OR = 1.69 [1.16-2.45], p = 0.006) and use of UFH (OR = 2.61 [1.80-3.79], p < 0.001) were associated with increased rate of amputation. Early initiation of anticoagulation (OR = 2.16 [1.63-2.85], p < 0.001) was associated with increased risk of bleeding complications requiring blood transfusions. Similarly, the use of UFH was associated with a higher rate of bleeding events compared to LWMH (OR = 2.61, [1.80-3.79], p < 0.001). Patients with the operative repair of arterial injuries receiving early perioperative anticoagulation demonstrated an improved limb salvage outcome than those who received late thromboprophylaxis. Our data also suggest that early initiation of prophylaxis may be associated with increased bleeding risk, which may be attenuated using LMWH compared to UFH.

Early Anticoagulation in Patients with Acute Ischemic Stroke Due to Atrial Fibrillation: A Systematic Review and Meta-Analysis.

Introduction: There is uncertainty regarding the optimal timing for initiation of oral anticoagulation in patients with acute ischemic stroke (AIS) due to atrial fibrillation (AF). Methods: We performed a systematic review and meta-analysis of randomized-controlled clinical trials (RCTs) and prospective observational studies to assess the efficacy and safety of early anticoagulation in AF-related AIS (within 1 week versus 2 weeks). A second comparison was performed assessing the efficacy and safety of direct oral anticoagulants (DOACs) versus vitamin-K antagonists (VKAs) in the two early time windows. The outcomes of interest were IS recurrence, all-cause mortality, symptomatic intracerebral haemorrhage (sICH) and any ICH. Results: Eight eligible studies (6 observational, 2 RCTs) were identified, including 5616 patients with AF-related AIS who received early anticoagulation. Patients that received anticoagulants within the first week after index stroke had similar rate of recurrent IS, sICH and all-cause mortality compared to patients that received anticoagulation within two weeks (test for subgroup differences p = 0.1677; p = 0.8941; and p = 0.7786, respectively). When DOACs were compared to VKAs, there was a significant decline of IS recurrence in DOAC-treated patients compared to VKAs (RR: 0.65; 95%CI: 0.52–0.82), which was evident in both time windows of treatment initiation. DOACs were also associated with lower likelihood of sICH and all-cause mortality. Conclusions: Early initiation of anticoagulation within the first week may have a similar efficacy and safety profile compared to later anticoagulation (within two weeks), while DOACs seem more effective in terms of IS recurrence and survival compared to VKAs.

Atrial CARdiac Magnetic resonance imaging in patients with embolic stroke of unknown source without documented Atrial Fibrillation (CARM-AF): Study design and clinical protocol.

BackgroundInitiation of anticoagulation therapy in ischemic stroke patients is contingent on a clinical diagnosis of atrial fibrillation (AF). Results from previous studies suggest thromboembolic risk may predate clinical manifestations of AF. Early identification of this cohort of patients may allow early initiation of anticoagulation and reduce the risk of secondary stroke.ObjectiveThis study aims to produce a substrate-based predictive model using cardiac magnetic resonance imaging (CMR) and baseline noninvasive electrocardiographic investigations to improve the identification of patients at risk of future thromboembolism.MethodsCARM-AF is a prospective, multicenter, observational cohort study. Ninety-two patients will be recruited following an embolic stroke of unknown source (ESUS) and undergo atrial CMR followed by insertion of an implantable loop recorder (ILR) as per routine clinical care within 3 months of index stroke. Remote ILR follow-up will be used to allocate patients to a study or control group determined by the presence or absence of AF as defined by ILR monitoring.ResultsBaseline data collection, noninvasive electrocardiographic data analysis, and imaging postprocessing will be performed at the time of enrollment. Primary analysis will be performed following 12 months of continuous ILR monitoring, with interim and delayed analyses performed at 6 months and 2 and 3 years, respectively.ConclusionThe CARM-AF Study will use atrial structural and electrocardiographic metrics to identify patients with AF, or at high risk of developing AF, who may benefit from early initiation of anticoagulation.

Acute Aortic Thrombus with Splenic Infarction in a Patient with COVID-19 Infection

Acute Aortic thrombus with splenic infarction is a rare complication of COVID-19. This manuscript highlights the importance of early identification of this complication with abdominal imaging and early initiation of anticoagulation despite moderate severity of the disease.

Rationale, Design and Methods of the Prospective Record of the Use of Dabigatran in Patients with Acute Stroke or TIA (PRODAST) Study.

BackgroundThe optimal timing of anticoagulation following acute ischaemic stroke or TIA in patients with atrial fibrillation (AF) is a frequent challenge. Early initiation of anticoagulation can reduce the risk for recurrent ischaemic events, but may lead to an increased risk for intracerebral haemorrhage.AimThe Prospective Record of the Use of Dabigatran in Patients with Acute Stroke or TIA (PRODAST) study was initiated to investigate outcome events under antithrombotic therapy after ischaemic stroke or TIA in patients with AF. The main objective is to compare the three-month rates of major haemorrhagic events between early (≤ 7 days) versus late (> 7 days) administration of dabigatran or treatment with vitamin-K antagonists started at any time. Occurrences of ischaemic and major haemorrhagic events will be evaluated to determine the optimal time point for initiation or resumption of anticoagulation.Design and MethodsPRODAST is a prospective, multicenter, observational, non-interventional post-authorization safety study. 10,000 patients with recent (≤ 1 week from index event) ischaemic stroke or TIA and non-valvular AF were recruited at 86 German sites starting in July 2015. The observational plan includes a baseline visit, documentation of data during hospitalization and a telephone-based, central follow-up at three months after the index event. The primary endpoint is the major bleeding rate within three months. Secondary endpoints include rates of recurrent ischaemic or haemorrhagic stroke, TIA, systemic embolism, myocardial infarction and death.SummaryPRODAST will provide important real-world data on safety and efficacy of antithrombotic therapy after acute stroke and TIA in patients with AF.

Abstract 1122‐000226: Collaborative Stroke Pathway for In‐Patient Implantation of Long‐Term Cardiac Rhythm Monitors for Atrial Fibrillation Detection

Introduction : Atrial fibrillation (AF) is a recognized risk factor of ischemic stroke and AF‐related stroke is twice more likely to prove fatal. Long‐term cardiac rhythm monitoring has greater diagnostic yield compared to conventional monitoring in detecting AF. Utility of implantable loop recorder (ILR) in detecting AF was established not only in patients with cryptogenic stroke but more recently in strokes due large artery atherosclerosis and small vessel disease Stroke AF trial. We present a collaborative care pathway and share multi‐year data on ILR implantation. Methods : A review of prospectively collected registry of ILR implantations performed at a Comprehensive stroke center was conducted. Data from 2017–2019 of in‐patient and out‐patient implantation was analyzed. Eligible patients identified by vascular neurology (VN) underwent in‐patient implantation primarily by interventional neurology (IN) and as out‐patient by electrophysiology Cardiology. In‐patient implant and programming were done on the day of discharge. Continuous monitoring was followed by EP Cardiology. AF detection was urgently communicated by EP Cardiology and anticoagulation initiated by VN. Patients lost to follow up or lacking information in medical records were excluded from analysis. Results : Total of 428 ILR implantations were performed over a period of 3 years (1/2017 ‐ 12/2019) with majority implants as in‐patient prior to discharge 290 (67.8%) and out‐patient 78 (32.2%). Inpatient ILR placement was noted to be 75% in 2017, 78% in 2018 and 80% in 2019. 57.2% of in‐patient ILRs were placed by IN and 42.8% by EP. Average time to in‐patient ILR was 4.1 days with 77% within 5, 18.5% within 10, and &lt;5% within 11 or more days post‐stroke. Average time to out‐patient ILR placement was 57 days with only 16% within 15, 29% within 30 day and 53% in more than 30 days from stroke. Over the course of 2 years of monitoring, AFib was detected in 33% with false detection in 1.5% (19.6% in 2017, 26% in 2018 and 36.5% in 2019). Conclusions : A multispecialty collaborative care pathway to increase implantation rate in eligible patients is recommended. In‐patient implantation allows establishing continuity of care, patient retention, prevents lost to follow‐up, avoids delay in monitoring, and importantly decreases the risk of stroke recurrence by early initiation of anticoagulation.

TIME TO INITIATION OF ANTICOAGULATION AND OUTCOME IN INTERMEDIATE RISK PULMONARY EMBOLISM

TOPIC: Pulmonary Vascular Disease TYPE: Original Investigations PURPOSE: Early diagnosis and timely treatment are essential to improve the outcomes of pulmonary embolism (PE), but limited information exists on the impact of anticoagulation timing on clinical outcomes in intermediate-risk acute PE patients. The objective of this study was to analyze the relationship between time to anticoagulation initiation and in-hospital mortality in intermediate-risk acute PE patients. METHODS: Medical records of 54 patients hospitalized in our institution with intermediate-risk PE over the last 5 years were reviewed. Age, gender, treatment interventions, and timing of initiation of anticoagulation after diagnosis of PE were noted. The outcome studied included the number of patients who expired and the number that survived. Correlation between time to initiation of anticoagulation and mortality was determined using Pearson’s correlation analysis. The difference in time in survivors and non-survivors was evaluated using an independent t-test. p ≤ 0.05 was deemed statistically significant. RESULTS: The mean age was 66.5+ 17 years; 49% were females. Mean time to initiation of anticoagulation was: 79 + 57 minutes. The number of survivors was 52. The mean time from diagnosis to the start of anticoagulation therapy was not significantly lower in survivors (87 + 74 minutes) than non-survivors (49 + 22 mins); p= 0.3. CONCLUSIONS: The timing of initiation of anticoagulation did not differ between the two groups (survivors and non-survivors). This result may be related to the small number of patients in the study. This needs to be studied in a larger group of patients to determine if early initiation of anticoagulation in intermediate-risk PE impacts outcomes. CLINICAL IMPLICATIONS: Early diagnosis and timely treatment are essential to improve the outcomes of pulmonary embolism (PE), however, the timing of initiation of anticoagulation did not differ between the two groups (survivors and non-survivors) in intermediate-risk PE from this study. This needs to be further explored in a larger group of patients to determine if early initiation of anticoagulation in intermediate-risk PE impacts the outcomes. DISCLOSURES: No relevant relationships by Soontharee Congrete, source=Web Response No relevant relationships by Debapriya Datta, source=Web Response

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.

Anticoagulation Favors Thrombus Recanalization and Survival in Patients With Liver Cirrhosis and Portal Vein Thrombosis: Results of a Meta-Analysis.

IntroductionBenefit and risk of anticoagulation in cirrhotic patients with portal vein thrombosis (PVT) remain controversial, especially in those with asymptomatic PVT and in non-liver transplant candidates. Furthermore, the predictors of portal vein recanalization and bleeding events after anticoagulation are critical for making clinical decisions, but still unclear. We conducted a meta-analysis to investigate the outcomes of anticoagulation for PVT in liver cirrhosis and explore the predictors of portal vein recanalization and bleeding events after anticoagulation.MethodsAll studies regarding anticoagulation for PVT in liver cirrhosis were searched via PubMed, EMBASE, and Cochrane Library databases. Thrombotic outcomes, bleeding events, and survival were compared between anticoagulation and non-anticoagulation groups. Predictors of portal vein recanalization and bleeding events were pooled. Risk ratios (RRs) or mean differences (MDs) with 95% confidence intervals (CIs) were calculated.ResultsThirty-three studies including 1696 cirrhotic patients with PVT were included. Anticoagulation significantly increased portal vein recanalization (RR = 2.61; 95% CI 1.99–3.43; P < 0.00001) and overall survival (RR = 1.11; 95% CI 1.03–1.21; P = 0.01) and decreased thrombus progression (RR = 0.26; 95% CI 0.14–0.49; P < 0.0001). Anticoagulation did not significantly influence overall bleeding (RR = 0.78; 95% CI 0.47–1.30; P = 0.34). Early initiation of anticoagulation (RR = 1.58; 95% CI 1.21–2.07; P = 0.0007) significantly increased portal vein recanalization. Child-Pugh class B and C (RR = 0.77; 95% CI 0.62–0.95; P = 0.02) and higher MELD score (MD = − 1.48; 95% CI − 2.20–0.76; P < 0.0001) were significantly associated with decreased portal vein recanalization. No predictor significantly associated with bleeding events was identified.ConclusionsEarly initiation of anticoagulation should be supported in liver cirrhosis with PVT. Predictors of portal vein recanalization should be taken into consideration to identify those who may not benefit from anticoagulation.RegistrationThe work was registered in PROSPERO with registration no. CRD42020157142.Electronic supplementary materialThe online version of this article (10.1007/s12325-020-01550-4) contains supplementary material, which is available to authorized users.

Timing of Anticoagulation in Atrial Fibrillation Status Post Cardioembolic Stroke

Background: Anticoagulation is the mainstay of secondary stroke prevention in patients with atrial fibrillation; however, few studies have assessed the optimal timing for initiation of anticoagulation post cardioembolic stroke. In the 2 weeks following an acute cardioembolic stroke, the risk of recurrent stroke is as high as 8%, but this risk must be balanced against the risk of hemorrhagic transformation with early initiation of anticoagulation. Purpose: This study described the time to initiation of anticoagulation and evaluated the in-hospital incidence of hemorrhagic and ischemic complications in 106 patients with atrial fibrillation post an acute cardioembolic stroke. Methods: A single-center retrospective cohort study was conducted to describe the time to initiation of therapeutic anticoagulation in patients with atrial fibrillation admitted to the hospital for an acute cardioembolic stroke. The primary outcome was the time to initiation of anticoagulation from the time of stroke onset. Secondary outcomes included the incidence of in-hospital hemorrhagic and ischemic complications. Results: The median time to initiation of anticoagulation was 59.5 hours after stroke onset for those who did not receive thrombolytic therapy and 82.6 hours for those who did received thrombolytic therapy. Out of 100 patients initiated on anticoagulation, no ischemic complications were observed. Four patients experienced a hemorrhagic conversion following initiation of anticoagulation. In 3 of these patients, anticoagulation was initiated within 48 hours of stroke onset. Conclusion: A small percentage of patients experienced an in-house hemorrhagic conversion when anticoagulation was initiated between 48 hours and 7 days.

Early Initiation of Anticoagulation with Direct Oral Anticoagulants in Patients after Transient Ischemic Attack or Ischemic Stroke

Direct oral anticoagulants (DOACs) are increasingly used for secondary prevention of cardioembolic stroke. While DOACs are associated with a long-term reduced risk of intracranial hemorrhage compared to vitamin K antagonists, pivotal trials avoided the very early period after stroke and few data exist on early initiation of DOAC therapy post stroke. We retrospectively analyzed data from our prospective database of all consecutive transient ischemic attack (TIA) or ischemic stroke patients with atrial fibrillation treated with DOACs during hospital stay. As per our institutional treatment algorithm for patients with cardioembolic ischemia DOACs are started immediately in TIA and minor stroke (group 1), within days 3-5 in patients with infarcts affecting one third or less of the middle cerebral artery, the anterior cerebral artery, or the posterior cerebral artery territories (group 2) as well as in infratentorial stroke (group 3) and after 1-2 weeks in patients with large infarcts (>⅓MCA territory, group 4). We investigated baseline characteristics, time to initiation of DOAC therapy after symptom onset, and hemorrhagic complications. In 243 included patients, administration of DOAC was initiated 40.5 hours (interquartile range [IQR] 23.0-65.5) after stroke onset in group 1 (n = 41) and after 76.7 hours (IQR 48.0-134.0), 108.4 hours (IQR 67.3-176.4), and 161.8 hours (IQR 153.9-593.8) in groups 2-4 (n = 170, 28, and 4), respectively. Two cases of asymptomatic intracranial hemorrhage (.8%) and 1 case of symptomatic intracranial hemorrhage (.4%) were observed, both in group 2. No severe safety issues were observed in early initiation of DOACs for secondary prevention after acute stroke in our in-patient cohort.

Treatment of non-cirrhotic, non-tumoural portal vein thrombosis

Thrombosis of the splenoportal axis not associated with liver cirrhosis or neoplasms is a rare disease whose prevalence ranges from 0.7 to 3.7 per 100,000 inhabitants. However, this entity is the second most common cause of portal hypertension. Prothrombotic factors are present as an underlying cause in up to 70% of patients and local factors in 10-50%. The coexistence of several etiological factors is frequent. Clinical presentation may be acute or chronic (portal cavernomatosis). The acute phase can present as abdominal pain, nausea, vomiting, fever, rectorrhagia, intestinal congestion, and ischemia. In this phase, early initiation of anticoagulation is essential to achieve portal vein recanalization and thus improve patient prognosis. In the chronic phase, symptoms are due to portal hypertension syndrome. In this phase, the aim of treatment is to treat or prevent the complications of portal hypertension. Anticoagulation is reserved to patients with a proven underlying thrombophilic factor.

153-03: Echocardiographic Predictors of Atrial Fibrillation Detection with Injectable Loop Recorders for Patients with Cryptogenic Stroke

Purpose of Study: Injectable loop recorders (ILR) are increasingly used for prolonged cardiac rhythm monitoring in patients with cryptogenic stroke. Echo parameters, including left atrial volume index (LAVI), E/e' and left ventricular ejection fraction (LVEF), have been associated with a higher risk of developing clinical atrial fibrillation. We evaluated these parameters in the setting of patients who received an ILR for evaluation of a cryptogenic stroke to determine if there is any association in this patient population. Methods Used: Patients from our remote monitoring clinic that had an ILR implanted for an indication of cryptogenic stroke were identified. There charts were reviewed retrospectively, including all ILR transmissions. An atrial fibrillation event recorded by the ILR was defined as an irregular rhythm with no discernible P waves on the rhythm strip. All events were reviewed by the two authors (J.M and J.B.) and verified. The LAVI, E/e' and LVEF were obtained from a transthoracic echocardiogram that was performed at our institution no earlier than 6 months prior to or 6 months after ILR implant. Discussion of Results: A total of 50 patients were identified that had an ILR implanted for an indication of cryptogenic stroke. Among the entire group of patients, 11 had an atrial fibrillation event detected for a total detection rate of 22% during their monitoring period. A total of 30 patients had a transthoracic echocardiogram performed in which the LAVI, E/e' and LVEF were reported. Of these patients, 7 had an atrial fibrillation event detected and the remaining 23 did not. The findings for the 30 patients with complete data are summarized in Table 1. Patients with cryptogenic stroke who had atrial fibrillation detected on ILR monitoring had significantly larger LAVI, lower LVEF and a higher CHADS2VASc score. The E/e' was not significantly different between the two groups. Conclusion: Among patients with cryptogenic stroke, those who have atrial fibrillation detected on ILR monitoring have larger LAVI and lower LVEF on transthoracic echocardiogram. LAVI and LVEF, in addition to previously reported CHADSsVASc1, may be useful in selecting among patients who have had a cryptogenic stroke or TIA for ILR monitoring and early initiation of anticoagulation.

Actuación ante la trombosis portal no cirrótica no tumoral

Thrombosis of the splenoportal axis not associated with liver cirrhosis or neoplasms is a rare disease whose prevalence ranges from 0.7 to 3.7 per 100,000 inhabitants. However, this entity is the second most common cause of portal hypertension. Prothrombotic factors are present as an underlying cause in up to 70% of patients and local factors in 10-50%. The coexistence of several etiological factors is frequent. Clinical presentation may be acute or chronic (portal cavernomatosis). The acute phase can present as abdominal pain, nausea, vomiting, fever, rectorrhagia, intestinal congestion, and ischemia. In this phase, early initiation of anticoagulation is essential to achieve portal vein recanalization and thus improve patient prognosis. In the chronic phase, symptoms are due to portal hypertension syndrome. In this phase, the aim of treatment is to treat or prevent the complications of portal hypertension. Anticoagulation is reserved to patients with a proven underlying thrombophilic factor.