Use Of Heparin Research Articles

Evaluation of unfractionated heparin therapy for venous thromboembolism using adjusted body weight in elderly or higher weight patients.

The use of weight-based unfractionated heparin (UFH) infusions is the standard of care in hospital management of venous thromboembolism (VTE). Initial dosing strategies for UFH in older adults and higher body weight patients remain uncertain given differences in pharmacokinetics and concerns for over-anticoagulation. Methods: This was a single-center, retrospective, pre-post study involving older adults aged ≥ 65years and patients weighing ≥ 100kg with suspected or confirmed VTE to determine if the use of adjusted body weight (AdjBW)-based UFH regimens improves time to therapeutic anti-Xa levels compared to total body weight (TBW)-based regimens Patients received weight-based UFH infusions, dosed according to either TBW or AdjBW, to target a therapeutic anti-Xa level. Each cohort consisted of 40 patients, stratified by whether they met age or weight criteria to ensure equal representation of elderly and higher body weight patients between cohorts. The median time to therapeutic anti-Xa levels was shorter in the AdjBW group compared to the TBW group (13.6h versus 20.9h; point estimate 5.3h (95% CI 0.2 to 9.9)). This finding was driven by those aged ≥ 65years and those who received a bolus dose at the start of the infusion. Among older adults and higher weight adults with suspected or confirmed VTE, the use of AdjBW to guide heparin infusion initiation was associated with shorter time to therapeutic anti-Xa levels. This finding driven by the older adult sample and the subgroup analyses did not find a statistically significant difference in time to therapeutic anti-Xa levels in higher body weight patients aged less than 65years.

Intraoperative Epoprostenol in Type II Heparin-Induced Thrombocytopenia During Left-Ventricular Assist Device Implantation: A Case Series and Review of Literature.

Type II heparin-induced thrombocytopenia and thrombosis (type II HITT) is a rare but serious complication in patients receiving heparin for anticoagulation. In type II HITT, an immune-mediated reaction against platelet factor four-heparin complexes results in thrombocytopenia and an elevated risk of thrombosis. This poses significant challenges for patients with advanced heart failure requiring urgent left-ventricular assist device (LVAD) implantation. The use of direct thrombin inhibitors, the typical alternative to heparin, is associated with increased bleeding risk and lacks a reversal agent, limiting their use in cardiac surgery. We present two cases of intraoperative epoprostenol to facilitate implantation of a durable LVAD in type II HITT, of which one case underwent preoperative plasmapheresis and intravenous immunoglobulin (IVIG) therapy. Epoprostenol, a prostacyclin analog, was used intraoperatively during LVAD implantation to inhibit platelet activation and allowed for the safe administration of heparin during cardiopulmonary bypass. Both patients underwent successful LVAD implantation without thrombotic or major bleeding complications. These cases highlight the potential of using intraoperative epoprostenol in conjunction with preoperative plasma exchange (PLEX) and IVIG to mitigate the risks associated with heparin use in patients with type II HITT, offering an alternative approach for this high-risk group requiring urgent cardiac surgery.

Heparin Immobilization Enhances Hemocompatibility, Re-Endothelization, and Angiogenesis of Decellularized Liver Scaffolds.

Bioengineered livers are currently an acceptable alternative to orthotopic liver transplants to overcome the scarcity of donors. However, the challenge of using a bioengineered liver is the lack of an intact endothelial layer in the vascular network leading to thrombosis. Heparin-modified surfaces have been demonstrated to decrease thrombogenicity in earlier research. However, in our study, we aimed to apply heparin immobilization to enhance the hemocompatibility, endothelial cell (EC) adhesion, and angiogenesis of rat decellularized liver scaffolds (DLS). Heparin was immobilized on the DLS by the end-point attachment technique. The scaffold's hemocompatibility was assessed using ex vivo blood perfusion and platelet adhesion studies. The heparinized scaffold (HEP-DLS) showed a significantly reduced thrombogenicity and platelet aggregation. HEP-DLS was recellularized with EA.hy926 cells via the portal vein and maintained in the bioreactor for 7 days, showing increased EC adhesion and coverage within the blood vessels. The Resazurin reduction assay confirmed the presence of actively proliferating cells in the HEP-DLS. The scaffolds were implanted subcutaneously into the dorsum of mice for 21 days to evaluate cell migration and angiogenesis. The results showed significant increases in the number of blood vessels in the HEP-DLS group. Our results demonstrated that heparin immobilization reduces thrombosis, promotes re-endothelialization, and enhances angiogenesis in DLS. The research provides insight into the potential use of heparin in the formation of a functioning vasculature.

Abstract 4138277: Protamine Administration and Bleeding Risk Following Transcatheter Aortic Valve Implantation: A Systematic Review and Meta-Analysis

Background: Bleeding risk is a major concern for patients receiving transcatheter aortic valve implantation (TAVI) due to heparin use. In recent studies, Heparin antagonists, such as protamine, have shown potential in mitigating this complication. We aim to evaluate its potential role in reducing the risk of bleeding in patients post-TAVI. Methods On March 18, 2024, related articles were searched in the following databases: PubMed, Embase, Scopus, Web of Science, Cochrane Library, Wiley Library, VHL, Google Scholar, and clinicaltrials.gov. The inclusion criteria consisted of studies that reported the use of protamine in patients who underwent TAVI, with the aim of reducing bleeding risk compared to administering a placebo or no treatment. Our primary outcomes included major bleeding, life-threatening bleeding, the need for blood transfusion, the 30-day mortality rate, and any events of stroke or transient ischemic attack (TIA). The effect size was calculated using the odds ratio with a 95% confidence interval. Meta-analysis was conducted based on random-effect model using Revman. Results Out of the 14,705 articles we obtained, only 5 papers were included. One was a randomized controlled trial; the remaining 4 were observational cohorts with control groups. These studies comprised a total of 3,502 patients. Protamine significantly reduced major bleeding (OR 0.44, 95% CI 0.29-0.69, p = 0.0003, I 2 = 37%), especially with full-dose administration (1 mg/100 U UFH) compared to partial-dose administration (0.5 mg/100 U UFH) (OR 0.38, 95% CI 0.25-0.58, p < 0.00001, I 2 = 0%). Similarly, protamine significantly reduced life-threatening bleeding (OR 0.37, 95% CI 0.20-0.67, p = 0.001, I 2 = 4%), particularly with full-dose usage compared to partial-dose (OR 0.37, 95% CI 0.18-0.73, p = 0.004, I 2 = 0%). However, no significant difference was observed in the need for blood transfusion (OR 0.75, 95% CI 0.46-1.24, p = 0.27, I 2 = 33%), stroke/TIA risk (OR 0.82, 95% CI 0.41-1.61, p = 0.56, I 2 = 49%), or 30-day mortality (OR 0.93, 95% CI 0.62-1.39, p = 0.73, I 2 = 0%). Conclusions The use of protamine appears to significantly reduce major and life-threatening bleeding. The need for blood transfusion, risk of stroke or TIA, and 30-day mortality did not show significant differences. These findings suggest that protamine may be an effective intervention for reducing bleeding complications post-TAVI. However, large randomized controlled trials are needed to validate these findings.

Understanding European patterns of deprescribing antithrombotic medication during end-of-life care in patients with cancer

BackgroundEven though antithrombotic therapy (ATT) probably has little or even negative effect on the well-being of patients with cancer near the end of life, it is often continued until death, possibly leading to excess bleeding complications, increased disease burden, reduced quality of life and higher healthcare costs. AimTo explore and describe European practice patterns and perspectives of healthcare professionals from different disciplines and specialties on ATT in the end-of-life care (EOLC) of patients with cancer. MethodsWe performed a two-week international cross-sectional survey study using flash-mob research methodology. Eligible were healthcare professionals from different institutions across Europe, who prescribed ATT and/or dealt with EOLC of patients with cancer. The survey comprised three parts, including a series of choice sets (hypothetical scenarios involving a set of characteristics changing in level [e.g., high vs. low thrombotic risk]) on ATT management in EOLC. The discrete choice experiment analysis was conducted using multinomial logistic regression. ResultsOut of 467 pre-registrants, 208 participated in the survey from 4 to 18 July 2023. The majority (53 %) considered a patient with cancer as in EOLC when life expectancy is below 3 months. Respondents reported seeing or treating 20 patients with cancer on ATT in EOLC per year (IQR 10–50). The median estimated frequency of considering ATT deprescription per healthcare professional was 10 times per year (IQR 4–10), while the frequency of actual deprescription was 5 times per year (IQR 2–10). Twenty percent of respondents had never deprescribed ATT in the context of EOLC. Across the eight choice sets, five respondents (2.7 %) found deprescribing inappropriate in any scenario. Deprescribing was more often considered in patients with poor ECOG-performance status, high bleeding risk and low-molecular-weight heparin use as opposed to oral ATT. Haemato-oncology and cardiovascular medicine specialists were more inclined to deprescribe antiplatelet therapy than other specialties. ConclusionOur study describes medical decision-making regarding ATT in EOLC of patients with cancer. Healthcare professionals' perspectives and practice patterns vary, and some preferences appear associated with the therapists' professional focus and region of practice.

Distal versus conventional transradial access for coronary angiography: a pooled analysis from the randomized RAPID trial

Abstract Background Transradial access (TRA) is the recommended approach for coronary procedures considering safety benefits over femoral access with radial artery occlusion (RAO) being the most frequent complication. Although usually not clinically significant, the presence of RAO affects potential future procedures and medical treatments. Distal TRA (dTRA) has been suggested to reduce the risk of postprocedural RAO compared to conventional TRA (cTRA) with, however, inconsistent results in clinical trials. Purpose This study aimed to compare the efficacy and safety of dTRA versus cTRA in patients undergoing diagnostic coronary angiography. Methods The RAPID trial is a single-center, open-label, 2x2 factorial, randomized study of patients undergoing coronary angiography through a 6-F radial access. The trial was stopped early by the data and safety monitoring board after the second pre-planned interim analysis and inclusion of 600 participants. Patients were randomized to dTRA or cTRA with further stratification according to periprocedural heparin use and preexisting oral anticoagulation. The primary endpoints were the incidence of RAO assessed by vascular ultrasound and puncture-site related bleedings. Results The final study population consisted of 298 patients randomized to dTRA and 302 patients to cTRA. Periprocedural heparin was administered in 382 patients (63.7%) and percutaneous coronary intervention was performed in 161 cases (26.8%) without differences between the study groups (p=0.700 and p=0.465; respectively). Distal TRA was associated with a significantly increased number of puncture attempts (2.4 ± 2.0 versus 1.5 ± 1.2; p<0.001) and failed punctures leading to access site crossover (11.7% versus 5.0%; p=0.003). Consequently, the total procedure time was longer in the dTRA group (30 min versus 25 min; p=0.004) without increasing fluoroscopy time (p=0.320), dose area product (p=0.245), or contrast volume (p=0.884). Patent hemostasis was achieved in 91.7% of patients with cTRA. The rates of RAO (16.1% versus 15.6%, p=0.855) and puncture-site related bleedings (6.7% versus 8.3%; p=0.466) were similar in both groups. Conclusions According to this study, dTRA does not reduce the risk of RAO or bleeding events compared to cTRA.

Post-PCI anticoagulation with unfractionated heparin in acute coronary syndrome: insight from the STOPDAPT-3 trial

Abstract Background The guidelines recommend the post-procedural anticoagulation should be discontinued after percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) except for the specific indications.(1) However, these guideline recommendations were not well supported by data, and therefore, post-PCI parental anticoagulation has been commonly implemented in patients with ACS in the previous studies.(2-5) Purpose To clarify the preference and clinical situations of post-PCI unfractionated heparin (UFH) in ACS patients and to explore the influence of post-PCI UFH on cardiovascular and bleeding outcomes. Methods STOPDAPT-3 trial is a randomized controlled trial to demonstrate the efficacy and safety of the aspirin-free prasugrel monotherapy strategy compared to the conventional dual antiplatelet therapy after PCI in patients with high-bleeding risk or ACS.(6) Data on periprocedural heparin use and its doses were vigorously collected. The current study population was the ACS patients enrolled in the STOPDAPT-3 without use of mechanical circulatory support devices. The two co-primary endpoints were the bleeding outcome defined as the BARC 3 or 5 criteria and the cardiovascular outcome defined as a composite of cardiovascular death, myocardial infarction, definite stent thrombosis, or ischemic stroke. Outcomes were assessed at 30 days from index PCI. Results Among 4088 ACS study patients, 2339 (57.2%) patients received post-PCI UFH. Median dose of UFH was 7.1 (IQR 6.0-8.8) units/kg/hour and the median duration was 25 (IQR 24-48) hours. As many as 57.7% of patients received 10000 units/day of heparin after PCI irrespective of body weight. STEMI patients more frequently received post-PCI UFH compared to NSTE-ACS (72.3% and 38.8%, P<0.001) and the patients with intraprocedural adverse angiographic findings such as thrombus, slow-flow, no-reflow, or final TIMI flow <=2 also more frequently received post-PCI UFH than those without (67.6% and 47.5%, P<0.001). Post-PCI UFH was associated with a significantly increased risk of bleeding endpoint (4.75% and 2.52%, adjusted HR 1.69 [95%CI 1.15-2.46], P=0.007) and a numerically increased risk of cardiovascular endpoint (3.16% and 1.72%, adjusted HR 1.56 [95%CI 0.98-2.46], P=0.06). Even in the patients with intraprocedural adverse angiographic findings, post-PCI UFH did not show a clear benefit for cardiovascular endpoint (3.15% and 1.72%, adjusted HR 1.73 [95%CI 0.88-3.41]. P=0.11). Conclusion(s) Post-PCI anticoagulation with UFH was frequently implemented in ACS patients enrolled in the latest large Japanese clinical trial. Post-PCI UFH use was associated with harm in terms of bleeding without a benefit in reducing cardiovascular events.

Unfractionated heparin or low molecular weight heparin in patients with acute pulmonary embolism: a meta-analysis of randomized controlled trials

Abstract Introduction There is limited data on the use of unfractionated heparin (UFH) and low molecular weight heparin (LMWH) in patients admitted for acute pulmonary embolism (PE). Current ESC guidelines preferred LMWH over UFH based on extrapolated data. We aimed to compare UFH and LMWH in patients with acute PE using randomized controlled trials (RCTs). Methods A comprehensive literature search was performed from inception to 02/01/2024 of the PubMed database. Studies of adult patients comparing UFH to LMWH were evaluated for short-term (7-to-12 days) mortality, long-term mortality (90-days to 180-days), short-term (7-to-12 days) and long-term major bleeding (90-days to 180-days). Odds ratio (OR) with 95% confidence intervals (CI) were calculated using DerSimonian-Laird method. Results Of a total 2400 studies, nine RCTs with 1,996 subjects (1025 UFH and 971 LMWH) were included with mean age of 62.9 years and 48.5% males. There was no difference in short-term (OR= 0.89 [95% CI 0.44-1.82]; p=0.75; I2=0%; 6 trials) and long-term mortality (OR= 0.77 [95% CI 0.50-1.21]; p=0.26; I2=0%; 6 trials) with use of LMWH or UFH (Figure Panel A and B). Similarly, there was no difference in short-term (OR= 0.70 [95% CI 0.38-1.32]; p=0.27; I2=0%; 9 trials) and long-term major bleeding (OR= 0.92 [95% CI 0.53-1.60]; p=0.77; I2=0%; 6 trials) with use of LMWH or UFH (Figure Panel C and D). Overall, there was no evidence of publication bias using either funnel plot or eggers test (p > 0.05). Conclusions In this meta-analysis of 9 RCTs, there was similar efficacy and safety of UFH and LMWH in patients admitted for acute PE. However, future large-scale trials are needs to confirm these findings.

Indication-based use of low molecular weight heparin during pregnancy: A retrospective study in Northern Greece

Introduction: Venous thromboembolism (VTE) is a condition with high morbidity and mortality rates and presents as the third leading cause of cardiovascular deaths, globally. During the antenatal period, the risk of VTE occurrence increases, therefore, in pregnant women at high-risk for VTE, the use of low molecular weight heparin (LMWH) is recommended. This study aimed to investigate the indication-based administration of LMWH in pregnancy. Material and methods: This was a retrospective cohort study (2019-2022) conducted at the Third Department of Obstetrics and Gynecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece. All pregnant women at the first trimester of pregnancy were eligible. Their physical characteristics were recorded and information about their personal, familial, gynecological and obstetrical medical history was collected. By utilizing the above characteristics, a score of the risk of developing VTE during pregnancy was calculated for each woman, using the algorithm recommended by the Royal College of Obstetricians & Gynecologists. Results: In total, 2,716 pregnant women were included in the study. Of these, 149 (5.5%) received LMWH throughout their pregnancy with only 2 of them (0.1%) having appropriate indications. Of the women not prescribed LMWH, 2,567 (94.5%), none had an indication for LMWH administration. Notably, 495 (19.3%) women had a history of at least one miscarriage and 89 (59.7%) of them used LMWH, regardless of whether they had an indication or not. Conclusion: There was a high percentage of women with no indication for LMWH who, in fact, received this medication. Physicians should refrain their use following evaluation based on appropriate risk factors.

Heparin therapy in sepsis and sepsis-associated disseminated intravascular coagulation: a systematic review and meta-analysis

BackgroundSepsis is a life-threatening condition that affects 49 million people annually. Managing sepsis-associated coagulopathy poses a significant challenge due to its high mortality rates in intensive care. Recent reports suggest that administering heparin may offer potential survival benefits in sepsis and coronavirus disease cases. However, there is currently no established evidence supporting the use of heparin for sepsis. Thus, in this study, we aimed to assess the efficacy of heparin administration in patients with sepsis.MethodsA systematic review was conducted following the PRISMA guidelines. The searches included MEDLINE, Cochrane, and Japanese databases up to January 2023. The inclusion criteria consisted of randomized control trials (RCTs) involving adult sepsis patients receiving heparin. The risk of bias was assessed using RoB2, and the data extraction included 28-day mortality and bleeding complications.ResultsOut of 1733 initial articles, only three studies met the inclusion criteria. The analysis, which included 426 patients, showed no significant difference in 28-day and in-hospital mortality between the heparin and control groups (risk ratio [RR] = 0.86, 95% confidence interval [CI]: 0.60–1.24). Subgroup analysis of sepsis-associated disseminated intravascular coagulation (DIC) patients (n = 109) also did not show a significant reduction in mortality (RR = 0.84, 95% CI: 0.51–1.38). Heterogeneity was zero, and no publication bias was observed. Additionally, there was significant difference in bleeding complications (RR = 0.49, 95% CI: 0.24–0.99, p = 0.047).ConclusionsThis meta-analysis did not demonstrate a survival benefit of heparin administration in patients with sepsis and sepsis-associated DIC. Further investigation into the potential benefits of heparin is warranted. Moreover, the analysis revealed no increase in bleeding risks with heparin administration; instead, a significant reduction in the risk of bleeding was noted.Trial registrationThis review was preregistered with PROSPERO (registration: CRD42023385091).

AN UPDATE ON DIAGNOSIS AND MANAGEMENT OF THROMBOEMBOLISM IN PREGNANCY

Thromboembolism during pregnancy poses a significant challenge in maternal healthcare, substantially contributing to maternal morbidity and mortality worldwide. Understanding its diagnosis and management is crucial for improving maternal and fetal outcomes. Objective: To evaluate the diagnosis and management of thromboembolism in pregnant women. Methods: A retrospective cohort study was conducted at Lady Reading Hospital, Peshawar, from July 2022 to July 2024. The study included 175 pregnant females diagnosed with venous thromboembolism (VTE) during their pregnancy. Data were collected on patient demographics, trimester of diagnosis, type of thromboembolism (deep vein thrombosis [DVT] or pulmonary embolism [PE]), treatment modalities, and outcomes. Patients were treated with either low molecular weight heparin (LMWH) or unfractionated heparin (UFH). Descriptive statistics were used to analyze the data, with results presented as percentages and means with standard deviations. Results: The mean age of the participants was 32.01 ± 2.35 years. Thromboembolism was most commonly diagnosed in the third trimester (65%), followed by the second trimester (25%) and the first trimester (10%). DVT was observed in 74% of patients, while PE occurred in 26%. Among the 160 patients treated with LMWH, 3% (5 patients) experienced a recurrence of VTE. Of the 15 patients who received UFH, 5% (8 patients) had significant bleeding complications. Overall maternal outcomes included a 3% recurrence rate of VTE and a 5% rate of significant bleeding complications. No maternal mortality was reported. Conclusion: Early diagnosis and timely management of thromboembolism in pregnancy, mainly through the use of low molecular weight heparin and a multidisciplinary care approach, significantly improve maternal and fetal outcomes. LMWH was associated with fewer complications compared to UFH, highlighting its effectiveness and safety in treating pregnant women with VTE.

Characteristics of Patients Hospitalized to Community Hospitals With Malignant Brain Tumors and Factors Associated With Discharge Destination.

Our main objective was to compare the characteristics and hospital outcomes of patients with primary and metastatic brain malignancies and to investigate the associated factors related to hospital outcomes. We conducted a retrospective, cross-sectional study of 1628 patients with brain malignancies from 8 community hospitals between 2017 and 2022 who were identified using International Classification of Disease codes. A stepwise logistic regression was used to identify demographics and clinical characteristics associated with in-hospital mortality and home discharge. The median age was 65 years old, with 72.5% of patients having metastatic brain malignancies. After 7.2 days of hospital stay, 49.2% were discharged home, and 102 patients expired during hospitalization. Increased age, medical coverage by Medicare, hemiplegia or paraplegia, lower initial hemoglobin level, increased length of stay, and the use of electrolyte replacement, antibiotics, laxatives, heparin, and anticonvulsants were associated with a decreased likelihood of discharge to home. No medical insurance, Medicaid insurance coverage, comorbidities of cerebrovascular disorder, the need to stay in the intensive care unit, patient safety indicator events, and the use of antibiotics, oral analgesics, and ipratropium-albuterol were associated with increased odds of in-hospital mortality. We identified several predictor variables that delineate differences between both mortality risk and home discharge in patients with primary and metastatic brain tumors. Understanding these predictor variables can be helpful in improving the acute and post-acute care of this population.

CONTINUOUS VENO-VENOUS HEMODIAFILTRATION IN MULTIPLE TRAUMA WITH ACUTE RENAL FAILURE

Abstract. Acute kidney injury (AKI) develops in 20 % of multiple trauma victims in intensive care units. In 10 % – 28 % of cases, these victims require renal replacement therapy. The aim of our study was to study the effect of continuous veno-venous hemodiafiltration (CVVHDF) on indicators of kidney function, hemodynamics, homeostasis and inflammation in victims of multiple trauma, complicated by rhabdomyolysis and AKI. Materials and methods. 71 victims with multiple trauma complicated by massive rhabdomyolysis and AKI were examined. The levels of total creatine kinase and myoglobin, indicators of kidney function, frequency of vasopressor support, indicators of general blood count, liver complex, coagulogram, and blood gas were studied. The study was conducted at admission, before and after each CVVHDF session and on the last day of treatment. The results. Multiple trauma with massive rhabdomyolysis resulted in AKI with oliguria, hyperazotemia, and hyperkalemia, as well as cardiovascular failure, anemia, hepatic dysfunction, and an inflammatory response. In the case of progressing renal failure despite conservative therapy, CVVHDF was started on day 2.7±0.5. After 1 session of CVVHDF, hyperazotemia was significantly reduced, and potassium levels were normalized. Indicators of the blood count and liver complex did not change. Due to the use of heparin in the circuit, there was a significant prolongation of activated partial thromboplastin time, which did not exceed the target values. 1 session of CVVHDF was sufficient for 71.8 % of victims. Among the survivors, restoration of diuresis was observed in 63.9 %. The mortality rate was 42.3 %. However, there was no significant difference in azotemia levels between survivors and non-survivors, but non-survivors had higher potassium levels, more severe thrombocytopenia, cardiovascular and hepatic failure, and hypocoagulation. In addition, the ISS score in non-survivors was 37.8 % (p=0.001) higher than in the survivors. Conclusions. Multiple trauma, complicated by massive rhabdomyolysis, causes the development of multiple organ failure, primarily renal. CVVHDF allows to effectively reduce the levels of azotemia and normalize the level of potassium after the first session, while avoiding abrupt fluctuations in the indicators of the function of other organs and systems. A single session of CVVHDF is sufficient to restore renal function in most patients. Mortality remains high and depends directly on the severity of anatomical injuries and the addition of insufficiency of other organs and systems.

The Efficacy and Safety of DOACs in Inherited Antithrombin Deficiency: A Cohort Study from a Tertiary Referral Center.

Individuals with inherited antithrombin deficiency (IATD) have a high risk of venous thromboembolism (VTE). Most VTEs are managed with direct oral anticoagulants (DOACs), but the utility of DOACs in antithrombin deficiency (ATD) is unreported. Patients with IATD treated with DOAC were identified from our institutions' IATD registry. We assessed patients' characteristics, ATD type, and initial VTE characteristics, thrombosis recurrence and bleeding rates. Thirty-three patients received DOACs for 73 (38.5-111.5) months (median (interquartile range)). Prior to taking DOACs, 12 (36%) patients had VTE recurrence: these occurred after anticoagulation was ceased (4), nonadherence to VKA prior to DOAC use (3), or during heparin use in pregnancy (5). There were no VTE recurrences on standard-dose DOAC, except in a noncompliant patient receiving dabigatran. There was one recurrence with compliant DOAC use-a patient receiving rivaroxaban 10 mg. Six (18%) patients experienced clinically relevant bleeding, which was predominantly menorrhagia (5/6). One major bleeding event, intracranial hemorrhage, occurred in a patient receiving full-dose rivaroxaban who had refractory hypertension (0.5 events/100 patient-years). In this cohort, compliant DOAC users had an overall VTE recurrence rate of 0.5/100 patient-years, whereas with low-dose DOACs the event rate was 3.5/100 patient-years. Standard-dose DOACs appear efficacious and relatively safe in IATD.

Impact of an updated venous thromboembolism prophylaxis guideline in critically ill trauma patients on rates of venous thromboembolisms

IntroductionThe objective of this analysis was to evaluate differences in incidence of venous thromboembolisms (VTE) in critically ill trauma patients between pre- and post-implementation of updated VTE prophylaxis guidelines. MethodsThis was a pre-post analysis of critically ill trauma patients receiving pharmacologic VTE prophylaxis. Trauma patients were included if they had an intensive care unit admission during their hospitalization. The primary outcome was incidence of detected VTE and was analyzed using a Chi-Squared test. A multivariate analysis assessed the effects of guideline implementation on VTE development when controlling for confounders. ResultsThere were 220 patients included. There was a significant increase in low molecular weight heparin use in initial (p ​= ​0.003) and final (p ​= ​0.004) prophylactic regimens between groups. There was no significant difference in VTE incidence between the pre and post groups (6.3% vs 1.9%, p ​= ​0.10). The multivariate analysis showed guideline implementation was independently associated with an 88% reduced odds of VTE (p ​= ​0.04). ConclusionThis analysis suggests the updated VTE prophylaxis guideline implementation was associated with a trend toward reduced VTE development among critically ill trauma patients.

Pre-hospital heparin is not associated with infarct vessel patency and mortality in ST-segment elevation myocardial infarction patients with out-of-hospital cardiac arrest.

Pre-hospital heparin administration has been reported to improve prognosis in patients with out-of-hospital cardiac arrest (OHCA). This beneficial effect may be limited to the subgroup of ST-segment elevation myocardial infarction (STEMI) patients. To assess the impact of pre-hospital heparin loading on TIMI (Thrombolysis in Myocardial Infarction) flow grade and mortality in STEMI patients with OHCA, we analyzed data from 2,566 consecutive patients from two hospitals participating in the prospective Feedback Intervention and Treatment Times in ST-segment Elevation Myocardial Infarction (FITT-STEMI) trial. In 394 participants with OHCA, 272 (69%) received heparin from the emergency medical service (EMS). Collapse witnessed by EMS (odds ratio (OR) = 3.53, 95%-confidence interval (CI) = 1.54-8.09; p = 0.003) and pre-hospital ECG recording (OR = 3.32, 95% CI = 1.06-10.35; p = 0.039) were identified as parameters significantly associated with pre-hospital heparin use. In univariate analysis, in-hospital mortality was lower in the group receiving heparin in the pre-hospital setting (26.8% vs. 42.6%, p = 0.002). However, in a regression model, pre-hospital heparin use was no longer a significant predictor of mortality (OR = 0.992; p = 0.981). Patency of the infarct artery prior to coronary revascularization, as measured by TIMI flow grade, was not associated with pre-hospital administration of heparin in OHCA patients (OR = 0.840; p = 0.724). In STEMI patients with OHCA, pre-hospital use of heparin is neither associated with improved early patency of the infarct artery nor with a better prognosis. Our results do not support the assumption of a positive effect of heparin administration in the pre-hospital treatment phase in STEMI patients with OHCA. ClinicalTrials.gov: NCT00794001.

Timing Matters: Ultra-Early and Early versus Late Thromboprophyaxis Following Spontaneous Intracerebral Hemorrhage: A Systematic Review and Meta-Analysis.

Spontaneous intracerebral hemorrhage (ICH) represents a critical and potentially devastating medical event resulting from the rupture of intracerebral vessels. Patients afflicted with ICH face an increased risk of venous thromboembolism (VTE) due to factors such as immobility. However, determining the ideal timing for initiating venous thromboembolism thromboprophylaxis (TP) remains uncertain, as it may carry the potential risk of exacerbating hematoma expansion. Thus, our objective was to ascertain the optimal timing for initiating TP following ICH through a comprehensive systematic review and meta-analysis.This systematic review and meta-analysis were performed following the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement guidelines, considering outcomes based on the time of intervention: Ultra early (UEPT) < 24h, Early (EPT) < 48h, Late (LPT) > 48h to perform an analysis on hematoma expansion and mortality.Of 2.777 Hematoma expansion was not more frequent in the 440 patients receiving UEPT/EPT (n = 440) versus 565 receiving LPT (Odds ratio (OR) 0.94 (95% CI; 0.62 to 1.43; I2 = 0%)). Similarly, mortality was not lower in the 293 received UEPT or EPT versus 477 receiving LPT (OR 0.63 (95% CI; 0.39 to 1.0; I2 = 0%).This study, through a systematic review and meta-analysis, conclusively found no difference in intracranial hematoma expansion and/or increased mortality between the use of heparin in the early thromboprophylaxis (< 48h) group compared to the late thromboprophylaxis (> 48h) group. Implementing this approach in the management of spontaneous cerebral hemorrhage could facilitate progress towards more optimal care protocols.

Community-Acquired Bacterial Meningoencephalitis: The New Guideline

Updating the vaccination recommendations against meningococci and pneumococci, in particular the introduction of the B vaccine as the standard vaccination for infants from January 2024 and the adaptation of the pneumococcal vaccination strategy for infants and adults aged 60 and over with the latest conjugate vaccines (PCV13, PCV15, PCV20).Emphasis on the need for rapid diagnostic lumbar puncture and simultaneous serum and cerebrospinal fluid analysis to increase diagnostic precision. The introduction of procalcitonin (PCT) in serum as an additional biomarker to differentiate between bacterial and viral meningitis.The use of multiplex PCR as a supplement, not a replacement, for standard diagnostics to speed up pathogen identification.Adaptation of antibiotic recommendations based on the current resistance situation, in particular for meningococcal meningitis, consideration of penicillin G only after resistance testing.Clarification of the areas and duration of use of dexamethasone in bacterial meningitis, particularly in pneumococcal meningitis and the controversial data situation in Listeria meningitis.New findings on the safe use of heparin in septic sinus thrombosis without increased risk of hemorrhage.

Hepatitis E Virus in Individuals Undergoing Heparin Therapy: An Observational Serological and Molecular Study.

Heparin is derived from swine and has been suggested as a possible source of HEV. To study the potential risk of HEV infection associated with heparin treatment, two groups of individuals were compared. Sera from heparinized (N=93) and non-heparinized individuals (N=111) were tested for markers of acute HEV infection and anti-HEV IgG seroprevalence. An acute HEV case was defined by the presence of anti-HEV IgM and/or HEV RNA. From the 93 heparinized individuals, one was positive for IgM and IgG anti-HEV and two were positive for HEV RNA (for both ORF3 and ORF2), and there were a total of two (2.2%) cases of current or recent HEV infection. From the 111 non-heparinized individuals, three were positive for IgM anti-HEV, one was positive for both IgM and IgG anti-HEV, and none was positive for HEV RNA, and there were a total of three (2.7%) cases of current or recent HEV infection. The difference between HEV cases in the heparinized individuals and the non-heparinized individuals was not statistically significant (2.2% vs. 2.7%; p = 0.799). Concerning IgG anti-HEV, it was detected in 32 individuals from the heparinized group and in 18 from the non-heparinized control group. A statistically significant difference was observed in the presence of anti-HEV IgG in heparinized individuals and controls (p = 0.003). This study has not found any association between heparin treatment and acute HEV infection, but has shown the use of therapeutic heparin as a risk factor for IgG anti-HEV seropositivity.

Incidence of Thrombocytopenia After Enoxaparin and Heparin Taking in Hospitalized Patients

Background: Heparin is the most common administered anticoagulant in hospitalized patients. Thrombocytopenia can occur after heparin s administered in these patients. This study was conducted to determine the incidence of thrombocytopenia in patients treated with heparin and their clinical outcomes. Methods: In this descriptive cross-sectional study, 754 patients admitted to Shahid Beheshti Hospital in Hamadan, Iran, who were treated with heparin were examined for the incidence of thrombocytopenia during 2022-2023. Data were extracted from the medical records of the patients and analyzed using SPSS software version 26. Results: Among the patients, 50.4% were male, and 49.6% were female. The mean and standard deviation of the age of the patients were 63.12±16.82 years. Platelet counts before and after heparin administration were 244.75±79.64 and 207.66±83.39×103 /µL, respectively. The frequency of thrombocytopenia in patients was 25.5%. The incidence of thrombocytopenia was 29.5% and 21.4% in men and women, respectively (P=0.011), and 19.3% and 28.1% of patients received enoxaparin and heparin, respectively (P=0.010). The mean age of patients with thrombocytopenia was 67.25±15.10 years compared to 61.61±17.17 years for those without thrombocytopenia (P&lt;0.001). Furthermore, the length of stay in the hospital for patients with and without thrombocytopenia was 36.12±52.16 and 20.9±6.45 days, respectively (P=0.015). Moreover, the mortality rate was 35.34% and 10% in patients with and without thrombocytopenia, respectively (P&lt;0.001). Conclusion: About a quarter of patients developed thrombocytopenia within 72 hours after receiving heparin. A significant relationship was observed between thrombocytopenia incidence and older age, female gender, and heparin use. Additionally, thrombocytopenia was significantly associated with increased hospital stay duration and higher mortality.