High Risk Of Thromboembolic Complications Research Articles

Challenges in managing severe homozygous protein c deficiency: a case report.

Protein C deficiency is a rare autosomal recessive disorder associated with a high risk of thromboembolic complications. This case report describes the challenges in managing a 23-year-old woman with severe homozygous protein C type 1 deficiency diagnosed since early infancy. Her medical history included misdiagnosed cellulitis, recurrent thrombosis, and permanent vision loss in one eye. The laboratory workup confirmed a diagnosis of severe protein C deficiency. Management involved a combination of fresh frozen plasma (FFP), protein C concentrate, warfarin, and heparin, with ongoing challenges due to recurrent thrombosis and anaphylaxis to FFP. This case highlights the challenges in the diagnosis and management of severe protein C deficiency. Although current treatment options provide partial control, further research is crucial to develop safer and more effective therapies to improve long-term outcomes for affected patients.

Atrial fibrillation and COVID-19: an analysis of the ambulatory database.

Atrial fibrillation (AF) is the most common heart rhythm disorder in clinical practice. It worsens the quality of life of patients, leads to an increase in the mortality rate because of its association with a high risk of thromboembolic complications. The current pandemic of a new coronavirus infection, which began in March 2020, was marked by an increase in cardiovascular diseases, including an increase in the number of patients with AF. That is why it is extremely relevant to find answers to questions about the association and mutual influence of AF and coronavirus infection to reduce the risk of vascular complications. However, most research in this area has focused on hospital patients. In this study, an electronic database of outpatients with AF, including patients with a history of COVID-19 infection was analyzed in order to assess the most significant risk factors for complications.

Safety and efficacy of apixaban vs. enoxaparin in thromboprophylaxis after spinal stenosis and degenerative spine surgery

IntroductionDegenerative spine surgeries often require postoperative immobilization or reduced mobility, predisposing patients to the formation of thrombosis and higher risk of thromboembolic complications. Despite the significance of this issue, there remains a lack of consensus on the optimal anticoagulant agent for postoperative thromboprophylaxis in spinal stenosis and degenerative spine surgeries. Low molecular weight heparins and direct Xa inhibitors represent two anticoagulant groups with high chemoprophylactic potential. MethodsThis study included a prospective cohort of patients undergoing posterior decompressive surgery with or without instrumentation for degenerative spine disease and/or spinal stenosis. Patients receiving postoperative prophylactic Enoxaparin and Apixaban were selected to evaluate the rate of complications, as assessed by Clavien-Dindo classification, thromboembolic events, and 30-day mortality, readmission, and reoperation rate between the two anticoagulants. Results130 patients were included in the analysis. 65 patients received Apixaban and Enoxaparin in each group. Mean age of the participants was 57.6±11.0. 83.1% underwent laminectomy and posterior spinal fusion, while 22 patients underwent decompressive surgery only. The incidence of venous thromboembolism (P-value=0.403), deep vein thrombosis (p-value=0.999), hematoma formation (p-value=0.403), surgical site infection (p-value=0.901), readmission (p-value=0.545), reoperation (p=0.510), mortality (p=0.648), and complications rate (p-value=0.232) were not statistically different between Enoxaparin and Apixaban. DiscussionBoth Apixaban and Enoxaparin may be viable options for postoperative thromboprophylaxis in spine surgeries with comparable efficacy and safety profile. Future research endeavors should investigate the efficacy of these agents in comparison to placebo in a randomized setting.

Chronic Kidney Disease is a Predictor of Recurrent Bleeding in Patients With Atrial Fibrillation After Resuming Anticoagulant Therapy (based on REGistry of Long-term AnTithrombotic TherApy (REGATA-2).

Patients with atrial fibrillation (AF) at high risk of thromboembolic complications who have had bleeding should strive to resume anticoagulant therapy. Existing traditional scales for assessing the risk of hemorrhagic complications are not highly specific for the risk of recurrent bleeding. Thus, searching is needed for clinical and laboratory predictors to identify patients who require a personalized monitoring regimen. The aim of the study was to assess the incidence rate and predictors of recurrent major and clinically significant bleeding in patients with AF after resumption of the anticoagulant therapy, as well as the contribution of changing the anticoagulant to the treatment safety. Based on a 5-year follow-up of 95 patients with AF who have had major and clinically significant bleeding, the incidence and clinical factors determining the recurrence of hemorrhagic complications were assessed.Results According to the data of the 5-year follow-up, the recurrence rate of major/clinically significant bleeding was 16.9/100 patient-years. Changing the oral anticoagulant significantly reduced the risk of relapse after clinically significant bleeding and did not affect the risk of recurrence of major bleeding. The predictor for relapse of major/clinically significant bleeding during the therapy resumption was chronic kidney disease with a decrease in creatinine clearance to less than 60 ml/ min, which increased the risk of relapse 2.27 times (95% confidence interval: 1.1253-4.6163; p=0.0221). The development of serious bleeding in a patient at high risk of thrombotic complications always requires a reassessment of risk factors and an adequate choice and dosage of the anticoagulant. Development of a unified protocol for the management of AF patients receiving anticoagulants and having a high risk of bleeding is essential and will reduce the risk of adverse outcomes.

Circulating Tumor DNA and Risk of Venous Thromboembolism in Locally Advanced Rectal Cancer

Venous thromboembolism (VTE) is a common complication in cancer patients, which negatively affects treatment delivery and, consequently, prognosis. The pathophysiology of cancer-associated thrombosis (CAT) is extremely complex, relying on cytokine release in response to interactions between tumor cells and macrophages, thus leading to endothelial damage and activation of coagulation. Several risk factors may contribute to VTE risk, including tumor types, advanced stage, and anti-cancer treatments. Anti-angiogenic agents or combination of systemic chemotherapy and concomitant radiotherapy (CT-RT), for instance, are well-established risk factors across different malignancies. Colorectal cancer (CRC) is not listed as a high-risk VTE tumor according to pivotal risk assessment models, although retrospective studies showed a VTE rate of around 20%. Consequently, considering the high prevalence of the disease, VTE in CRC represents a main burden in terms of morbidity, increased healthcare costs, and mortality. Rectal cancer (RC) comprises approximately 30% of all CRC. The treatment of locally advanced disease (LARC) consists of a multimodal approach which includes chemotherapy, radiotherapy, and surgery. In the context of CRC management, circulating tumor DNA (ctDNA) is a fast-growing tool able to detect minimal residual disease, useful for improving patients' stratification and prognosis. Moreover, its determination at the time of diagnosis may represent a surrogate of tumor burden, potentially increasing the risk of VTE compared to ctDNA negative patients. Due to the paucity of prospective data of VTE in LARC, the aim of this analysis is to describe the rate of VTE and the potential association between ctDNA levels at baseline and VTE occurrence. We conducted a prospective observational study enrolling patients with LARC managed with neoadjuvant CT-RT (capecitabine 1650 mg/m2 concomitant with 50,4 Gy pelvic long course radiotherapy), surgery, plus/minus adjuvant chemotherapy at European Institute of Oncology (IEO) between November 2014 and November 2019. Blood samples for ctDNA were obtained at pre-planned timepoints: baseline (T0), end of CT-RT (T1), after surgery (T2), end of adjuvant chemotherapy (T3). ctDNA was extracted from plasma and mutations detected on tumor biopsy (KRAS, NRAS, BRAF, PIK3CA) were evaluated on ctDNA. Among other clinical information, VTE events were collected, including pulmonary embolism (PE), deep vein thrombosis (DVT) and visceral venous thrombosis (VVT). VTE was counted when occurred after or whitin 30 days before LARC diagnosis. The ctDNA value, defined as variant allele frequency (VAF) in a targeted mutation, was analyzed for correlation with clinical outcomes and VTE events. Median baseline ctDNA value was set as threshold to subdivide patients in VAF high and VAF low. We enrolled 111 patients. Sixty-one (55%) patients harboring tumoral tissue mutations underwent liquid biopsy. KRAS mutation was the most frequent one (42%), followed by NRAS (7%) and PIK3CA (5%). Fifty-one patients (83%) had a clinical node positive disease. Baseline Khorana Score (KS) was 0 in 54 patients (88%) and 1 in 7. Median ctDNA value at T0 was 0.11 ng/2ml (range: 0.00 - 17.40). After a median follow up of 82 months, 9 VTE events (15%) were diagnosed, 4 PE, 3 DVT and 2 VVT. The median time from diagnosis to VTE event was 14 months (IQR 6 - 51). VTE occurrence was associated with VAF high at baseline, even though not statistically significant (Hazard Ratio [HR]: 2.85; 95% CI: 0.71-11.4, p value = 0.14). Looking specifically at KRAS mutant patients, 6 VTE events were observed, all experienced by VAF high patients (HR not estimable, p value = 0.001). Considering the overall population, VTE rate was 14% and no statistical differences were observed for VTE development according to mutational profile. In our prospective study on LARC patients, VTE was associated with high levels of ctDNA at diagnosis, although not statistically significant. However, the association was significant in KRAS mutant tumors, which may represent a subset of patients with higher risk of thromboembolic complications. Prospective translational studies using deeper molecular techniques and wider populations are required to define the role of ctDNA as additional predictive tool to stratify VTE risk in cancer patients.

ФАКТОРЫ ТРОМБОЭМБОЛИЧЕСКОГО РИСКА У ПАЦИЕНТОВ ТЕРМИНАЛЬНОЙ СТАДИЕЙ ХБП С ДИАЛИЗНОЙ ТЕРАПИЕЙ И НЕКЛАПАННОЙ ФИБРИЛЛЯЦИЕЙ ПРЕДСЕРДИЙ ПО CHA2 DS2 -VASc И УРОВНЮ D-ДИМЕРА

Introduction. Patients suffering from end-stage chronic kidney disease have a high risk of developing rhythm disorders, such as atrial fibrillation, and variations in the hemostatic system. There are only limited options to use the drug-based prophylaxis of thromboembolic complications in patients of this category. Aim. Our study aimed to compare the risk factors of developing thromboembolic complications in end-stage chronic kidney disease (CKD) patients with non-valvular atrial fibrillation, receiving renal replacement therapy, by their CHA2 DS 2-VASc and D-dimer levels. Materials and Methods. A prospective study was conducted on 143 end-stage CKD patients receiving extracorporeal renal replacement therapy in a single dialysis center. In patients with a high risk of thromboembolic complications, the most common signs were found according to the CHA2 DS 2-VASc scale. After examining hemostasis parameters, patients were divided into groups with normal and high D-dimer levels. Logistic and correlation analyses were performed according to the significantly different characteristics studied. Results and Discussion. Non-valvular atrial fibrillation was detected in 36 patients (25.17%), of which a high risk of thromboembolic complications was identified in 15 patients (41.7%). Risk of thromboembolic complications in combination with the high D-dimer level was observed in 7 patients (19.4%). Conclusions. Signs of high thromboembolic risk at the CHA2 DS 2-VASc scale were as follows: Arterial hypertension, vascular diseases, age, and female gender. A high level of D-dimer was closely associated with “dialysis experience,” C-reactive protein and ferritin levels, the primary nosology nature, and the fact of vascular access thrombosis. Assessment level using the CHA2 DS 2-VASc scale did not significantly correlate with an increased level of D-dimer.

Perioperative continuation or ultra-early resumption of antithrombotics in elective neurosurgical cranial procedures.

Discontinuation of antithrombotics (AT) prior to elective cranial procedures is common practice, despite the higher risk of thromboembolic complications in these patients. The aim of this study was to investigate the risks and benefits of a new perioperative management protocol of continuation or ultra-early AT resumption in elective cranial procedures. This study was an analysis of a prospectively collected cohort of patients undergoing elective cranial surgery with (AT group) and without (control group) AT. For extraaxial or shunt surgeries, acetylsalicylic acid (ASA) was continued perioperatively. For intraaxial pathologies, ASA was discontinued 2 days before surgery and resumed on postoperative day 3. All other AT were discontinued according to their pharmacokinetics, and resumed on postoperative day 3 after unremarkable postoperative imaging. Additionally, the authors performed a retrospective analysis of patients with AT who underwent surgery before implementation of this new AT management protocol (historical AT group). Primary and secondary outcomes were the incidence of hemorrhagic and thromboembolic complications within 3 months after surgery. Outcomes of 312 patients were analyzed (83 [27%] in the AT group, 106 [34%] in the control group, and 123 [39%] in the historical AT group). For all 3 patient groups, the most common type of surgery was craniotomy for intraaxial tumors (14 [17%] in the AT group, 28 [26%] in the control group, and 60 [49%] in the historical AT group). The most commonly used AT were ASA (38 [46%] in the AT group and 78 [63%] in the historical AT group), followed by non-vitamin K oral anticoagulants (32 [39%] in the AT group and 18 [15%] in the historical AT group). The total perioperative discontinuation time in the AT group was significantly shorter than in the historical AT group (median of 4 vs 16 days; p < 0.001). The rate of hemorrhagic complications was 4% (95% CI 1-10) (n = 3/83) in the AT group, 6% (95% CI 2-12) (n = 6/106) in the control group, and 7% (95% CI 3-13) (n = 9/123) in the historical AT group (p = 0.5). The rate of thromboembolic complications was 5% (95% CI 1-12) (n = 4/82) in the AT group, 8% (95% CI 3-15) (n = 8/104) in the control group, and 7% (95% CI 3-13) (n = 8/120) in the historical AT group (p = 0.7). The presented perioperative management protocol of continuation or ultra-early resumption of AT in elective cranial procedures does not seem to increase the hemorrhagic risk. Moreover, it appears to potentially protect patients from thromboembolic complications.

Некоторые особенности лабораторных показателей у пациентов с SARS-CoV-2 на фоне избыточной массы тела и ожирения

INTRODUCTION: The data of SARS-CoV-2 pandemic studies indicate a pronounced influence of overweight and obesity on the course of the new coronavirus infection and the risk of lethal complications. In this regard, of particular interest are the changes in the parameters of the main routine diagnostic complex identified in patients with SARS-CoV-2 infection having excess body weight and obesity, and also the search for pathophysiological relationships between these changes and the excess body weight. AIM: To evaluate the changes in the parameters of systemic inflammation and coagulogram, as well as of the peripheral blood leukocyte count in patients with COVID-19 with excess body weight and obesity. MATERIALS AND METHODS: 73 patients with PCR-positive result for SARS-CoV-2 in the age group of 44–65 years old admitted to the infectious diseases department of Semashko Republican Clinical Hospital were examined. The patients were divided into 3 clinical groups depending on body mass index (BMI): Group 1 — patients with BMI &lt; 25 kg/m2, Group 2 — patients with excessive body weight, and Group 3 — patients with 1st degree obesity. On admission to the hospital, the patients underwent the general blood analysis, analysis of C-reactive protein (CRP) level, erythrocyte sedimentation rate (ESR), ferritin, coagulogram parameters, as well as a computer tomography (CT) of the chest organs. RESULTS: All the patients with new coronavirus infection had significantly higher parameters of systemic inflammation (CRP and ferritin) compared to the control group (p &lt; 0.05). The group of patients with 1st degree obesity recorded the highest absolute numbers of band and segmented neutrophils, ferritin, and D-dimer (р1–3 &lt; 0.05; р2–3 &lt; 0.05). The levels of ESR, CRP, and fibrinogen were significantly higher in the overweight and obese groups, but no significant differences between groups 2 and 3 were found in the intergroup comparisons (р1–2 &lt; 0.05; р1–3 &lt; 0.05; р2–3 &gt; 0.05). The values of activated partial tromboplastin time and thrombin time did not differ significantly between the clinical groups (p &gt; 0.05). It is also worth noting that the percentage of pulmonary tissue lesions according to CT data varied significantly depending on BMI, with the highest rate in the group of patients with 1st degree obesity (p &lt; 0.05). CONCLUSIONS: Obese patients with COVID-19 have higher level of inflammation and a high risk of thromboembolic complications, which requires more careful monitoring of this category of patients during the course of the disease and in the post-COVID period.

CONDITION OF THE BLOOD COAGULATION SYSTEM AND RISK OF VENOUS THROMBOSIS AND EMBOLISM IN ACUTE CALCULOUS CHOLECYSTITIS AND ITS COMPLICATIONS

Background. Acute calculous cholecystitis (ACC) is one of the most frequent causes of urgent hospitalization in general surgical departments. It is known that the pathways of inflammation and coagulation are closely related. The most striking manifestation of a violation of hemostasis and rheology under the influence of the inflammatory process is the development of hypercoagulation in acute cholecystitis.&#x0D; Aim: determine the condition of the blood coagulation system and assessing the risk of venous thrombosis and embolism (VTE) during treatment of patients with acute calculous cholecystitis and its complications.&#x0D; Materials and methods. The design of the study was retrospective analysis of the results of treatment of 206 patients with acute calculous cholecystitis (ACC) and its complications in the Department of surgery and endoscopy of Postgraduate education faculty, Lviv Danylo Halytsky national medical university (at Municipal non-profit enterprise "1st Territorial medical association of Lviv", St. Panteleimon hospital) for the period 2014-2018. Women predominated – 135 (65.5%). Age distribution of patients ranged 18-90 (average – 60.8±15.83). The length of stay of patients in the hospital ranged 1-41 days. Following forms of ACC were: phlegmonous – 86 (41,7%), gangrenous – 115 (55,8%), perforated – 5 (2,4%) patients.&#x0D; Results. Of the entire cohort, cholecystomy was performed in 190 (92.2%) patients, of which 129 (62.6%) underwent laparoscopic and 61 (29.6%) – conventional. Cholecystectomy lasted from 15 min to 1.5 hours (average duration 65±46.15 min). During the laboratory examination in patients with complicated ACC, coagulation system was studied, in which the presence of normocoagulation was detected in 19.2% of patients, hypocoagulation – in 30.4% and hypercoagulation – in 50.4%. Examination of the hemostasiogram in patients with complicated ACC revealed hypocoagulation with the following parameters: prothrombin time – 17”, prothrombin index – 74.2%, fibrinogen – 2.63 g/L; hypercoagulation with the following indicators: prothrombin time – 6.5”, prothrombin index – 130.2%, fibrinogen – 6.5 g/L. The risk of VTE in the treatment of patients with ACC and its complications was assessed by the J. Caprini scale and found that the vast majority (over 71.8%) of patients have a high and very high risk of thromboembolic complications, namely: low risk – 5.8%; average – 12.6%; high – 45.2%; very high – 36.4%.&#x0D; Conclusion. Hypercoagulation is present in 79.3% of patients with uncomplicated and complicated ACC. The appearance of complications of ACC leads to the development of hypercoagulation in 50.4% of patients. Number of patients with complicated ACC with an extremely high risk of VTE according to J. Caprini scale significantly exceeds (p&lt;0,05) the number without complications and is 52.2%. Inclusion of test for blood D-dimers in the examination protocol and ultrasonographic scanning of the veins of the lower extremities will facilitate the early detection, prevention and treatment of VTE.

Optimal management of long-term air leakage after lung resections for cancer

Lung resection is the main diagnostic and therapeutic surgical intervention in terms of lung cancer management. Air leak through pleural drains often occurs after lung resections due to damage to the pulmonary parenchyma. Therefore, proper drainage of the pleural cavity is very important for the successful outcome of the operation. The installation of a single pleural drainage after anatomical resection, the refusal to use vacuum aspiration and the earliest possible removal of drains contribute to the rapid activation of patients in the postoperative period. Prolonged air leakage (PAL) after lung resection, on average, develops in 15 % of lung cancer patients, remaining one of the most common complications adversely affecting the rehabilitation of patients and leading to delayed discharge from the hospital. The incidence of empyema with prolonged air leakage is 10.4 % with air discharge for more than 7 days compared to 1 % with air leaks less than or equal to 7 days. PAL requires prolonged drainage of the pleural cavity, which increases postoperative pain, causing shallow breathing, difficulty coughing leads to an increased risk of pneumonia, decreased mobility is accompanied by a high risk of thromboembolic complications. In addition, the treatment of complications is associated with the need to perform additional invasive interventions such as chemical or mechanical pleurodesis. Prolonged air leakage is associated with an increase in hospital mortality. Patients with an air leak have a 3.4 times greater risk of death than patients without it. Active tactics in relation to PAL include preoperative prediction of a high risk of complications, intraoperative measures to prevent air leak from the lung parenchyma and postoperative treatment to reduce the duration of PAL. The urgency of the problem is due to the fact that prolonged air leakage in patients with lung cancer after organ-preserving operations is associated with an increased risk of infectious complications due to the need for prolonged drainage of the pleural cavity. In this review, the main attention is paid to two components of postoperative management of PAL: diagnosis with an accurate assessment of the intensity of air leak and treatment of alveolar-pleural fistulas.

Extracranial Carotid Artery Aneurysms: 20-Year Experience of Surgical Management

Extracranial carotid artery aneurysm (ECAA) is a rare vascularpathology with reported incidence of 0.2-5.0% of all carotid artery surgical interventions. Most of ECAAs remain clinically asymptomatic, however, they can manifest in neurological symptoms as transient ischemic attack or stroke. The presence of a pulsating formation, swallowing disorders, signs of compression of cranial nerves may beindicative of the aneurysm growth, which is associated with higher risk of thromboembolic complications and less oftenwith rupture. Surgical treatment is a method of choice in symptomatic patients or in cases of the aneurysm growth and includes resection with arterial reconstruction, ligation of the artery or endovascular intervention.&#x0D; The aim. To improve the results of surgical treatment of ECAAs.&#x0D; Materials and methods. The results of clinical examination, laboratory, instrumental, intraoperative observations were analyzed in 39 patients (35 [89.7%] men and 4 [10.3%] women) with 44 ECAAs, who were admitted to the Vascular Surgery Department of Lviv Regional Clinical Hospital for the period from 2003 to 2022. To conϐirm the diagnosis of ECAA, preoperative instrumental examination included duplex ultrasonography and multispiral computed tomography angiography.&#x0D; Results. Etiological causes of ECAAs included: atherosclerosis (79.5%),ϐibromuscular dysplasia (7.7%), trauma (5.1%), previous operations in the neck region (5.1%) and infection (2.6%). The justiϐication of the choice of surgical tactics depended on the localization of aneurysm, concomitant carotid occlusive disease or pathological deviation of carotid arteries. Early results of surgical treatment were evaluated up to 30 days of the postoperative period. The postoperative complications included: transient ischemic attack in 1 (2.6%), ischemic stroke in 2 (5.1%), cranial nerve damages in 4 (10.3%), thrombosis of arterial reconstruction in 2 (5.1%), hematoma of postoperative wound in 4 (10.3%), infection of postoperative wound in 1 (2.6%) cases. Postoperative mortality was 2.6%.&#x0D; Conclusion. ECAA is a rare clinical disease that requires an active surgical approach to reduce the risk of ischemic stroke. Reconstructive surgery of ECAAs is a highly effective method of treatment that allows to achieve satisfactory results and prevent the development of severe complications.

Профілактика і прогнозування розвитку плацента-асоційованих ускладнень у пацієнтки з обтяженим тромботичним та акушерським анамнезом (клінічний випадок)

Purpose - to analyze the effectiveness of the timely appointment of pathogenetically justified secondary prevention in a patient with a burdened thrombotic and obstetric anamnesis based on the assessment of the course of pregnancy and the postpartum period in this woman. Clinical case. A woman with fetal loss syndrome and recurrent venous thrombosis applied for a consultation to plan pregnancy. The examination revealed a homozygous polymorphism of the F2-prothrombin gene (-20210 G&gt;A), a decrease in protein S activity to the level of 35%, which indicated an extremely high risk of thromboembolic complications. Pregnancy occurred on the background of anticoagulant therapy in combination with pregravid cofactor vitamin therapy. During pregnancy, the patient received low molecular weight heparins in therapeutic doses in combination with acetylsalicylic acid at a dose of 150 mg per day, diosmin 600 mg and cofactor vitamin therapy. According to the results of combined screening in the I trimester, with the calculation of the risks of preeclampsia, the woman was classified as a high risk group for its development. At 23-24 and 32-33 weeks of gestation, an analysis was performed to calculate the risk of perinatal complications in the II-III trimesters by determining the ratio of water-soluble tyrosine kinase-1 / placental growth factor (Sflt-1/PlGF). The data obtained indicated that the preventive therapy prescribed to the patient was adequate and effective. The pregnancy was completed at the full 37 weeks of gestation by spontaneous delivery in cephalic presentation without complications. A boy was born weighing 2950 g, Apgar score - 7/8. Conclusions. The clinical case is a vivid example of how well-timed, adequate prophylactic therapy can work efficiently and effectively, even in women with a rather burdensome thrombotic and obstetric history. This case confirms the necessity and expediency of using the entire modern diagnostic arsenal that exists in Ukraine to predict the occurrence of «Great» obstetric syndromes, which to this day occupy one of the leading places in the structure of maternal and perinatal losses. The research was carried out in accordance with the principles of the Helsinki Declaration. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors.

Increased Body Mass Index and Risk of Left Atrial Thrombus in Nonvalvular Atrial Fibrillation Patients-Data from the Left Atrial Thrombus on Transesophageal Echocardiography (LATTEE) Registry.

An increased body mass index (BMI) is associated with a higher incidence of atrial fibrillation (AF) and a higher risk of thromboembolic complications in AF patients. The aim of this study was to investigate the effect of BMI on the risk of left atrial thrombi (LATs) in patients with nonvalvular AF/atrial flutter (AFl) (NV AF/AFl). Patients diagnosed with NVAF/AFl (between November 2018 and May 2020) were selected from the multicenter, prospective, observational Left Atrial Thrombus on Transesophageal Echocardiography (LATTEE) registry that included AF/AFl patients referred for cardioversion or ablation followed by transesophageal echocardiography. A total of 2816 AF/AFl patients (63.6% males; mean age 65.8 years; mean BMI 29.8 kg/m2) were included in the study. Two hundred and twenty-two of them (7.9%) had LATs. Compared with normal-weight patients, those with BMIs ≥ 25 kg/m2 more frequently presented clinical factors potentially provoking LATs, such as non-paroxysmal AF/AFl (p = 0.04), hypertension (p < 0.001), and diabetes (p < 0.001); had higher CHA2DS2 scores (p < 0.001); and had larger LA dimensions (LA diameter and LA area) (p < 0.001 for both parameters). On the other hand, they showed some features negatively related to thromboembolic risk; for example, they were younger (p < 0.001) and were more often male (p = 0.002). In addition, patients with abnormal BMIs were more likely to be smokers (p = 0.006) and to be treated with oral anticoagulants (p = 0.005). Despite these differences in the prevalence of thromboembolic risk factors, the incidence of LATs was not increased in patients with abnormal body weight (overweight and obese compared to normal-weight patients) in this large real-life cohort of AF/AFl patients. This is probably due to the balanced composition regarding the prevalence of positive and negative thromboembolic risk factors.

Safety and efficacy of dual antiplatelet therapy combining aspirin and ticagrelor in patients with undergoing intracranial stenting procedures.

Thromboembolic complications are one of the major periprocedural complications following neuroendovascular procedures. Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel remain the principal agents for prevention of thromboembolic complications. However, clopidogrel resistance is associated with higher risk of thromboembolic complications. This study investigated the safety and efficacy of DAPT with ticagrelor and aspirin in patients undergoing intracranial stenting procedures. This retrospective study was based on patients with intracranial aneurysms who undergoing intracranial stenting procedures at our institution between August 2017 and July 2020. These patients received DAPT with ticagrelor and aspirin were included. DAPT with 90 mg ticagrelor twice daily and aspirin 100 mg daily was continued for 3 months after the intracranial stenting procedure and aspirin continued for 1 year. In this study, 151 patients were identified. The most common aneurysm location was the internal carotid artery with 127 (71.8%) patients. Of the 151 cases with 160 treated aneurysms, 30 (18.8%) patients were treated by flow diverters (FDs), and 130 (81.2%) by stent-assisted coiling. Five (3.3%) patients had thromboembolic complications. Intraprocedural aneurysmal rupture was observed in one patient because of coil extrusion during coil insertion. None of the patients showed a newly DAPT-related intracerebral hemorrhage. Two patients developed dyspnea, and the symptom resolved without intervention. Furthermore, ecchymoma and gastrointestinal bleeding occurred in one patient respectively. DAPT-related thromboembolic and hemorrhagic complications were not significantly different between the FD group and stent-assisted coiling group. In our study, DAPT combining ticagrelor and aspirin seems to be a safe and efficient treatment for preventing thromboembolic complications in patients with intracranial aneurysms, without any increase in hemorrhagic complications. Ticagrelor may be an effective alternative for patients undergoing neurointervention.

Rotational thromboelastometry in patients with type 2 diabetes and mild COVID-19 pneumonia: A pilot prospective study.

Background:It was repeatedly demonstrated that patients with severe COVID-19 pneumonia, as well as patients with type 2 diabetes (T2D) have higher risk of thromboembolic complications. Rotational thromboelastometry (ROTEM®) is a viscoelastic hemostatic assay which allows complex assessment of hemostasis in whole blood. The aim of this study was to compare changes in hemostasis measured by ROTEM® in diabetic and nondiabetic patients with mild COVID-19 pneumonia.Methods:We performed a pilot, prospective, observational study and enrolled 33 consecutive patients (14 with T2D and 19 nondiabetic ones) admitted to regular ward with mild COVID-19 pneumonia. The control group consisted from 11 healthy, nondiabetic blood donors. Blood samples were tested with ROTEM® using INTEM® and EXTEM® reagents.Results:We detected significant differences in EXTEM® clotting time (CT), clot formation time (CFT), and maximum clot firmness (MCF) comparing patients with mild COVID-19 pneumonia and healthy donors. However, there were no significant differences in EXTEM®, INTEM®, and HEPTEM® parameters (CT, CFT, and MCF) according to diabetes status.Conclusions:Our study demonstrated hypercoagulation in patients with mild COVID-19 pneumonia. T2D did not affected ROTEM® parameters in patients with mild COVID-19 pneumonia.

Tactics of therapy for acute gastrointestinal bleeding

The number of patients with non-varicose acute gastrointestinal bleeding who needanticoagulants has increased in the last decade. The choice of method and amount of safetherapy in case of acute gastrointestinal bleeding is complicated. A reasonable optimalbalance of therapy between hypo- and hypercoagulant components was determined on thebasis of an objective assessment of risk factors for re-bleeding and thromboemboliccomplications. A council of surgeons, resuscitators and cardiologists decided on therationality of anticoagulant therapy and its scope. With a low risk of recurrent bleeding and ahigh risk of thromboembolic complications, hemostatic therapy (tranexamic acid,ethamsylate) was combined with the introduction of low molecular weight heparin(bemiparin) in prophylactic doses. An important parameter for the appointment ofconservative therapy were thromboelastography. The data obtained indicate the safety ofhemostatic and thromboprophylactic therapy (the level of re-bleeding did not differ from thelevel of bleeding without the use of low molecular weight heparins, according to theliterature). Stroke was observed in only 1 patient. The complexity, multifactorial and diversityof clinical conditions of patients with acute gastrointestinal bleeding indicates the need forfurther study of the treatment problem.

Modern Anticoagulant Therapy for Atrial Fibrillation: Patient Adherence in Clinical Practice

Aim. To assess the adherence of doctors and patients to anticoagulant therapy for atrial fibrillation (AF).Materials and methods. An observational prospective study included 99 patients with AF at high risk of thromboembolic complications in Ryazan and Omsk. To study adherence, a questionnaire for quantitative assessment of treatment adherence ("QAA-25") was used. The questionnaire allows you to assess adherence by three main parameters separately: adherence to drug therapy, lifestyle modification and medical support. For the purposes of the study, adherence rates of less than 75% were regarded as insufficient, 75%. % or more as sufficient. To assess food preferences and determine the risk of changes in the activity of warfarin, a questionnaire of food preferences was used. The questionnaire allows you to assess the risk of alimentary increase (≥30 points) and decrease (≥60 points) of warfarin activity, as well as the overall risk of alimentary change (≥90 points) of warfarin activity in each patient, taking into account the volume and frequency of consumption of products that affect the activity of warfarin.Results. After the first visit, 99% of respondents received anticoagulant treatment. Rivaroxaban was the leader in prescribability among anticoagulants (36.7%). About a third of respondents were prescribed apixaban by a doctor (30.6%) and dabigatran (17.3%) and warfarin (19.4%) were prescribed almost twice as rarely as rivaroxaban. Respondents with the highest rates of adherence to drug therapy, lifestyle modification and medical support are AF patients taking apixaban. The respondents who were prescribed rivaroxaban had the lowest level of adherence to drug therapy and lifestyle modification. And the lowest level of commitment to medical support is among respondents who have been prescribed warfarin. The number of people with a sufficient level of commitment did not reach half. Only 43.9% were ready to take prescribed medications and slightly more than a third (34.7%) agreed to come to appointments for a long time. But, despite the importance of lifestyle modification in patients with AF, only 16.3% of respondents said they were ready to give up bad habits, lose weight and lead a more active lifestyle. The proportion of people with sufficient adherence to drug therapy was the smallest in the group taking rivaroxaban (25.7%). The least number of respondents with sufficient commitment to medical support in the group taking dabigatran (25%). Only one in ten patients (11.1%) taking warfarin had a sufficient level of commitment to lifestyle modification. 15% of the study participants had an increased risk of alimentary changes in the activity of warfarin.Conclusion. Assessment of adherence to anticoagulant therapy by doctors in two regional centers (Omsk and Ryazan) showed high prescribability of preventive antithrombotic therapy, which corresponds to modern therapeutic approaches. At the same time, patients demonstrated rather low levels of adherence to drug therapy, lifestyle modification, and medical support.

Anticoagulation for atrial fibrillation in active cancer (Review)

Atrial fibrillation (AF) may often pre-exist in patients with newly diagnosed cancer or occur with increased frequency shortly after cancer diagnosis. Patients with active cancer and AF have a particularly high risk of thromboembolic complications, as both conditions carry a risk of thrombosis. Thromboembolic risk is determined by several factors, including advanced age, sex (females), cancer histology (adenocarcinomas), location (e.g., pancreas, stomach), advanced stage, anticancer regimens (e.g., platinum compounds, anti-angiogenic therapies, immune modulators), comorbidities (e.g., obesity, kidney disease) and concurrent therapies (e.g., surgery, central catheters). Physicians are often reluctant to prescribe anticoagulants to patients with active cancer and AF, mainly due to fear of bleeding complications, which is partly related to the paucity of evidence in the field. Decision making regarding anticoagulation for the prevention of ischemic stroke and systemic embolism in patients with active cancer and AF may be challenging and should not simply rely on the risk prediction scores used in the general AF population. By contrast, the administration and choice of anticoagulants should be based on the comprehensive, individualized and periodic evaluation of thromboembolic and bleeding risk, drug-drug interactions, patient preferences and access to therapies.

Patients with a Combination of Atrial Fibrillation and Chronic Heart Failure in Clinical Practice: Comorbidities, Drug Treatment and Outcomes

Aim. To assess in clinical practice the structure of multimorbidity, cardiovascular pharmacotherapy and outcomes in patients with a combination of atrial fibrillation (AF) and chronic heart failure (CHF) based on prospective registries of patients with cardiovascular diseases (CVD).Materials and Methods. The data of 3795 patients with atrial fibrillation (AF) were analyzed within the registries RECVASA (Ryazan), RECVASA FP (Moscow, Kursk, Tula, Yaroslavl), REGION-PO and REGION-LD (Ryazan), REGION-Moscow, REGATA (Ryazan). The comparison groups consisted of 3016 (79.5%) patients with AF in combination with CHF and 779 (29.5%) patients with AF without CHF. The duration of prospective observation is from 2 to 6 years.Results. Patients with a combination of AF and CHF (n=3016, age was 72.0±10.3 years; 41.8% of men) compared with patients with AF without CHF (n=779, age was 70.3±12.0 years; 43.5% of men) had a higher risk of thromboembolic complications (CHA2DS2-VASc – 4.68±1.59 and 3.10±1.50; p&lt;0.001) and hemorrhagic complications (HAS-BLED – 1.59±0.77 and 1.33±0.76; p&lt;0.05). Patients with a combination of AF and CHF significantly more often (p&lt;0.001) than in the absence of CHF were diagnosed with arterial hypertension (93.9% and 83.8%), coronary heart disease (87.9% and 53,5%), myocardial infarction (28.4% and 14.0%), diabetes mellitus (22.4% and 7.7%), chronic kidney disease (24.8% and 16.2%), as well as respiratory diseases (20.1% and 15.3%; p=0.002). Patients with AF in the presence of CHF, compared with patients without CHF, were more often diagnosed with a permanent form of arrhythmia (49.3% and 32.9%; p&lt;0.001) and less often paroxysmal (22.5% and 46.2%; p&lt;0.001) form of arrhythmia. Ejection fraction ≤40% (9.3% and 1.2%; p&lt;0.001), heart rate ≥90/min (23.7% and 19.3%; p=0.008) and blood pressure ≥140/90 mm Hg (59.9% and 52.2%; p&lt;0.001) were recorded with AF in the presence of CHF more often than in the absence of CHF. The frequency of proper cardiovascular pharmacotherapy was higher, albeit insufficient, in the presence of CHF (64.9%) than in the absence of it (56.1%), but anticoagulants were prescribed less frequently when AF and CHF were combined (38.8% and 49, 0%; p&lt;0.001). The frequency of unreasonable prescription of antiplatelet agents instead of anticoagulants was 52.5% and 33.3% (p&lt;0.001) in the combination of AF, CHF and coronary heart disease, as well as in the combination of AF with coronary heart disease but without CHF. Patients with AF and CHF during the observation period compared with those without CHF had higher mortality from all causes (37.6% and 30.3%; p=0.001), the frequency of non-fatal cerebral stroke (8.2% and 5.4%; p=0.032) and myocardial infarction (4.7% and 2.5%; p=0.036), hospitalizations for CVD (22.8% and 15.5%; p&lt;0.001).Conclusion. Patients with a combination of AF and CHF, compared with the group of patients with AF without CHF, were older, had a higher risk of thromboembolic and hemorrhagic complications, they were more often diagnosed with other concomitant cardiovascular and chronic noncardiac diseases, decreased left ventricular ejection fraction, tachysystole, failure to achieve the target blood pressure level in the presence of arterial hypertension. The frequency of prescribing proper cardiovascular pharmacotherapy was higher, albeit insufficient, in the presence of CHF, while the frequency of prescribing anticoagulants was less. The incidence of mortality from all causes, the development of non-fatal myocardial infarction and cerebral stroke, as well as the incidence of hospitalizations for CVDs were higher in AF associated with CHF.

Features of atrial fibrillation treatment in a patient with high risk of thromboembolic complications receiving oral anticoagulation

<h3></h3> В статье описан пациент с фибрилляцией предсердий и тромбоэмболическими осложнениями, проявившимися тромбозом ушка левого предсердия на фоне приема оральных антикоагулянтов (ривароксабан 20 мг), а также рецидивирующими нарушениями мозгового кровообращения (дабигатран 150 мг 2 раза в день). Пациенту был имплантирован окклюдер ушка левого предсердия, после чего назначен низкомолекулярный гепарин (эноксапарин натрия 80 мг в сутки) на 45 дней. Учитывая наличие у больного дополнительных факторов риска тромбоэмболических осложнений (остаточный кровоток по данным чреспищеводной эхокардиографии 5 мм, сниженная фракция выброса левого желудочка и повышенный уровень Д-димера), антикоагулянтная терапия была продолжена, что способствовало предотвращению тромбоэмболических осложнений в отдаленном периоде наблюдения.