High Risk Of Thromboembolic Events Research Articles

Prophylaxis Against Thromboembolic Events During Chemotherapy for Germ Cell Cancer.

IntroductionPatients with advanced germ cell tumors (GCT) receiving cisplatin-based chemotherapy have high rates of thromboembolic events (TEE) which can negatively affect their overall survival. While primary TEE prophylaxis during chemotherapy may prevent these events, it is unclear which patients will benefit in this setting.Materials and MethodsA review of PubMed/Medline was conducted in December 2020 and all pertinent articles were evaluated for relevancy and quality of data for inclusion in the review.ResultsStudies on patients receiving initial cisplatin-based chemotherapy for advanced GCT have reported up to a 19% rate of TEE. This high rate may be associated with multiple factors including retroperitoneal lymphadenopathy, advanced clinical stage, high risk Khorana scores and presence of a central line. Large phase III clinical trials have demonstrated the benefit of low-molecular-weight-heparin and direct oral anticoagulants for primary prophylaxis and against recurrent TEE. However, primary prophylaxis is currently underutilized with GCT patients starting chemotherapy.ConclusionPrecise models to predict TEE risk and consideration of anticoagulation are difficult to develop owing to the relatively uncommon nature of GCT and lack of representation in primary TEE prophylaxis clinical trials. Despite these limitations, we believe that the benefits of prophylactic anticoagulation outweigh the risk of major bleeding in select GCT patients with higher risk of TEE. We have developed a simple algorithm to help guide TEE prophylaxis selection based on patient factors and route of chemotherapy administration. Given the high rate of TEE in GCT patients, we believe better utilization of primary prophylaxis in patient starting cisplatin-based chemotherapy will have clinical benefit.

Left atrial reverse remodeling improves sinus restoration following mitral valve replacement: A case report.

IntroductionMitral stenosis is one of the most common abnormalities in rheumatic heart disease (RHD). These patients often experience atrial fibrillation, due to left atrial dilatation, causing a high risk of thromboembolic events; rhythm or heart rate control are thus important treatment strategies. In patients undergoing surgery, sinus rhythm restoration is not fully understood, and not all surgical patients return to sinus rhythm. We report an adult woman with mitral regurgitation who experienced sinus restoration after mitral valve replacement (MVR) surgery.Case presentationA 44-year-old woman presented with chief complaints of orthopnea and shortness of breath during activity for 2 months. Electrocardiography (ECG) revealed atrial fibrillation with normal ventricular response, and echocardiography showed severe mitral stenosis with Wilkins score of 10 (3-2-3-2), moderate mitral and aortic regurgitation due to RHD, moderate tricuspid regurgitation with probable pulmonary hypertension, normal left ventricular systolic function, ejection fraction of 60.5% (biplane). MVR surgery was performed using a mechanical mitral valve. Postoperative ECG found sinus rhythm and first-degree AV block. Postoperative echocardiography found a decreased left Atrial volume index of 70.8 mL/m2, indicating further remodeling of the patient's heart.ConclusionSinus restoration sometimes occurs in patients after MVR. The correction procedure causes minimal anatomical changes, particularly the loss of non-conductive and pathological tissue, followed by hemodynamic changes that eventually lead to the left atrial reverse remodeling mechanism.

Thrombin generation potential is enhanced in systemic sclerosis: impact of selected endothelial biomarkers.

Systemic sclerosis (SSc) is a rare immune-mediated heterogenous entity characterised by excessive tissue fibrosis and vascular injury. Recently, increased risk of thromboembolic events has been documented in that disease. Our aim was to investigate prothrombotic plasma properties together with selected laboratory biomarkers of endothelial injury in SSc. In 56 clinically stable SSc patients and 67 well-matched controls we assessed plasma thrombin generation profile and measured circulating vascular cell adhesion molecule-1 (VCAM-1), cellular fibronectin (cFN), and thrombomodulin, as well as analysed their relationships with disease clinical parameters and autoimmune antibodies profile. SSc was characterised by 18.3% increased endogenous thrombin potential (ETP), 14.5% higher thrombin peak (p<0.001 both, also after adjustment for potential confounders), and similar endothelial damage biomarkers, as compared to controls. Surprisingly, raised thrombin generation was related to the lower thrombomodulin and VCAM-1. Inflammatory markers, factor VIII activity, and blood eosinophilia predicted positively ETP, whereas platelet count and thrombomodulin had negative impact on that parameter in a multiple regression model. Intriguingly, patient group had also 6.7% extended lag-time (p=0.01 after adjustment for confounders) which was independently determined by higher thrombomodulin and cFN, as well as lower VCAM-1. Former cyclophosphamide therapy, thus more severe type of the disease was referred to the increased thrombin generation. SSc is characterised by enhanced thrombin generation potential which might contribute to the higher risk of thromboembolic events in that disease. Endothelium may play hereby an additional role, although large observational and experimental studies are needed to verify this hypothesis.

Evaluation of Hemorrhage Immediately after Extraction and Postextraction in Patients on Oral Anticoagulant Therapy for Last 5 Years

Aim and Objective: The aim of our study was to evaluate hemorrhage immediately after extraction and postextraction in patients on oral anticoagulant therapy for the past 5 years. Materials and Methods: A total of 100 patients, equally divided into study group and control group of 50 patients each, who were on anticoagulant therapy for the past 5 years were included in the study and were assessed for general medical status, drug dosage, indication for anticoagulant therapy, and duration of treatment before being included in the study. Before undertaking any procedure, the international normalized ratio (INR) for each of the patient under study was requested and the study was only performed if INR was within the therapeutic range of 2.0–4.0 for each patient. Any patients with INR outside the therapeutic range, patients with liver disease, patients on other drugs that affect the hemostasis (long-term use of nonsteroidal anti-inflammatory drug, chemotherapeutic and immunosuppressant drugs), and patients who refused to sign the consent for the study were excluded from the study. Results: None of the patients, in study group, had any immediate postoperative bleeding during the 30 min that they were observed after the extractions, and no patient in study group had any bleeding during the first 24 h. One patient from the study group (50-year-old female, INR 3.2) had intermittent oozing on the 3rd day postoperatively, after extractions of lower right 2nd molar. Conclusion: We conclude that hemorrhagic episodes postextraction in patients on anti-coagulant therapy is manageable following atraumatic extraction, hemostatic agents and sutures. Its also concluded that patients on anticoagulant are at high risk of thromboembolic events than postextraction hemorrhage so anticoagulant therapy should be continued without any alteration.

Point of care diagnostic of hypercoagulability and platelet function in COVID-19 induced acute respiratory distress syndrome: a retrospective observational study

BackgroundCoronavirus disease 2019 (COVID-19) associated coagulopathy (CAC) leads to thromboembolic events in a high number of critically ill COVID-19 patients. However, specific diagnostic or therapeutic algorithms for CAC have not been established. In the current study, we analyzed coagulation abnormalities with point-of-care testing (POCT) and their relation to hemostatic complications in patients suffering from COVID-19 induced Acute Respiratory Distress Syndrome (ARDS). Our hypothesis was that specific diagnostic patterns can be identified in patients with COVID-19 induced ARDS at risk of thromboembolic complications utilizing POCT.MethodsThis is a single-center, retrospective observational study. Longitudinal data from 247 rotational thromboelastometries (Rotem®) and 165 impedance aggregometries (Multiplate®) were analysed in 18 patients consecutively admitted to the ICU with a COVID-19 induced ARDS between March 12th to June 30th, 2020.ResultsMedian age was 61 years (IQR: 51–69). Median PaO2/FiO2 on admission was 122 mmHg (IQR: 87–189), indicating moderate to severe ARDS. Any form of hemostatic complication occurred in 78 % of the patients with deep vein/arm thrombosis in 39 %, pulmonary embolism in 22 %, and major bleeding in 17 %. In Rotem® elevated A10 and maximum clot firmness (MCF) indicated higher clot strength. The delta between EXTEM A10 minus FIBTEM A10 (ΔA10) > 30 mm, depicting the sole platelet-part of clot firmness, was associated with a higher risk of thromboembolic events (OD: 3.7; 95 %CI 1.3–10.3; p = 0.02). Multiplate® aggregometry showed hypoactive platelet function. There was no correlation between single Rotem® and Multiplate® parameters at intensive care unit (ICU) admission and thromboembolic or bleeding complications.ConclusionsRotem® and Multiplate® results indicate hypercoagulability and hypoactive platelet dysfunction in COVID-19 induced ARDS but were all in all poorly related to hemostatic complications..

High incidence of thromboembolism in patients with chronic GVHD: association with severity of GVHD and donor-recipient ABO blood group

Chronic graft-versus-host disease (cGVHD) after allogeneic hematopoietic cell transplantation (HCT) is associated with systemic inflammation and endothelial dysfunction, increasing risk for thromboembolic events (TEE). In 145 adult recipients who developed cGVHD after a matched sibling or umbilical cord blood donor HCT from 2010 to 2018, 32(22%) developed at least 1 TEE event, and 14(10%) developed 2 TEE events. The 5-year cumulative incidence of TEE was 22% (95% CI, 15–29%) with a median time from cGVHD to TEE of 234 days (range, 12–2050). Median time to the development of LE DVT or PE was 107 (range, 12–1925) compared to 450 days (range, 158–1300) for UE DVT. Cumulative incidence of TEE was 9% (95% CI, 0–20%), 17% (95% CI, 9–25%), and 38% (95% CI, 22–55%) in those with mild, moderate, and severe GVHD, respectively. Higher risk for TEE was associated with cGVHD severity (hazard ratio [HR] 4.9, [95% CI, 1.1–22.0]; p = 0.03), non-O-donor to recipient ABO match compared to O-donor to O-recipient match (HR 2.7, [95% CI, 1.0–7.5]; p = 0.053), and personal history of coronary artery disease (HR 2.4, [95% CI, 1.1–5.3]; p = 0.03). TEE was not associated with 2-year non-relapse mortality or 5-year overall survival.

28-Year-Old Man With Recurrent Vertigo, Syncope, and Progressive Memory Impairment

28-Year-Old Man With Recurrent Vertigo, Syncope, and Progressive Memory Impairment

Transesophageal Versus Intracardiac Echocardiogram in Patients at High-Risk for Thromboembolic Events Undergoing Atrial Fibrillation Ablation

Objective: To compare safety outcomes in patients at high-risk of thromboembolic events (TE) that underwent atrial fibrillation (AF) ablation with pre-procedural transesophageal echocardiography (TEE) versus intracardiac echocardiogram (ICE). Background: TEE is routinely performed in selected patients undergoing AF ablation, particularly in non-paroxysmal AF and high-risk of TE. Method: Patients at high-risk for TE (CHA2DS2 -VASc >2 and non-paroxysmal AF) were selected from the Montefiore Medical Center prospective AF ablation registry. Rates of left atrial and/or left atrial appendage (LA/LAA) thrombi or cerebrovascular accidents within 48 hours of the procedure and at 30 days follow-up were compared between patients that had LA/LAA screening with TEE vs. ICE. Results: A total of 231 patients [38 (16.5%) warfarin, 120 (59.1%) apixaban, 65 (28.1%) rivaroxaban, and 8 (3.5%) dabigatran] were enrolled. There were no differences between groups regarding baseline demographics. All patients had non-paroxysmal AF and the mean CHA2DS2-VASc was 4.0 {plus minus} 1.1 (TEE: 4.1 +/- 1.0; ICE: 3.9 +/- 1.1, p = 0.42). Forty patients (17.3%) had TEE prior to AF ablation. Of these patients, 14 (35%) had smoke and none (0%) had LA/LAA thrombus. In the ICE group (191 patients, 83%), none (0%) had LA/LAA thrombus or smoke. There were no TE within 48 hours of AF ablation in either group. There was one TE (stroke) in the ICE group (p=0.32) during follow up. Conclusion: TEE may not be necessary when performing AF ablation in patients at high-risk of TE if appropriate peri-procedural anticoagulation and detailed LA/LAA evaluation with ICE is implemented.

Influence of Antiplatelet and Anticoagulant Drug Use on Outcomes after Chronic Subdural Hematoma Drainage.

We aim to describe the outcomes after chronic subdural hematoma drainage (CSDH) management in a large cohort of patients on antithrombotic drugs, either antiplatelets or anticoagulants, at presentation and to inform clinical decision making on the timing of surgery and recommencement of these drugs. We used data from a previous UK-based multi-center, prospective cohort study. Outcomes included recurrence within 60 days, functional outcome at discharge, and thromboembolic event during hospital stay. We performed Cox regression on recurrence and multiple logistic regression on functional outcome. There were 817 patients included in the analysis, of which 353 (43.2%) were on an antithrombotic drug at presentation. We observed a gradual reduction in risk of recurrence for patients during the 6 weeks post-CSDH surgery. Neither antiplatelet nor anticoagulant drug use influenced risk of CSDH recurrence (hazard ratio, 0.93; 95% confidence interval [CI], 0.58–1.48; p = 0.76) or persistent/worse functional impairment (odds ratio, 1.08; 95% CI, 0.76–1.55; p = 0.66). Delaying surgery after cessation of antiplatelet drug did not affect risk of bleed recurrence. There were 15 in-hospital thromboembolic events recorded. Events were more common in the group pre-treated with antithrombotic drugs (3.3%) compared to the non-antithrombotic group (0.9%). Patients on an antithrombotic drug pre-operatively were at higher risk of thromboembolic events with no excess risk of bleed recurrence or worse functional outcome after CSDH drainage. The data did not support delaying surgery in patients on antithrombotic therapy. In the absence of a randomized controlled trial, early surgery and early antithrombotic recommencement should be considered in those at high risk of thromboembolic events.

Platelet Protein-Related Abnormalities in Response to Acute Hypoglycemia in Type 2 Diabetes.

IntroductionPatients with severe COVID-19 infections have coagulation abnormalities indicative of a hypercoagulable state, with thromboembolic complications and increased mortality. Platelets are recognized as mediators of inflammation, releasing proinflammatory and prothrombotic factors, and are hyperactivated in COVID-19 infected patients. Activated platelets have also been reported in type 2 diabetes (T2D) patients, putting these patients at higher risk for thromboembolic complications of COVID-19 infection.MethodsA case-control study of T2D (n=33) and control subjects (n=30) who underwent a hyperinsulinemic clamp to induce normoglycemia in T2D subjects: T2D: baseline glucose 7.5 ± 0.3mmol/l (135.1 ± 5.4mg/dl), reduced to 4.5 ± 0.07mmol/l (81 ± 1.2mg/dl) with 1-hour clamp; Controls: maintained at 5.1 ± 0.1mmol/l (91.9 ± 1.8mg/dl). Slow Off-rate Modified Aptamer (SOMA)-scan plasma protein measurement was used to determine a panel of platelet proteins.ResultsProthrombotic platelet proteins were elevated in T2D versus controls: platelet factor 4 (PF4, p<0.05); platelet glycoprotein VI (PGVI p<0.05); P-selectin (p<0.01) and plasminogen activator inhibitor I (PAI-1, p<0.01). In addition, the antithrombotic platelet-related proteins, plasmin (p<0.05) and heparin cofactor II (HCFII, p<0.05), were increased in T2D. Normalization of glucose in the T2D cohort had no effect on platelet protein levels.ConclusionT2D patients have platelet hyperactivation, placing them at higher risk for thromboembolic events. When infected with COVID-19, this risk may be compounded, and their propensity for a more severe COVID-19 disease course increased.Clinical Trial Registration https://clinicaltrials.gov/ct2/show/NCT03102801, identifier NCT03102801.

Clinical characteristics and outcomes of splenic infarction in cancer patients: a retrospective, single center report of 206 cases

Cancer patients have a high risk of thromboembolic events including splenic infarct (SI). However, risk factors for SI in cancer patients are poorly understood, and the utility of systemic anticoagulation in such patients is uncertain. We performed a retrospective cohort study of all cancer patients with SI treated at Yale New Haven Hospital from 2008 to 2017. Central review of radiology imaging was performed to confirm the diagnosis of SI. Baseline differences in variables among patients with and without recurrent SI were compared using Fisher's exact test, Pearson's χ2 test, and t-test. Multivariable regression models were conducted to identify factors associated with recurrent SI. Of 206 patients with cancer and SI, 42 had a prior venous thromboembolic event, while 29 had atrial fibrillation/flutter. At a median follow-up of 11.4months (range: 0-142.3months), 152 patients underwent follow-up imaging, with only 6 having recurrent SI. The use of anticoagulation after initial SI was associated with a nonsignificant increase in recurrent SI (p = 0.054) and was not associated with development of venous thromboembolism after SI (p = 0.414). In bivariate analyses, the risk of recurrent SI showed a significant association with lower platelet counts (p < 0.001) and with atrial fibrillation/flutter (p = 0.036). In a multivariable logistic regression model, no variables were identified that were associated with a higher risk of recurrent SI. SI in cancer patients is typically an isolated event with low recurrence risk. Anticoagulation use should be guided by other thromboembolic risk factors.

COVID-19 Complicating Perioperative Management of Left Ventricular Assist Device Implantation

IntroductionThe coronavirus 2019 disease (COVID-19) affected almost 40 million people worldwide and caused more than one million deaths. Some conditions are associated with worse prognosis such as heart failure and left ventricular assist device (LVAD) recipients.Case ReportA 31-year-old male patient without comorbidities was admitted due to cardiogenic shock and pneumonia. He required IABP and ECMO. The patient recovered from organ dysfunctions and ECMO was weaned off. He persisted dependent on dobutamine and IABP. Echocardiogram showed severe left ventricular dysfunction and moderate right ventricular dysfunction (RVD), but right heart catheterization revealed no pulmonary hypertension. SARS-CoV-2 RT-PCR was negative and myocardiopathy investigation was inconclusive after endomyocardial biopsy. LVAD implantation was planned as a bridge to transplant. A Heart Mate 3 was successfully implanted. The patient presented fever in the operating room and persisted febrile for 3 days. COVID-19 was suspected and SARS-CoV-2 RT-PCR was positive. He was extubated on 3rd postoperative day (POD) and echocardiogram showed only mild RVD. On 5th POD, he became hypoxemic requiring high flow nasal cannula, and chest X-ray revealed multiple pulmonary bilateral opacities. Antibiotics and corticosteroids were prescribed. Echocardiogram showed severe RVD and hemodynamic instability led to milrinone and dobutamine requirement in maximal doses. On 10th POD endotracheal intubation was required. The patient experienced severe acute respiratory distress syndrome (ARDS) and multiple complications: shock, bacterial pneumonia, hemothorax, pneumothorax due to barotrauma and bloodstream infection. He had no thromboembolic events. After 48 days he was free from mechanical ventilation and from inotropes. Echocardiogram showed moderate RVD and pulmonary artery systolic pressure 35mmHg. After 51 days he was discharged from the intensive care unit and is now in rehabilitation program.SummarySevere cases of COVID-19 are associated with a cytokine storm and a prothrombotic state. LVAD recipients are at particular risk of unfavorable outcomes. Besides the higher risk of thromboembolic events, LVAD recipients are more vulnerable to RVD in the setting of ARDS. This could be particularly critical during the perioperative management of RV failure as presented in this case.

P90.02 BRAF Mutation And Peridiagnosis Thromboembolic Events In Advanced NSCLC Patients

Metastatic lung cancer is associated with an increased risk of thromboembolic events (TEE). Certain molecular subtypes of lung cancer, as patients with tumors harboring ALK or ROS1 gene rearrangements, have been recently associated with higher risk of TEE, in the range of 20-30%. Whether BRAF mutant lung cancer is associated with higher risk of TEE is unknown. We aimed to describe the incidence, characteristics, and time of onset of TEE in advanced BRAF mutant non-small-cell lung cancer (NSCLC) patients. We performed a retrospective search of BRAF mutant advanced NSCLC patients (stage IIIB or greater) diagnosed in our institution between October 2016 and February 2020. BRAF status was assessed by NGS in tissue/plasma or both as part of molecular pre-screening for clinical trials (Oncomine Focus Assay®; FoundationOne®; Guardant360®). Clinicopathologic and molecular data were extracted from electronic medical records. BRAF mutations were annotated and divided into Class I (V600) and Class II/III/VUS (non-V600) using OncoKB database. Venous TEE (deep venous thrombosis [DVT], superficial venous thrombosis [SVT] or pulmonary embolism [PE]) and arterial TEE (myocardial infarction [MI], cerebrovascular accident [CVA], peripheral arterial disease [PAD] or mesenteric ischemia [MIS]), number of events and dates were annotated. BRAF mutation was identified in 11/192 patients (incidence 5.7%): BRAF V600E in 2 cases (1%), and non-V600 in 9 cases (4.7%). Adenocarcinoma was the histology for all the cases. The incidence rate of TEE was 36.4% (4/11 patients). A total of 9 TEE were documented among 4 patients, as 3 of them developed several events, both arterial and venous. The TEE were DVT (n=2), SVT (n=1), PE (n=2), CVA (n=3), MIS (n=1). TEE was the form of disease presentation in 3/4 cases (acute stroke in 2 cases). TEE were found in 1 patient with V600E mutation and in 3 with non-V600. TEE were found more frequently in patients with PS ≥1, low albumin and Khorana score ≥2. Type of treatment was not related to TEE: 1 patient BRAF V600E mutated was treated with dabrafenib + trametinib without TEE, 4 patients were treated with immune-checkpoint inhibitors (1 with TEE) and 2 cases of TEE were detected before the initiation of treatment. Median overall survival was shorter in patients with TEE vs. without-TEE: 2.3 months vs 29 months (p=0.047). BRAF mutant lung cancer could be associated with a higher risk of TEE, both arterial and venous, and worse survival. If these results are confirmed in larger cohorts, prophylactic anticoagulation may be recommended in these patients.

Characterization of risk factors and timing of venous thromboembolism in patients with uterine carcinosarcoma

Objectives: The purpose of this study was to evaluate the timing and risk factors associated with venous thromboembolism in women with uterine carcinosarcoma in a racially and ethnically diverse urban population. Methods: A retrospective cohort study was performed with all women diagnosed with carcinosarcoma from 2005–2018 at Montefiore Medical Center in Bronx, NY. Data regarding patient demographics, medical comorbidities, treatment course, Khorana score and timing of thromboembolic events were abstracted. A Cox proportional hazards model which included time-dependent covariates for treatment course variables was estimated to examine the association between patient-related variables and the incidence and timing of venous thromboembolism. Results: Forty (31%) of 130 included patients developed venous thromboembolism and there were no significant associations between patient demographics, medical comorbidities, or cancer treatment with thromboembolic events. Being within 6 weeks of surgery was associated with a higher hazard of venous thromboembolism (HR 3.8, 95% CI [1.09–13.50], P = 0.04). Thirty-two (80%) patients who developed venous thromboembolism did so outside of the perioperative window. Patients receiving chemotherapy with a Khorana score ≥2 had a significantly increased risk of developing venous thromboembolism (HR 3.5, 95% CI [1.30–9.23], P = 0.01). Conclusions: Patients with uterine carcinosarcoma have a high risk of thromboembolic events throughout the entire disease course and were found to be at greatest risk during the 6 weeks following surgery. Although no patient or treatment-related factors were associated with an increased risk of venous thromboembolism, we found that the Khorana score may be helpful in identifying patients who may benefit from thromboprophylaxis while receiving chemotherapy.

Clinical and functional characteristics of the cardiovascular system in patients with paroxysmal atrial fibrillation

Annotation. Atrial fibrillation (AF) is a potentially dangerous heart rhythm disorder that is diagnosed in 2 % of the population. Patients with AF have a five times higher risk of thromboembolic events. The reason for its appearance is stable coronary heart disease, hypertension, cardiomyopathy, hyperthyroidism. However, a review of recent studies suggests that psychological stress may also be a risk factor for AF paroxysm. The aim of the study was to investigate the clinical, psychological and functional characteristics of the cardiovascular system in patients with paroxysmal AF, considering the anxiety and depressive symptoms. The psychometric method combines the use of materials such as: psychosocial scale L. Reeder’s stress and perceived stress-10; hospital scale of anxiety and depression (HADS) to study the presence and level of affective disorders; PHQ-15 health questionnaire to assess somatization disorders; PHQ-9 health questionnaire to detect mental disorders of the non-psychotic register. The statistical processing of the obtained results was subjected to mathematical and statistical analysis using the computer program STATISTIKA-19 and the package of statistical functions of the program “Microsoft Office Excel”, classical methods of variation statistics. The results of the study show that the appointment of mebicar eliminates the manifestations of astheno-vegetative syndrome. Significantly reduces stress, anxiety and depressive symptoms, improves myocardial conduction and increases its contractility, normalizes lipid profile and electrolyte balance. Thus, the addition of mebicar to the standard of care helped to reduce stress and somatization disorders, reduces the score of anxiety and depression, increases the ejection fraction of the left ventricle and potentiates the manifestations of dyslipidemia. The prospect of clinical research is the feasibility of further implementation of the results in clinical practice.

Novel NSAIDs

Nonsteroidal anti-inflammatory drugs (NSAIDs) are some of the most commonly used drugs to relieve a multitude of pain symptoms.F They are readily available and used extensively. There is a lot of concern about their adverse side effects namely cardiovascular (CV) and gastrointestinal (GI) side effects. It is important to have a good grasp of the pharmacology of these drugs in order to use them safely and effectively. NSAIDs work by inhibiting the cyclooxygenase (COX) enzyme system responsible for production of prostaglandins. Prostaglandins mediate pain inflammation and temperature regulation in the body. NSAIDS can be divided into selective and non-selective types. Three isoforms of COX have been identified COX-1, COX-2 and COX-3. Selective NSAIDs act on these isoforms. COX-1 is anti-inflammatory, COX-2 pro-inflammatory and COX-3, a variant of COX-1, does not produce prostaglandins. The CV side effects of these drugs can be wide ranging and include a rise in blood pressure (BP) and a higher risk of thromboembolic events. Patients also suffer from peptic ulcer disease or bleeding in the stomach as a result of their use. NSAIDs can cause liver and kidney toxicity and should be used with caution in patients with bleeding tendencies. New NSAIDs on the market include; lornoxicam (xefo®), meloxicam (coxflam®), celecoxib (celebrex®), parecoxib (rayzon®) and etoricoxib (arcoxia®). New ways of delivering NSAIDs to the body with minimal or no side effects are being researched. Novel technology in this field includes nano formulated NSAIDs; indomethacin (tivorbex®) and dicofenac (zorvolex), prodrugs and multi action drugs; cyclooxygenase inhibiting nitric oxide donors and hydrogen sulphide releasing drugs. Further exciting innovations are in the pipeline that could change the face of how we use these drugs. Until then they must be used with careful consideration and only if the benefits of use outweigh the risks.

Prophylactic administration of tirofiban for preventing thromboembolic events in flow diversion treatment of intracranial aneurysms

BackgroundFlow diverter (FD) is widely used in the treatment of intracranial aneurysms. However, thromboembolic events (TEs) continue to be the major complications during the periprocedural phase. To evaluate the safety...

Interactions of Key Hematological Parameters with Red Cell Distribution Width (RDW) Are Associated with Incidence of Thromboembolic Events (TEs) in Polycythemia Vera (PV) Patients: A Machine Learning Study (PV-AIM)

Interactions of Key Hematological Parameters with Red Cell Distribution Width (RDW) Are Associated with Incidence of Thromboembolic Events (TEs) in Polycythemia Vera (PV) Patients: A Machine Learning Study (PV-AIM)

COVID-19 and its implications on patient selection for TAVI and SAVR: Are we heading into a new era?

COVID-19 and its implications on patient selection for TAVI and SAVR: Are we heading into a new era?

Thromboembolic complications in adult congenital heart disease: the knowns and the unknowns.

Despite impressive improvement in long-term survival, adults with congenital heart disease (CHD) remain exposed to a significant cardiovascular morbidity over lifetime. Thromboembolic events (TE) are a major issue. Specific anatomic groups have been shown a particular high risk of TE, including cyanotic heart disease and Fontan circulation. Many intercurrent clinical factors add a substantial risk such as intracardiac medical devices, atrial arrhythmia, endocarditis, or pregnancy. Nevertheless, what is unknown exceeds what is known, especially regarding the management of this heterogenous patient population. Anticoagulation decision should always be individualized weighing balanced with the alternative risk of hemorrhagic complications. In this review, we aim to synthetize existing literature on TE in adults with CHD, discuss management issues, highlight gaps in knowledge, and intend to suggest high priority research.