High Rate Of Thromboembolic Events Research Articles

Thromboembolic events after major bleeding events in patients with mechanical heart valves: a 13-year analysis.

Anticoagulation in patients with mechanical heart valves (MHV) is associated with a risk of major bleeding episodes (MBE). In case of MBE, anticoagulant interruption is advocated. However, there is lack of data regarding the thrombo-embolic events (TE) risk associated with anticoagulant interruption. The main objective of the study was to evaluate the rate and risk factors of 6-months of TEs in patients with MHV experiencing MBE. This observational study was conducted over a 13-year period. Adult patients with a MHV presenting with a MBE were included. The main study endpoint was 6-month TEs, defined by clinical TEs or an echocardiographic documented thrombosis, occurring during an ICU stay or within 6-months. Thromboembolic events were recorded at ICU discharge, and 6 months after discharge. Seventy-nine MBEs were analysed, the rate of TEs at 6-months was 19% CI [11-29%]. The only difference of presentation and management between 6-month TEs and free-TE patients was the time without effective anticoagulation (TWA). The Receiver Operator Characteristic curve identified the value of 122 h of TWA as a cut-off. The multivariate analysis identified early bleeding recurrences (OR 3.62, 95% CI [1.07-12.25], p = 0.039), and TWA longer than 122h (OR 4.24, 95% CI [1.24-14.5], p = 0.021), as independent risk factors for 6-month TEs. A higher rate of TE was associated with anticoagulation interruption longer than 5 days and early bleeding recurrences. However, the management should still be personalized and discussed for each case given the heterogeneity of causes of MBE and possibilities of haemostatic procedures.

Thromboembolic events associated with neoadjuvant chemotherapy for muscle invasive cancer of the bladder.

586 Background: Patients with muscle invasive bladder cancer who undergo platinum-based neoadjuvant chemotherapy (NAC) followed by radical cystectomy or radiotherapy are at high risk of venous and arterial thromboembolic events (TEE). TEE is associated with delay to radical cancer treatment, significant morbidity and even mortality. This study aimed to document the incidence and characteristics of TEE during NAC and prior to radical treatment. Methods: Retrospective data was collected on all patients in our centre who underwent NAC prior to radical treatment. TEE events were identified based on routine imaging to assess for response to NAC; or imaging based on clinical symptoms developed during (or within 28 days) of NAC but prior to radical treatment. Results: Data was collected on 148 patients between January 2015 and September 2023. Age range: 44 - 82 years, the majority (73.6%) of whom were male. All patients received platinum-based chemotherapy (median 4 cycles). A total of 31 patients (20.9%) developed 35 TEE, including 27 venous events (24 pulmonary emboli and 3 deep venous thromboses), and 8 arterial events (3 aortic thrombus, 4 limb ischaemia, 1 ischemic stroke). Four patients had a venous and arterial TEE. The majority of pulmonary venous TEE were subclinical. Conclusions: Our single-centre study demonstrates that the incidence of TEE during NAC prior to radical treatment for bladder cancer is high. Improved imaging techniques and routine scans post-NAC led to identification of subclinical TEE that require treatment as they are likely to become clinically significant. The high rate of TEE in this patient population is likely to benefit from prophylactic anticoagulation during NAC and should be investigated in future prospective clinical trials.

Health-Related Complications during Follow-Up and Their Impact on Blood Cancer Survivors: Results from the “Aftercare in Blood Cancer Survivors” (ABC) Study

Introduction: Blood cancer survivors are at increased risk for medical complications. Methods: Our questionnaire-based study involved 1,551 blood cancer survivors with a ≥3-year interval since the last intense treatment. Its goal was to quantify health-related complications during follow-up and assess their impact on the patients’ lives. Results: A total of 20.4% of the responding survivors reported a disease relapse, most often in indolent lymphomas. Second primary malignancies occurred in 14.1%, primarily in lymphoma and allogeneic transplantation survivors. The most frequent malignancy was basal cell carcinoma of the skin, but myeloid malignancies, melanoma, bladder, head-and-neck, and thyroid cancer also appeared disproportionately frequent. An increased infection rate was reported by 43.7%, most often after allogeneic transplantation. New cardiovascular diseases were reported by 30.2%, with a high rate of thromboembolic events in multiple myeloma (MM) and myeloproliferative diseases. Polyneuropathies were reported by 39.1%, most often by survivors with a history of MM or aggressive lymphoma. Disease relapse was perceived as the highest burden, followed by second primary malignancy, increased infection frequency, and polyneuropathy. In each area investigated, the range of perceived severities was wide. Conclusions: Health-related complications are frequent during blood cancer follow-up, with significant repercussions on the patients’ lives.

Abstract 16704: Impact of Infective versus Sterile Transvenous Lead Removal on Outcomes in Cardiac Implantable Electronic Devices

Introduction: Transvenous lead removal (TLR) is associated with increased mortality and morbidity. This study sought to evaluate the impact of TLR on in-hospital mortality and outcomes in patients with and without CIED infection. Methods: Using the nationally representative, all-payer, Nationwide Readmissions Database, we evaluated patients undergoing TLR for CIED infection between January 1, 2017, and December 31, 2020. The indications of TLR were determined on the basis of the presence or absence of bacteremia, septicemia, sepsis, or endocarditis during the initial admission for CIED infection. The impact of infective vs sterile indications of TLR on mortality and major adverse events was studied. Results: Of the 25,144 patients who underwent TLR, 14,037 (55.8%) underwent TLR due to sterile indications and 11,114 (44.1%) underwent TLR due to infective indications with 4,495 patients with (40.5%) systemic and 6,612 (59.53%) with isolated pocket infection. Infective indications of TLR were associated with a significant increase in in-hospital mortality (8.73% vs 0.96%; OR= 5.89; 95% CI 4.81-7.20; <0.001) but not conversion to open heart surgery. Infective indications of TLR were also associated with a significantly increased risk of thromboembolic events of pulmonary emboli and embolic stroke (OR= 3.80; 95% CI 3.23-4.47, <0.001). Conclusions: A higher rate of thromboembolic events associated with infective indications of lead removal may warrant further pursuing this diagnosis in asymptomatic patients.

Impact of Genetic Variations on Thromboembolic Risk in Saudis with Sickle Cell Disease.

Sickle cell disease (SCD) is a Mendelian disease characterized by multigenic phenotypes. Previous reports indicated a higher rate of thromboembolic events (TEEs) in SCD patients. A number of candidate polymorphisms in certain genes (e.g., FVL, PRT, and MTHFR) were previously reported as risk factors for TEEs in different clinical conditions. This study aimed to genotype these genes and other loci predicted to underlie TEEs in SCD patients. A multi-center genome-wide association study (GWAS) involving Saudi SCD adult patients with a history of TEEs (n = 65) and control patients without TEE history (n = 285) was performed. Genotyping used the 10× Affymetrix Axiom array, which includes 683,030 markers. Fisher's exact test was used to generate p-values of TEE associations with each single-nucleotide polymorphism (SNP). The haplotype analysis software tool version 1.05, designed by the University of Göttingen, Germany, was used to identify the common inherited haplotypes. No association was identified between the targeted single-nucleotide polymorphism rs1801133 in MTHFR and TEEs in SCD (p = 0.79). The allele frequency of rs6025 in FVL and rs1799963 in PRT in our cohort was extremely low (<0.01); thus, both variants were excluded from the analysis as no meaningful comparison was possible. In contrast, the GWAS analysis showed novel genome-wide associations (p < 5 × 10-8) with seven signals; five of them were located on Chr 11 (rs35390334, rs331532, rs317777, rs147062602, and rs372091), one SNP on Chr 20 (rs139341092), and another on Chr 9 (rs76076035). The other 34 SNPs located on known genes were also detected at a signal threshold of p < 5 × 10-6. Seven of the identified variants are located in olfactory receptor family 51 genes (OR51B5, OR51V1, OR51A1P, and OR51E2), and five variants were related to family 52 genes (OR52A5, OR52K1, OR52K2, and OR52T1P). The previously reported association between rs5006884-A in OR51B5 and fetal hemoglobin (HbF) levels was confirmed in our study, which showed significantly lower levels of HbF (p = 0.002) and less allele frequency (p = 0.003) in the TEE cases than in the controls. The assessment of the haplotype inheritance pattern involved the top ten significant markers with no LD (rs353988334, rs317777, rs14788626882, rs49188823, rs139349992, rs76076035, rs73395847, rs1368823, rs8888834548, and rs1455957). A haplotype analysis revealed significant associations between two haplotypes (a risk, TT-AA-del-AA-ins-CT-TT-CC-CC-AA, and a reverse protective, CC-GG-ins-GG-del-TT-CC-TT-GG-GG) and TEEs in SCD (p = 0.024, OR = 6.16, CI = 1.34-28.24, and p = 0.019, OR = 0.33, CI = 0.13-0.85, respectively). Seven markers showed novel genome-wide associations; two of them were exonic variants (rs317777 in OLFM5P and rs147062602 in OR51B5), and less significant associations (p < 5 × 10-6) were identified for 34 other variants in known genes with TEEs in SCD. Moreover, two 10-SNP common haplotypes were determined with contradictory effects. Further replication of these findings is needed.

Occurrence of Thromboembolic Events and Mortality Among Hospitalized Coronavirus 2019 Patients: Large Observational Cohort Study of Electronic Health Records.

Background Most symptoms of coronavirus 2019 (COVID-19) are mild; however, some patients experience cardiovascular complications, including thromboembolic events and death. Data are needed to better inform prevention and treatment of these events. This analysis was designed to describe patient characteristics, medication use, thromboembolic events, and all-cause mortality in hospitalized COVID-19 patients in the United States. Methods This retrospective, observational cohort study identified adults hospitalized with COVID-19 (January 21, 2020-January 07, 2021) in the deidentified Optum COVID-19 Electronic Health Records dataset. Thromboembolic events and all-cause mortality were collected at any time during the variable follow-up period (up to 50 weeks). Results Of 181,995 COVID-19 patients who met eligibility criteria, 40,524 (22.3%) were hospitalized with COVID-19. Hospitalized patients had a mean age of 63 years and a Quan-Charlson comorbidity index of 1.3. Anticoagulants were used in 89.2% of patients during hospitalization and in 18.7% of postdischarge patients. Of hospitalized patients, 17.6% had a thromboembolic event during the entire follow-up period (mean time to the first event of 15 days), of whom 13.4% had an event during hospitalization; of discharged patients, 4.3% had a thromboembolic event (mean time from discharge to event of 43 days). Death during the follow-up period was reported in 15.0% of patients. Conclusions In this large, observational cohort study, patients hospitalized with COVID-19 had high rates of thromboembolic events during hospitalization and in the postdischarge period; mortality was also high in this population. Anticoagulant use was common during hospitalization. These findings support further studies to optimize in-hospital and extended prophylaxis for hospitalized COVID-19 patients.

Evaluating Post-discharge Thromboembolic Events in Patients With COVID-19

Background: COVID-19 is associated with a high rate of thromboembolic events in hospitalized patients, but it is unclear whether this risk remains high after discharge. This study aimed to evaluate the association of underlying factors with post-discharge thrombolytic events in COVID-19 patients and the association of thrombolytic events with subsequent mortality and ischemic heart disease. Methods: In this study, eligible patients with COVID-19 who were admitted to the respiratory ward of Loghman Hakim Hospital, Tehran, Iran, followed up for about 3 months after discharge to record any thromboembolic events. Patients who reported postdischarge thromboembolic events were confirmed based on their diagnostic tests. The Chi-square test was used to evaluate the association between thromboembolic events and qualitative parameters, and an independent t-test was used to evaluate their association with quantitative parameters. Logistic regression analysis was performed to assess the association between independent variables and the composite outcome. Results: Thromboembolic events were diagnosed in 35 patients (5.04%), including Myocardial Infarction (MI) in 17 patients (2.44%), venous thromboembolism in 10 patients (1.44%), and ischemic stroke in 8 patients (1.15%). None of the 26 patients who received thromboprophylaxis had thromboembolic events. During follow-up, 22 patients (3.17%) died, of whom, 10 patients (43.47%) had thromboembolic events. Thromboembolic events were not associated with sedentary life and oxygen (O2) dependency after discharge (P value of 0.40 and 0.098, respectively). Regression analyses showed that thromboembolic events were significantly associated with ischemic heart disease and mortality (P=0.007 and P&lt;0.001, respectively). Conclusion: Our findings support a high rate of post-hospitalization thromboembolic events in COVID-19 patients; however, it needs more large-scale trials.

Increased risk for thromboembolic events from combination of a gynecologic malignancy with severe acute respiratory syndrome coronavirus 2 infection: a case report

PurposeDuring the severe acute respiratory syndrome coronavirus 2 pandemic, several patient groups are at particular risk. Mortality is higher among cancer patients and may be increased further by thromboembolic events, which are more common in coronavirus 2019 patients according to recent publications. We discuss the association of gynecologic malignancies, Severe acute respiratory syndrome coronavirus 2, and thromboembolism by reporting a case study and summarizing available literature.Case reportA 71-year-old Caucasian patient with ovarian cancer receiving first-line chemotherapy was diagnosed with deep vein thrombosis and pulmonary embolism. Routine screening revealed infection with severe acute respiratory syndrome coronavirus 2 in absence of specific symptoms. After uneventful recovery, oncologic treatment could be continued a few weeks later.MethodsWe performed a systematic review of the literature on PubMed following Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. The search included articles ahead of print, published between 1 December 2019 and 1 June 2020. Cross-searches were conducted on all relevant articles.ResultsWe identified five articles meeting the defined criteria, including two retrospective studies, a review, a position paper, as well as a letter to the editor.ConclusionCancer patients infected with severe acute respiratory syndrome coronavirus 2 have a relatively poor outcome, which may partially be due to a higher rate of thromboembolic events. Thromboprophylaxis is recommended, and scoring systems are helpful in early detection. In cancer patients with severe acute respiratory syndrome coronavirus 2, individual risk for thromboembolic events should be taken into account when considering interruption versus continuation of antitumoral therapy. However, further data and studies are required.

Timing of Resumption of Anticoagulation After Polypectomy and Frequency of Post-procedural Complications: A Post-hoc Analysis.

Optimal timing for anticoagulation resumption after polypectomy is unclear. We explored the association between timing of anticoagulation resumption and occurrence of delayed post-polypectomy bleeding (PPB) and thromboembolic (TE) events. We performed a post-hoc analysis of patients in an earlier study whose anticoagulants were interrupted for polypectomy. We compared rates of clinically important delayed PPB and TE events in relationship to timing of anticoagulant resumption. Late resumption was defined as > 2days after polypectomy. Among 437 patients, 351 had early and 86 late resumption. Compared to early resumers, late resumers had greater polypectomy complexity. PPB rate was higher (but not significantly) in the late versus early resumers (2.3% vs. 0.9%, 1.47% greater, 95% CI [-2.58 to 5.52], p = 0.26). TE events were more frequent in late versus early resumers [0% vs. 1.2% at 30days, 0% vs. 2.3%, 95% CI 0.3-8, (p = 0.04) at 90days]. On multivariate analysis, timing of restarting anticoagulation was not a significant predictor of PPB (OR 0.97, 95% CI 0.61-1.44, p = 0.897). Significant predictors were number of polyps ≥ 1cm (OR 4.14, 95% CI 1.27-13.66, p = 0.014) and use of fulguration (OR 11.43, 95% CI 1.35-80.80, p = 0.014). Physicians delayed anticoagulation resumption more commonly after complex polypectomies. The timing of restarting anticoagulation was not a significant risk factor for PPB and late resumers had significantly higher rates of TE events within 90days. Considering the potentially catastrophic consequences of TE events and the generally benign outcome of PPBs, clinicians should be cautious about delaying resumption of anticoagulation after polypectomy.

Left ventricular thrombus and anticoagulation: how long should we treat?

Abstract Background Left ventricular thrombus (LVT) is a potential complication of acute myocardial infarction and is associated with a high rate of thromboembolic events. With the advent of more potent antithrombotic medications and quicker reperfusion strategies, the incidence of LVT has been reduced. However, current guidelines recommendations are based on older evidence and some aspects of the treatment are being questioned, such as the optimal duration of anticoagulation. Purpose To determine how length of anticoagulation influences the risk of thromboembolic events and mortality in a tertiary-care cardiac center with primary percutaneous coronary intervention (PCI) capability. Methods A cohort of consecutive cases of patients with IVT diagnosed by transthoracic echocardiography between 2014 and 2020 was retrospectively analyzed. Results A total of 72 cases of LVT were identified. Etiology was ischemic cardiomyopathy in 60 (82.0%) patients and 13 (20.0%) were female. LVT was diagnosed in the setting of acute myocardial infarction in 23 (32.0%) of cases. Prolonged anticoagulation regimes were significantly associated with fewer systemic thromboembolic events (21.4% vs 6.1%; p=0.04), without a significant effect on mortality (Figure 1). Conclusion Clinical manifestations and epidemiology of LVT has recently changed after the advent of improved treatments. In our cohort, an indefinite anticoagulation strategy was significantly associated with fewer thromboembolic events, suggesting that future investigations should clarify these issues. Funding Acknowledgement Type of funding sources: None.

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.

Acute thromboembolic events (TE) within 30 days of COVID-19 infection in cancer patients.

e18691 Background: Increased rates of TE have been reported in patients (pts) with coronavirus disease (COVID-19), even without prior predisposition to thrombosis. Patients with cancer are already predisposed to a hypercoagulable state. We aimed to assess whether COVID-19 further increased the risk of TE in pts with active cancer at Montefiore Medical Center, Bronx, NY. Methods: The EMR of 90 cancer pts diagnosed with COVID-19 from March 15th to April 10th, 2020 were reviewed. COVID-19 testing was performed by PCR of nasal swab samples. Active cancer was defined as disease treated &lt;1 year. Reports of imaging studies performed &lt;30 days of the COVID-19+ test, either for new symptoms or for other reasons, were reviewed for new arterial (ATE) and/or venous thromboses (VTE). Patient were followed for 30 days from the date of COVID-19+ test for development of TE, hospital length of stay (LOS) and mortality. Results: Of 90 pts, 11 (12.2%) were found to have 13 new TE within 30 days of COVID-19+ test, 8 (8.9%) arterial and 5 (5.6%) venous. Of the 8 ATE, 7 were new strokes and/or microvascular cerebral disease (MCD) and 1 was a spleen infarct (SI). Of the 5 VTE, 3 were deep venous thrombosis, 1 pulmonary embolism (PE) and 1 patient presented with a superficial VTE. Two patients had 2 new TE each; stroke/PE and MCD/SI, respectively. Peak D-dimer (DD) value was higher in the TE group; mean DD (SD), TE vs no TE, 7.1 (3.4) vs 6.4 (7) ug/mL, p=0.03. Pts on either prophylactic or therapeutic anticoagulation (AC) had less TE; AC vs no AC, 9.1% vs 90.9%, p=0.0003. Only 1 pt on Enoxaparin prophylaxis developed TE. Of the 20 pts on therapeutic AC, 25% were newly started due to concern for thrombosis; the rest were already receiving AC for other reasons. Mortality was higher in the TE group; HR, TE vs no TE, 2.6, 95% CI (1.2 - 5.6), p=0.009. There was no correlation of cancer type, disease stage (metastatic or not), administration of prior chemotherapy or immunotherapy, common comorbidities, patient setting (inpatient, ICU, outpatient, ED visit), LOS or ventilation status with increased incidence of TE. Conclusions: Pts with COVID-19 have high rates of TE, and this is true for our pts with cancer. A high incidence of ATE was noted. TE was associated with increased mortality.[Table: see text]

Thromboembolic events in metastatic testicular cancer treated with cisplatin-based chemotherapy.

BACKGROUNDTesticular germ cell tumor (TGCT) is the most curable solid tumor and most common cancer among men 18-39 years. While cisplatin-based chemotherapy has significantly lengthened the survival of patients with TGCT, it is associated with a high rate of thromboembolic events (TEE).AIMTo summarize our single-center experience highlighting patients who were diagnosed with TGCT and received platinum-based chemotherapy, with special attention to those patients who suffered a TEE.METHODSA retrospective analysis of the medical records and imaging studies of 68 consecutive individuals who were diagnosed with TGCT and received platinum-based chemotherapy at our Institution in a metropolitan community between January 1, 2014 and December 31, 2019.RESULTSA total of 19 (28%) patients experienced a TEE following orchiectomy which occurred during chemotherapy in 13 (68%) of these patients. Patients with a higher pathologic stage (stage III) were significantly (P = 0.023) more likely to experience a TEE compared to patients who had a lower stage. Additionally, patients who were treated with 3 cycles of bleomycine, etoposide, and cisplatin and 1 cycle of etoposide and cisplatin or 4 cycles of etoposide and cisplatin were significantly 5 (P = 0.02) times more likely to experience a TEE compared to patients who were treated with only 3 cycles of bleomycine, etoposide, and cisplatin.CONCLUSIONDue to numerous factors that predispose to a TEE such as large retroperitoneal disease, higher clinical stage, greater number of chemotherapy cycle, central venous catheter, cigarette smoking, and possible cannabis use, high-risk ambulatory patients with TGCT treated with cisplatin-based chemotherapy may benefit from prophylactic anticoagulation. Randomized studies to evaluate the safety and efficacy of prophylactic anticoagulants are warranted in this young patient population generally devoid of medical co-morbidities.

Vascular thromboembolic events following COVID‐19 hospital discharge: Incidence and risk factors

BackgroundCoronavirus disease 2019 (COVID‐19) is associated with high rates of thromboembolic events in hospitalized patients. It remains to be determined if this risk persists following hospital discharge. MethodsWe conducted a retrospective cohort study of outpatients recently hospitalized for COVID‐19 to determine the incidence of vascular thromboembolic events within 30 days of discharge. We investigated the risk factors associated with these events, including intensive care admission, age, and anticoagulation. ResultsAmong 447 patients hospitalized for COVID‐19, 2.0% experienced a vascular thromboembolic event within 30 days of discharge. No risk factor variable was significantly associated with an increased risk for these events. ConclusionsThe incidence of vascular thromboembolic events following hospital discharge for COVID‐19 is low. These findings suggest against the routine use of postdischarge thromboprophylaxis in patients with COVID‐19.

Increased Intracranial Hemorrhage Amid Elevated Inflammatory Markers in Those With COVID-19 Supported With Extracorporeal Membrane Oxygenation.

COVID-19-related coagulopathy is a known complication of SARS-CoV-2 infection and can lead to intracranial hemorrhage (ICH), one of the most feared complications of extracorporeal membrane oxygenation (ECMO). We sought to evaluate the incidence and etiology of ICH in patients with COVID-19 requiring ECMO. Patients at two academic medical centers with COVID-19 who required venovenous-ECMO support for acute respiratory distress syndrome (ARDS) were evaluated retrospectively. During the study period, 33 patients required ECMO support; 16 (48.5%) were discharged alive, 13 died (39.4%), and 4 (12.1%) had ongoing care. Eleven patients had ICH (33.3%). All ICH events occurred in patients who received intravenous anticoagulation. The ICH group had higher C-reactive protein (P = 0.04), procalcitonin levels (P = 0.02), and IL-6 levels (P = 0.05), lower blood pH before and after ECMO (P < 0.01), and higher activated partial thromboplastin times throughout the hospital stay (P < 0.0001). ICH-free survival was lower in COVID-19 patients than in patients on ECMO for ARDS caused by other viruses (49% vs. 79%, P = 0.02). In conclusion, patients with COVID-19 can be successfully bridged to recovery using ECMO but may suffer higher rates of ICH compared to those with other viral respiratory infections.

Thromboembolic Rates Are Similar Between Intensive Care Unit and Nonintensive Care Unit Hospitalized Patients With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2): A Retrospective Cohort Study.

High rates of thromboembolic events have been described in intensive care unit (ICU) patients. Data regarding thromboembolic events in all hospitalized patients has been less frequently reported, raising concerns that thromboembolic events in non-ICU may be underrecognized. In addition, optimal anticoagulation type and dose is still unsettled at this time. This is a retrospective cohort study of 159 hospitalized patients with coronavirus disease 2019 (COVID-19) pneumonia during a 9-month period to determine an association between the frequency of thromboembolic rates and hospitalized patients with COVID-19. Secondary outcomes sought to investigate association of thromboembolic events with relation to place of admission, risk factors, anticoagulation, mortality, hospital length of stay, and discharge disposition. Among the cohort of 159 hospitalized patients who met criteria, 16 (10%) were diagnosed with a thromboembolic event. There were a total of 18 thromboembolic events with 12 venous and 6 arterial. Admission to the ICU was not associated with a higher frequency of thromboembolic events compared with non-ICU patients (37.5% vs 62.5%), p = .71. Patients with a thromboembolic event had a significantly higher mortality compared with those with no thromboembolic event (37.5% vs 13.3%), p = .012. Patients hospitalized with COVID-19 have increased rates of thromboembolic events, both venous and arterial, which contribute to a significant increase in mortality. However, the frequency of thromboembolism in patients admitted to the ICU was similar to events in non-ICU patients. We hope to increase awareness of the increased risk of hypercoagulability in all hospitalized patients with COVID-19 including non-ICU patients.

Adequate anticoagulation and ECMO therapy in COVID-19 patients with severe pulmonary embolism

SARS-CoV-2 (COVID-19) infections have been recently shown to be associated with a high rate of thromboembolic events due to pro-coagulative mechanisms that have not yet been fully understood. This paper reports on a 55-year-old female COVID-19 patient with severe ARDS and pulmonary embolism (PE) complicated by cardiogenic shock after 12 days of hospitalization under initial prophylactic anticoagulation with low molecular weight heparin (LMWH). An ultima-ratio va (veno-arterial) ECMO implantation and subsequent rapid upgrade to vvaECMO due to insufficient oxygenation was performed. The patient developed severe coagulopathy with intrapulmonary bleeding. The present report aims to highlight and discuss the pros and cons of various anticoagulation strategies in COVID-19 patients focusing on current scientific debates to address this frequently observed complication in the current situation worldwide.

Concomitant Use of Direct Oral Anticoagulants and Antiepileptic Drugs: A Prospective Cohort Study in Patients with Atrial Fibrillation.

BackgroundEuropean guidelines do not recommend the use of carbamazepine, levetiracetam, phenobarbital, phenytoin, topiramate and valproic acid in patients taking direct oral anticoagulants (DOACs). Little is known regarding the clinical relevance of the interaction between DOACs and antiepileptic drugs.ObjectivesTo evaluate the incidence of thromboembolic and bleeding events in patients with non-valvular atrial fibrillation (AF) concurrently treated with DOACs and antiepileptic drugs.MethodsThis is a prospective multicentre cohort study of patients with non-valvular AF concurrently treated with DOACs and antiepileptic drugs. The primary outcome was ischaemic stroke/transient ischaemic attack (TIA)/systemic embolism (SE). Secondary outcome was major bleeding (MB). Incidence rates (% patient-year) were evaluated for the study outcomes.ResultsOverall, 91 patients were included. Mean age was 78 ± 9.5 years, 49.5% were female. Mean CHA2DS2-VASc score was 4.76 ± 1.59 and mean HAS-BLED was 2.67 ± 1.26. Overall, 41, 20, 11, 10 and 9 out of 91 patients were treated with levetiracetam, valproic acid, phenobarbital, carbamazepine and other antiepileptic drugs, respectively. During a median follow-up of 17.5 ± 14.5 months, stroke/TIA/SE occurred in 9 patients (5.7% patient-year) and MB in 3 patients (1.9% patient-year). Ischaemic stroke was fatal in 3 patients (1.9% patient-year) and MB in one patient (0.6% patient-year).ConclusionIn this cohort, patients with non-valvular AF treated with DOACs and antiepileptic drugs appear to have a relatively high rate of thromboembolic events.

COVID-19 and ST elevations-keep an open mind: a case report.

BackgroundCoronavirus disease 2019 (COVID-19) has been associated with a range of cardiovascular manifestations, including myocardial injury and thrombo-embolism. Pulmonary embolism (PE) causing anteroseptal/anterior ST elevations that mimic myocardial infarction have previously been described. This phenomenon is thought to be related to right ventricular injury from large emboli.Case summaryA 48-year-old woman with history of type 2 diabetes mellitus and hypertension presented to her local hospital with fever, cough, nausea, and dyspnoea. A test for SARS-CoV-2 was taken, and she was discharged with instructions to self-quarantine. She was subsequently notified of a positive SARS-CoV-2 result. Three days later, she re-presented with worsening dyspnoea and respiratory failure requiring intubation. On hospital Day 6, she became acutely hypoxic and hypotensive. Telemetry was noted to have ST changes, prompting ECG that revealed sinus tachycardia with prominent new ST elevations in her precordial leads. Transthoracic echocardiogram showed normal left ventricular function; however, the right ventricle was moderately dilated with positive McConnell’s sign. Due to her unstable clinical state and high suspicion for PE, she was treated with tenecteplase 50 mg i.v. with complete resolution of her ST elevations and improved oxygenation.DiscussionGiven the high rates of thrombo-embolic events in COVID-19 patients, PE should be in the differential diagnosis of ST elevation, particularly in younger patients with few risk factors for coronary artery disease.

Apixaban for Stroke Prevention in Atrial Fibrillation: Why are Event Rates Higher in Clinical Practice than in Randomized Trials?-A Systematic Review.

Recent reports suggest an important contribution from frequent off-label use of apixaban 2.5 mg twice daily to the higher rates of thromboembolic events observed in observational studies (OSs) relative to in randomized controlled trials (RCTs), and consequently, advocate against such use in all patients. To examine factors contributing to the higher thromboembolic event rates, we estimated the prevalence of off-label use in contemporary practice, and compared patient characteristics and rates of stroke/systemic embolism, major bleeding, and mortality by apixaban dose and by study design in a systematic review and meta-analysis. We identified 18 OSs and 2 RCTs that included 155,228 and 11,928 patients, respectively. Patients in OSs more often received apixaban 2.5 mg twice daily (31.3% vs. 5.1%), were older (mean age 73.8 vs. 69.8 years), and had higher CHA2DS2-VASc scores (mean 3.6 vs. 2.9) versus those in RCTs. We observed a consistent pattern of higher rates of thromboembolic events, bleeding, and mortality in patients treated with 2.5 versus 5 mg twice daily apixaban in both OSs and RCTs. The higher risk profiles of patients in OSs versus RCTs, and higher rates of both bleeding and mortality not attributable to thromboembolism in patients treated with apixaban 2.5 versus 5 mg twice daily suggest that differences in patient characteristics are additional important contributors to the higher than expected thromboembolic event rates in clinical practice.