Hospitalization For Gastrointestinal Bleeding Research Articles

Use of Direct-Acting Oral Anticoagulants in Patients With Atrial Fibrillation and Significant Tricuspid Regurgitation.

There are limited data on the efficacy and safety of direct oral anticoagulants (DOACs) in patients with atrial fibrillation with significant tricuspid regurgitation (TR), which can lead to hepatic dysfunction and intestinal malabsorption. We aimed to compare the efficacy and safety of DOACs and warfarin for patients with atrial fibrillation with significant (moderate to severe) TR. A total of 1215 patients with significant TR and atrial fibrillation who were treated with warfarin (N=491) or DOACs (N=724) were retrospectively analyzed. The primary outcomes were ischemic stroke, systemic embolic events, and hospitalization for major bleeding. The secondary outcomes were intracranial hemorrhage, hospitalization for gastrointestinal bleeding, all-cause mortality, and a composite outcome. The median follow-up duration was 2.4 years. In the inverse probability treatment weighting-adjusted cohort, DOACs and warfarin had a similar risk for ischemic stroke and systemic embolic events (adjusted hazard ratio [aHR], 0.95 [95% CI, 0.67-1.36]; P=0.79) and major bleeding (aHR, 0.78 [95% CI, 0.57-1.06]; P=0.11). For the secondary outcomes, relative to warfarin, DOACs had a lower risk of intracranial hemorrhage and the composite outcome, and a comparable risk for gastrointestinal bleeding and all-cause mortality. In the subgroup analysis, the effects of DOACs on ischemic stroke and systemic embolic events were comparable to the effects ofwarfarin, even in patients with inferior vena cava plethora (increased right atrial pressure) or severe TR. In this study, relative to warfarin, DOACs demonstrated comparable efficacy for ischemic stroke and systemic embolic events and major bleeding, with a lower intracranial hemorrhage risk in patients with significant TR and atrial fibrillation, indicating their effectiveness and safety.

Vascular and neurological outcomes in patients with atrial fibrillation treated with edoxaban; effects of cancer

Abstract Introduction Data from novel oral anticoagulants (NOACs) trials has shown superior outcomes of NOACs compared to warfarin in vascular and bleeding events in patients with AF, both with and without cancer, however, little discussion has been provided on their effect in congestive heart failure (CHF). NOACs also may have biological benefits in Alzheimer disease (AD). We investigated the impact of edoxaban on vascular and bleeding events, CHF, and AD, in patients with AF, with and without cancer. Methods In this nationwide retrospective cohort study from Taiwan National Health Insurance Research Database, we identified a total of 5683 patients with non-valvular AF (NVAF) treated with edoxaban and matched them for gender and age to 11366 patients treated with warfarin. Subsequently, we similarly matched 703 patients with NVAF and cancer (NVAF-C) treated with edoxaban to 1406 patients treated with warfarin. The crude and adjusted hazard ratios (HRs) were applied for outcome assessments. Outcomes included arterial/venous ischemic events, CHF, Alzheimer disease (AD) , bleeding, acute kidney injury (AKI), and all-cause mortality.Results:Compared to warfarin, edoxaban showed significantly lower adjusted HRs for all-cause mortality (0.37 in NVAF, 0.39 in NVAF with cancer [NVAF-C]), hospitalization for gastrointestinal bleeding (0.74 in NVAF, 0.67 in NVAF-C), and CHF (0.26 in NVAF, 0.31 in NVAF-C) in both NVAF and NVAF-C groups (all p < 0.05). The adjusted HRs of acute myocardial infarction (0.71, p = 0.0051), peripheral artery disease (HR = 0.48, p < 0.001), venous thromboembolism (0.55, p = 0.0003), pulmonary embolism (0.20, p = 0.0002), and AD (0.66, p < 0.001) were also significantly lower for NVAF patients using edoxaban versus warfarin. However, edoxaban was associated with significantly higher adjusted HR of other hospitalized bleeding than warfarin (1.19, p = 0.0016) in NVAF patients but not in NVAF-C patients. Conclusion Edoxaban is associated with reduced risks of CHF in both NVAF and NVAF-C patients, and lower incidence of AD in NVAF when comparing to warfarin. These findings further support the use of edoxaban in patients with AF.

Incidence and risk factors for major bleeding events in atrial fibrillation patients on direct oral anticoagulant therapy: data from the National Patient-Centered Clinical Research Network

Abstract Background Direct oral anticoagulation (DOACs) prevent stroke in patients with atrial fibrillation (AF) and have a superior safety profile compared with vitamin K antagonists (VKA). Yet, better definition of incidence and risk factors for major bleeding associated with DOACs in clinical practice may be important given emerging stroke prevention technologies, both pharmacologic and nonpharmacologic. Purpose To describe the incidence of and risk factors for major bleeding in individuals with AF on DOAC therapy. Methods We reviewed electronic health record data for two patient cohorts with AF prescribed DOACs: (1) Duke University Health System (DUHS) (2010–2018) and (2) Sites within the Patient-Centered Clinical Research Network (PCORnet) (2015–2019) which had ≥6 years assimilated data from both inpatient and outpatient encounters (7 sites). In each cohort, we assessed the 5-year incidence of major bleeding events defined as hospitalization for intracranial hemorrhage, or hospitalization for gastro-intestinal bleeding or procedure to control bleeding accompanied by transfusion within ±7 days or death within 30 days. Multivariable Fine-Gray proportional hazards modeling in each cohort was performed to evaluate independent risk factors for major bleeding on DOAC therapy. Results The cohorts included 10,625 patients (DUHS) and 58,321 patients (PCORnet) with AF. Major bleeding events occurred within 5 years of diagnosis in 639 (7.9%) of DUHS patients and 2568 (6.6%) of PCORnet patients (Table 1). The DUHS model predicted time to first major bleeding event with a C-index of 0.756 (95% CI 0.737, 0.775) and the PCORNet model had a c-index of 0.745 (0.736, 0.755) (Table 2). Independent factors associated with major bleeding consistent across both models (p<0.001 in PCORnet for all unless noted) were higher CHA2DS2-VASc scores, lower eGFR, anemia (HR per 1-point increase in hemoglobin up to 12 g/dL 0.79 [0.76, 0.82]), prior major bleeding (HR 2.70 [2.22, 3.30]), cancer (HR 1.23 [1.12, 1.36]), recent cardiac surgery (HR 0.70 [0.51, 0.97]; p=0.030), alcohol use (HR 1.56 [1.29, 1.88]), aspirin use (HR 1.44 [1.32, 1.57]), and selective serotonin reuptake inhibitor use (HR 1.30 [1.19, 1.42]). Conclusions Across a large and geographically diverse contemporary population, risk of bleeding on DOAC for stroke prevention in AF remains a frequent and important clinical problem. There is an unmet need for stroke prevention therapies with improved safety profiles. We identified risk factors for major bleeding events on DOAC therapy, some of which are not represented in traditional risk scores, which may inform shared decision making for stroke prevention. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Bayer Pharmaceuticals

S2586 Don’t Get 2 Comfortable: A Rare Case of Meckel’s Diverticulum Causing Hemorrhagic Shock in an Adult

Introduction: Meckel’s diverticulum (MD) is a true diverticulum that results from incomplete obliteration from the vitelline duct during embryonic development. It is a one of the most common congenital disorders of the gastrointestinal (GI) tract. Often characterized using “The Rule of 2’s”: MD occurs in approximately 2% of the population, is 2 inches long, is within 2 feet from the ileocecal valve, is twice as common in males than females, can contain 2 types of tissue (gastric or pancreatic), 2% become symptomatic, and most present before the age of 2. The majority of symptomatic MD occur as painless hematochezia in children and therefore is often lower on the differential of an adult with a GI bleed. Even when MD is suspected as an etiology for GI bleeding in an adult, the evaluation can be challenging. Case Description/Methods: A 25-year-old male with no significant past medical history was admitted to the hospital for GI bleeding and then developed hemorrhagic shock requiring resuscitation with transfusion of large volumes of blood products. The etiology of his GI bleed remained elusive for several days despite evaluation with upper endoscopy, three colonoscopies, three CT angiograms of the abdomen and pelvis, and a video capsule endoscopy. Subsequently, he underwent two separate fluoroscopic angiograms with interventional radiology. While the first angiogram was unrevealing, the second angiogram demonstrated a tortuous ileal artery branch with active extravasation that was treated with embolization. Given IR findings, a Meckel’s scan was performed which was negative. A multi-disciplinary review of the case prompted further review of the patient’s abdominal CT angiogram and a potential finding of MD was seen at the distal ileum. Ultimately, the surgery team decided to take the patient to the operating room where they found and resected a segment of small bowel with tissue examination revealing the MD (Figure 1). Discussion: A Meckel’s scan is often considered the modality of choice for diagnosing MD in children, however, its diagnostic accuracy is considered to be much lower in adults. The typical approach to GI bleeding via upper endoscopy, colonoscopy, capsule endoscopy, CT and procedural angiography may be negative, as seen in our case. Balloon assisted enteroscopy, where available, may also be a potentially useful tool for diagnosing MD. This case highlights the importance of maintaining a broad differential diagnosis for GI bleeding and the challenges with current diagnostic modalities.Figure 1.: Meckel's diverticulum at the level of distal small bowel, approximately 60 cm from the ileocecal valve.

Acute Myocardial Infarction Following Hospitalization for Gastrointestinal Bleeding: Incidence, Predictors, Management, and Outcomes

BackgroundClinical characteristics of patients with acute myocardial infarction after gastrointestinal bleeding are poorly characterized. We sought to evaluate the incidence, management and outcomes of myocardial infarction following hospitalization for gastrointestinal bleeding. MethodsPatients admitted with a diagnosis of gastrointestinal bleeding with and without subsequent hospital readmissions for acute myocardial infarction within 90 days were identified in the 2014 U.S. Nationwide Readmission Database. Patients with myocardial infarction with and without a recent prior gastrointestinal bleed were compared to determine differences in management and in-hospital outcomes. Logistic regression models were used to estimate odds of invasive management and all-cause in-hospital mortality after covariate adjustment. ResultsA total of 644,622 patients with gastrointestinal bleeding were identified, of which 7523 (1.2%) were readmitted for myocardial infarction within 90 days. Compared to patients with myocardial infarction without recent gastrointestinal bleeding, patients with myocardial infarction within 90 days after gastrointestinal bleeding were older, more likely to be women, have kidney disease, presented with non-ST segment elevation myocarsdial infarction, and were less likely to undergo invasive management of acute myocardial infarction (28% vs 63%, P < .01). Prior gastrointestinal bleeding was associated with higher all-cause in-hospital myocardial infarction mortality (22% vs 9%, P < .01). ConclusionIn the first 3 months after hospitalization for gastrointestinal bleeding, 1 of every 83 patients was readmitted with acute myocardial infarction. Patients with myocardial infarction after gastrointestinal bleeding were less likely to undergo invasive management and coronary revascularization and had higher mortality than those without recent bleeding.

The Association Between Proton Pump Inhibitor Exposure and Key Liver-Related Outcomes in Patients With Cirrhosis: A Veterans Affairs Cohort Study

The impact of proton pump inhibitory (PPI) medications on adverse outcomes in cirrhosis remains controversial. We aimed to evaluate the association between PPI exposure and all-cause mortality, infection, and decompensation in a large national cohort. This was a retrospective study of patients with cirrhosis in the Veterans Health Administration. PPI exposure was classified as a time-updating variable from the index time of the cirrhosis diagnosis. Inverse probability treatment weighting-adjusted Cox regression was performed with additional adjustment for key time-varying covariates, including cardiovascular comorbidities, gastrointestinal bleeding (GIB), and statin exposure. The study included 76,251 patients, 23,628 of whom were on a PPI at baseline. In adjusted models, binary (yes/no) PPI exposure was associated with reduced hazard of all-cause mortality in patients with hospitalization for GIB (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.84-0.91; P < .001) but had no significant association in all others (HR, 0.99; 95% CI, 0.97-1.02; P= .58). However, cumulative PPI exposure was associated with increased mortality in patients without hospitalization for GIB (HR, 1.07 per 320 mg-months [omeprazole equivalents]; 95% CI, 1.06-1.08; P < .001). PPI exposure was significantly associated with severe infection (HR, 1.21; 95% CI, 1.18-1.24; P < .001) and decompensation (HR, 1.64; 95% CI, 1.61-1.68; P < .001). In a cause-specific mortality analysis, PPI exposure was associated with increased liver-related mortality (HR, 1.23; 95% CI, 1.19-1.28) but with decreased nonliver-related mortality (HR, 0.88; 95% CI, 0.85-0.91). PPI exposure is associated with increased risk of infection and decompensation in cirrhosis, which may mediate liver-related mortality. However, PPI use was associated with reduced all-cause mortality in those with prior GIB, suggesting benefit in the presence of an appropriate indication.

Management dilemmas in restarting anticoagulation after gastrointestinal bleeding

Systemic anticoagulants are widely prescribed to prevent and treat thromboembolism, among other indications. A common complication of using these agents is gastrointestinal bleeding. While early resumption of anticoagulants after the bleeding has resolved can increase the risk of rebleeding, delayed resumption puts the patient at increased risk of thromboembolic events and mortality. There is limited data on this topic to guide clinicians on resuming anticoagulation after hospitalization for gastrointestinal bleeding and to educate patients regarding the subsequent risks of recurrent gastrointestinal bleeding, thromboembolism, and mortality. The optimal time to resume anticoagulation is also unknown. This review summarizes the existing literature and available data on the commonly encountered dilemma of restarting anticoagulation therapy after hospitalization for gastrointestinal bleeding.

Abstract 12474: Acute Myocardial Infarction Following Hospitalizations for Gastrointestinal Bleeding: Incidence, Predictors, Management, and Outcomes

Introduction: Patients hospitalized with gastrointestinal bleeding (GIB) are at risk for acute myocardial infarction (AMI). Clinical characteristics of patients with AMI after a GIB are poorly characterized. We sought to evaluate the incidence, management and outcomes of AMI following hospitalization for GIB. Methods: Patients admitted with a diagnosis of GIB were identified in the 2014 United States Nationwide Readmission Database using ICD-9 diagnosis codes. Hospital readmissions for AMI within 90 days of GIB were identified. Patients with AMI after GIB were compared to those without a prior GIB to determine differences in management and in-hospital outcomes. Invasive management of AMI was defined as invasive angiography or coronary revascularization. Logistic regression models were used to estimate odds of invasive management and all-cause, in-hospital morality after adjustment for clinical covariates. Results: A total of 644,622 patients with GIB were identified, of which 7,523 (1.2%) were readmitted for AMI within 90 days. Older age, diabetes mellitus, chronic kidney disease, coronary and peripheral artery disease, unknown GIB source, and AMI during the index GIB hospitalization were associated with 90-day AMI readmission. Compared to AMI patients without a recent GIB, patients with AMI within 90 days after GIB were older (74.4 vs. 68.4 years, p&lt;0.01), more likely to be women (47% vs. 41.1%, p&lt;0.01), have kidney disease (43.2% vs. 22.4%, p&lt;0.01), present with non-ST segment elevation MI (82% vs. 73%, p&lt;0.01), and were less likely to undergo invasive management of AMI (28% vs 63%, P&lt;0.01; adjusted odds ratio [aOR] 0.40, 95% CI 0.37-0.44). Recent hospitalization for GIB within 90 days was associated with higher all-cause in-hospital AMI mortality (22% vs 9%, P&lt;0.01; aOR 1.86 [1.68-2.06]). Conclusion: In the first 3 months after hospitalization for GIB, 1 of every 83 patients was readmitted with AMI. Patients with AMI after GIB were less likely to undergo invasive management of AMI and had higher mortality than those without recent GIB. Strategies to reduce morbidity and mortality of GIB-associated thrombosis are needed.

S2299 Mysterious Bleeding in a Patient With Roux-en-Y Gastrectomy

Introduction: Obscure gastrointestinal bleeding (GIB) accounts for 5% of admissions for GIB. Management of recurrent obscure GIB is problematic and costly, requiring repeat hospitalizations, various imaging modalities and multiple endoscopies with bleeding often ceasing at time of endoscopy, only to recur at a later time. Angiography can be diagnostic and therapeutic, but may be complicated by kidney damage and ischemia. Nuclear medicine bleeding scan is time consuming and often unreliable. Surgical intervention is a last resort, carries significant morbidity, and may not be a permanent solution as in the case of bleeding from angioectasias. Case Description/Methods: A 39 year old woman with gastric bypass 15 years ago initially presented to outside hospital with reports of rectal bleeding and anemia requiring transfusions. At that time, ileocolonoscopy and push enteroscopy were performed, and were unrevealing for etiology of bleeding. She presented to our institution a month later with same complaints. Nuclear bleeding scan suspected bleeding in the colon; repeat colonoscopy was again unrevealing. Small bowel capsule endoscopy was planned, but patient returned to the hospital with symptomatic anemia (Hgb 4.9 g/dL) and rectal bleeding. CT-angiography was unrevealing. After a discussion with the patient, endoscopy with heparin provocation was planned. After colonoscope was advanced into terminal ileum, IV Heparin 10,000u was administered. Terminal ileum and colon were carefully examined with two passes of the scope; no blood or etiology of bleeding identified. Push enteroscopy was then performed up to jejuno-jejunal anastomosis, where fresh blood was encountered. Active oozing from large bed of vascular ectasias was apparent. Protamine Sulfate 50mg IV was administered and ectasias were treated with Argon Plasma Coagulation and hemoclips placement with successful cessation of bleeding. The patient was discharged home and had no further hospitalizations for GIB. Discussion: Heparin provocation has been used in rare cases of obscure GIB to provoke bleeding and identify responsible site at time of endoscopy. This is useful in patients with recurrent overt obscure bleeding, especially in poor surgical candidates. Heparin provocation has been controversial due to fear of inducing a life-threatening bleed. However, as this case demonstrates, such procedures can be performed safely and effectively even in a community hospital setting with proper preparation and use of Protamine to reverse anticoagulation effects.Figure 1.: 1. J-J anastomosis filled with blood 2. J-J anastomois with active bleeding 3. Status post treatment with cautery and hemoclip placement.

Body Mass Index and Clinical Outcomes in Asian Patients With Atrial Fibrillation Receiving Oral Anticoagulation.

The influence of body mass index (BMI) on clinical outcomes in patients with atrial fibrillation remains controversial, especially among Asians. We aimed to evaluate the association between BMI and clinical outcomes in Asian patients with atrial fibrillation receiving oral anticoagulants. Using the Korean National Health Insurance database between January 2015 and December 2017, we identified oral anticoagulant new users among patients with nonvalvular atrial fibrillation who had BMI information. We analyzed ischemic stroke, intracranial hemorrhage, hospitalization for gastrointestinal bleeding, major bleeding, all-cause death, and the composite clinical outcome according to BMI categories. A total of 43 173 patients were included across BMI categories (kg/m2): underweight (<18.5) in 3%, normal (18.5 to <23) in 28%, overweight (23 to <25) in 24%, obese I (25 to <30) in 39%, and obese II (≥30) in 6%. Higher BMI (per 5 kg/m2 increase) was significantly associated with lower risks of ischemic stroke (hazard ratio [HR], 0.891 [95% CI, 0.801-0.992]), hospitalization for gastrointestinal bleeding (HR, 0.785 [95% CI, 0.658-0.937]), major bleeding (HR, 0.794 [95% CI, 0.686-0.919]), all-cause death (HR, 0.658 [95% CI, 0.605-0.716]), and the composite clinical outcome (HR, 0.751 [95% CI, 0.706-0.799]), except for intracranial hemorrhage (HR, 0.815 [95% CI, 0.627-1.061]). The underweight group was associated with an increased risk of composite clinical outcome (HR, 1.398 [95% CI, 1.170-1.671]), mainly driven by an increased risk of all-cause death. The effects of non-vitamin K antagonist oral anticoagulant versus warfarin on clinical outcomes were similar across BMI groups. Higher BMI was independently associated with a lower risk of ischemic stroke, major bleeding, and better survival. Underweight patients had a higher risk of all-cause death and composite clinical outcome. The optimal BMI for patients with atrial fibrillation should be defined and managed according to an integrated care pathway.

Restarting Warfarin vs Direct Oral Anticoagulants After Major Gastrointestinal Bleeding and Associated Outcomes in Atrial Fibrillation: A Cohort Study

Limited data exist on the management of anticoagulation after hospitalization for gastrointestinal bleeding (GIB) and the risks of recurrent GIB and thromboembolism in patients who are prescribed warfarin vs direct oral anticoagulants (DOACs). The purpose of this study was to assess the risk of recurrent GIB and thromboembolism with resumption of anticoagulation after GIB. This was a retrospective analysis of adults with atrial fibrillation prescribed warfarin or DOACs and subsequently hospitalized for GIB. We used claims data from IBM MarketScan Databases from January 2008 through December 2017. Multivariable time-varying regression was used to determine the risks of recurrent GIB and thromboembolism within 6 months of the index hospitalization. There were 2991 patients hospitalized for GIB on anticoagulants (warfarin, n= 1872; rivaroxaban, n= 676; dabigatran, n= 293; and apixaban, n= 250). Of warfarin users, 46% (n= 869) resumed warfarin after discharge compared with 43% (n= 483) of DOAC users who resumed DOACs. In the regression analysis modeling time-varying coefficients for anticoagulant use, warfarin resumption was associated with an increased risk of recurrent GIB (hazard ratio [HR], 2.12; 95% CI, 1.43-3.14; P= .0002) compared with no anticoagulant resumption, whereas there was no association with DOAC resumption and recurrent bleeding (HR, 1.43; 95% CI, 0.81-2.52; P= .22). Rivaroxaban was the only individual DOAC that was associated with recurrent GIB (HR, 2.73; 95% CI, 1.43-5.20; P= .002). Both warfarin (HR, 0.61; 95% CI, 0.39-0.96; P= .033) and DOAC (HR, 0.52; 95% CI, 0.28-0.98; P= .044) resumption as a class was associated with a decreased risk of thromboembolism. Either warfarin or DOAC resumption after hospitalization for GIB was associated with a decreased risk of thromboembolism, whereas warfarin and rivaroxaban resumption were associated with an increased risk of recurrent GIB.

67 Clinical Outcomes of Oral Factor Xa-Inhibitor Associated Gastrointestinal Bleeds Treated with or without 4F-PCC among US Medicare Patients

Prior to the availability of a specific oral factor Xa (fXa) inhibitor reversal agent, off-label replacement agents including 4-factor prothrombin complex concentrates (4F-PCC) were used to treat life-threatening hemorrhage including gastrointestinal (GI) bleeds. We compared outcomes of US Medicare patients hospitalized for oral fXa-inhibitor associated GI bleeds treated with or without 4F-PCC. We utilized a 20% random sample of Medicare fee-for-service beneficiaries who had Part A and D (medication) coverage. We included adult (≥ 18 years) patients experiencing their first hospitalization (index event) for major GI bleeding identified via ICD9/10 codes, between 10/2013 and 9/2017. Serious GI bleeds were defined by ICD9/10 codes developed based on the Cunningham and Joos et al. algorithms. Inclusion criteria were continuous medical and prescription coverage and a claim for apixaban, edoxaban, or rivaroxaban during the 6-months prior to the index event. Patients were divided into two cohorts based on treatment with or without 4F-PCC during the index GI bleed hospitalization. Fresh frozen plasma, cryoprecipitates, packed red blood cells, activated PCC, recombinant factor VIIa, desmopressin acetate, tranexamic acid and vitamin K administration were allowed in either cohort. Use of more than one agent in either group was defined as concomitant therapy. Endpoints included the 1) intensive care unit (ICU) treatment, 2) total hospital length of stay, 3) discharge disposition and 4) 30-day readmission. Among 8,169 patients hospitalized for GI bleeding, 62 (0.75%) patients were treated with 4F-PCC. Mean age was 78.4 years and 58.8% were female. Because of the low numbers the two groups could not be propensity matched. Overall in-hospital mortality was 1.7%. Concomitant therapy was 56.5% 4F-PCC-treated vs. 45.3% non-4F-PCC patients. Incidence of ICU was 71.0% 4F-PCC vs 39.4% non-4F-PCC patients. Median (Interquartile range) hospital stay was 6 (4, 10) for 4F-PCC vs 5 (4, 6) days non-4F-PCC patients. Discharge disposition home was 45.2% for 4F-PCC vs 57.8% non-4F-PCC patients. All-cause readmission at 30 days was 18.0% for 4F-PCC vs 18.8% non-4F-PCC patients (Table 1). In a large descriptive analysis of hospitalized Medicare patients with oral fXa-inhibitor associated major GI bleeds, those treated with 4F-PCC had higher concomitant medication use, longer LOS, and lower frequency of discharge to home. Whether this is a result of off-label use of 4F-PCC or other variables in these complex patients is uncertain and deserves further study.Table 1Characteristics of US Medicare patients hospitalized for oral fXai-associated GI bleedsAll (N=8,169)4F-PCC Treated (N=62)Non-4F-PCC Treated (N=8,107)Indication for fXa inhibitors (%)Atrial fibrillation75.879.075.8Deep vein thrombosis/venous thromboembolism24.025.824.0Any concomitant medication (%)45.456.545.3Packed RBCs (%)43.853.243.7Characteristics of index hospitalizationLength of stay in days (Median; interquartile range)5.0 (4.0-6.0)6.0 (4.0-10.0)5.0 (4.0-6.0)Index hospitalization as ICU (%)39.771.039.4Discharge status (%)Home57.745.257.8Discharge to a location other than home (including in-hospital death)*42.354.842.2*Data on in-hospital death alone was not reported by treatment cohort in order to comply with the Centers for Medicare and Medicaid Services’ Cell Size Suppression Policy Open table in a new tab

Iron Supplementation is Underutilized after Hospitalization for Gastrointestinal Bleeding

Iron Supplementation is Underutilized after Hospitalization for Gastrointestinal Bleeding

AML-360: The Coexistence of Hyperimmunoglobulin E Syndrome and Myelodysplastic Syndrome

Context Hyperimmunoglobulin E syndrome (Job Syndrome) is one of the primary immunodeficiency syndromes and is generally inherited in an autosomal dominant fashion. This syndrome is characterized by elevation of serum immunoglobulin E level, chronic eczema, recurrent sinusitis and pneumonia, tendency for recurrent pyogenic infection, and soft tissue infections such as large abscesses. This disorder is associated with an increased risk for malignancies, especially lymphomas. Here, we report of a 45-year-old male with hyper-IgE syndrome who developed MDS transformed AML. Patient The patient had multiple erythematous papules and nodules with ulcerations on his face, left forearm, and legs. He had pancytopenia. Bone aspiration and biopsy were performed, which confirmed diagnosis of myelodysplastic syndrome with increased blasts. After 3+7 (idarubicin+cytarabine) induction chemotherapy, he had recurrent pneumonia, pre-septal cellulitis, a breast abscess, and catheter infection. We found elevated IgE. He was diagnosed with Hyperimmunoglobulin E syndrome. After receiving two cycles of azacytidine, he still had refractory disease. He was shifted to decitabine and venetoclax. He required intensive care unit hospitalization for gastrointestinal bleeding but passed away. Conclusion As in our case, hyperimmunoglobulin E syndrome should be considered in patients with hematological malignancies and recurrent soft tissue infections.

Thalidomide for refractory gastrointestinal bleeding from vascular malformations in patients with significant comorbidities.

BACKGROUNDRefractory gastrointestinal bleeding (GIB) secondary to gastrointestinal vascular malformations (GIVM) such as gastrointestinal angiodysplasia (GIAD) and gastric antral vascular ectasia (GAVE) remains challenging to treat when endoscopic therapy fails. Recently thalidomide has been suggested as a treatment option for refractory GIB.AIMTo determine the outcome of patients treated with thalidomide for refractory GIB due to GIVM.METHODSIRB approved, single center, retrospective review of electronic medical records from January 2012 to November 2018. Patients age > 18 years old, who had > 3 episodes of GIB refractory to medical or endoscopic therapy, and who had been treated with thalidomide for at least 3 mo were included. The primary endpoint was recurrence of GIB 6 mo after initiation of thalidomide.RESULTSFifteen patients were included in the study, all with significant cardiac, hepatic, or renal comorbidities. The cause of GIB was GIAD in 10 patients and GAVE in 5 patients. Two patients were lost to follow up. Of the 13 patients followed, 38.5% (n = 5) had no recurrent GIB or transfusion requirement after treatment with thalidomide. Furthermore, 84.6% (n = 11) of patients had a reduction in transfusion requirements and hospitalizations for GIB. Thalidomide was discontinued in 2 patients due to cost (n = 1) and medication interaction (n = 1). Reported adverse reactions included fatigue (n = 3), neuropathy (n = 2), dizziness (n = 1), and constipation (n = 1). Six patients died during follow up due to unknown cause (n = 4) and sepsis (n = 2).CONCLUSIONThalidomide appears to be an effective treatment for refractory GIB due to GIAD or GAVE in a Western population with significant comorbidities.

Discordance between the Clinical Presentation and Morphology of Myocardial Infarction in a Patient with Acute post-Hemorrhagic Anemia

While atherosclerotic plaque disruption remains the hallmark of type 1 myocardial infarction (T1MI), multiple other mechanisms provoking myocardial supply/demand mismatch (eg, anemia and tachyarrhythmias) are recognized as the potential causes of type 2 myocardial infarction (T2MI). In clinical practice, angiography is underutilized in patients with MI that have typical T2MI triggers, although the presence of these triggers and various forms of atherosclerotic coronary artery disease is not mutually exclusive. We describe a 70-year-old man that developed MI during hospitalization for gastrointestinal bleeding. He was treated conservatively without angiography due to posthemorrhagic anemia, which is a recognized T2MI trigger, and subsequently developed refractory cardiogenic shock. Autopsy revealed atherothrombosis, which is characteristic of T1MI.

SMAD4 mutation and the combined juvenile polyposis and hereditary hemorrhage telangiectasia syndrome: a single center experience.

Mutations of the SMAD4 gene can result in a distinct syndrome with combined clinical features of both juvenile polyposis syndrome (JPS) and hereditary hemorrhagic telangiectasia (HHT). Even though it is known that patients with the overlap syndrome are at increased risk for colorectal malignancies and bleeding, the outcomes of this patient population have not been extensively studied. Retrospective study aiming to describe the phenotype and clinical outcomes of patients with genetically confirmed JP-HHT combined syndrome in a single large tertiary center in North America. A total of 22 patients were identified, the majority females (59%) with a median age diagnosis at 24years. Polyps were more commonly seen in the lower gastrointestinal (GI) tract, and tubular adenomas were seen in 50%. Epistaxis and pulmonary arteriovenous malformations (AVM) were the most common manifestations of HHT, with a median Curacao score of 3 [1-4]. Hospitalization for gastrointestinal bleeding and cerebrovascular events occurred at a rate of 28% and 4%, respectively. Two patients had GI malignancies, one rectal and one small bowel adenocarcinoma. Overall mortality was 14%. Patients with the combined JP-HHT syndrome remain at risk for life-threatening vascular complications and gastrointestinal malignancies; close follow-up is necessary to minimize morbidity and mortality in this patient population.

Resuming Anticoagulation Following Hospitalization for Gastrointestinal Bleeding Is Associated with Reduced Thromboembolic Events and Improved Mortality: Results from a Systematic Review and Meta-Analysis.

Systemic anticoagulants are widely prescribed for prevention and treatment of thromboembolism, but are commonly complicated by gastrointestinal bleeding (GIB). Limited data exist on the management of anticoagulation after hospitalization for GIB and the subsequent risks of recurrent GIB, thromboembolism, and mortality. We performed a systematic review and meta-analysis of studies to determine risk of recurrent GIB, thromboembolism, and mortality after resuming anticoagulation following GIB. PubMed, EMBASE, and Scopus were searched for randomized controlled trials and cohort studies in patients with atrial fibrillation, venous thromboembolism, or valvular heart disease who received long-term warfarin or direct oral anticoagulants before experiencing GIB. Studies were included if data were available on anticoagulation management and outcomes of recurrent GIB, thromboembolism, and mortality following GIB. A total of 5354 studies were reviewed of which 10 were included in the meta-analysis. There were 2080 patients who resumed anticoagulation and 2296 patients who discontinued anticoagulation post-index GIB. Resumption of anticoagulation was associated with a significant increase in recurrent GIB (OR 1.646, 95% CI 1.035-2.617, p = 0.035). There was a significant decrease in thromboembolic events in patients who resumed anticoagulation compared to those who did not (OR 0.340, 95% CI 0.178-0.652, p = 0.001, I2 = 62.7%). Resumption of anticoagulation was associated with a significant reduction in all-cause mortality (OR 0.499, 95% CI 0.419-0.595, p < 0.0001). While resumption of anticoagulation following index GIB was associated with a significant increase in recurrent GIB, it was also associated with a significant decrease in thromboembolic events and all-cause mortality.

585 Risks of Recurrent Bleeding in Patients Hospitalized With Gastrointestinal Bleeding While on Warfarin vs Direct Oral Anticoagulants

INTRODUCTION: There is limited data on the management of anticoagulation following hospitalization for gastrointestinal bleeding (GIB) and the subsequent risks of recurrent GIB and thromboembolism in patients who are on warfarin compared to direct oral anticoagulants (DOACs). METHODS: We conducted a retrospective analysis of medical claims data from the IBM®MarketScan® Research Databases from January 1, 2008 through December 31, 2017. We collected data on adults with atrial fibrillation treated with warfarin or DOACs and subsequently hospitalized for GIB. Post discharge readmissions for recurrent GIB and thromboembolism within 180 days of initial discharge were reviewed. Univariable and multivariable cox regression were used to determine risks of recurrent GIB and thromboembolism. RESULTS: There were 2,991 patients hospitalized for GIB while on anticoagulants (warfarin, n = 1872; rivaroxaban, n = 676; dabigatran, n = 293; apixaban, n = 250). Differences between warfarin and DOAC users are reported in Table 1. Twenty-nine percent (n = 869) of warfarin users had warfarin resumed following discharge with a median time to resumption of 27 days (IQR 10-63), compared to 16% percent (n = 485) of DOAC users who had DOAC resumed (median time to resumption of 32 days (IQR 16-69). Discharge on warfarin was associated with the highest risk of recurrent GIB (HR 1.69, 95% CI 1.23-2.31) whereas discharge on dabigatran (HR 0.13, 95% CI 0.02-0.90) and apixaban (HR 0.38, 95% CI 0.14-1.01) had the lowest risk of recurrent GIB (Table 2). In a multivariable model adjusting for demographics, comorbidities, in-hospital management, source of bleeding, and post-discharge anticoagulant resumption, resumption of warfarin was associated with an increased risk of recurrent GIB (HR 1.53, 95% CI 1.07-2.18) compared to resumption of DOAC (HR 0.85, 95% CI 0.51-1.42). Variables associated with thromboembolism on multivariable regression included preceding venous thromboembolism (HR 2.42, 95% CI 1.66-3.51) and history of left ventricular assist device (HR 7.84, 95% CI 3.20-19.2). Survival analysis showed a significant association between type of anticoagulant on discharge and risk of recurrent GIB (log-rank, P = 0.001) (Figure 1). CONCLUSION: Resumption of warfarin following hospitalization for gastrointestinal bleeding was associated with an increased risk of recurrent GIB when compared to DOACs.

P4769Optimal rivaroxaban dose in Asian patients with atrial fibrillation and normal or mildly impaired renal function

Abstract Background Although rivaroxaban 15 mg was only given to patients with creatinine clearance (CrCl) &lt;50mL/min in the pivotal clinical trial, this dose has been commonly prescribed in Asian patients with non-valvular atrial fibrillation (AF) regardless of renal function. There is a paucity of information regarding the clinical outcomes of rivaroxaban 15 mg compared to rivaroxaban 20 mg in patients with CrCl ≥50mL/min. This study aimed to examine the effectiveness and safety of two doses of rivaroxaban in Asian patients with AF and CrCl ≥50mL/min. Methods Using the Korean National Health Insurance Service database, patients with AF and normal or mildly impaired renal function (CrCl ≥50mL/min) and naïve to rivaroxaban or warfarin were included from January 2014 to December 2016. Three separate 1:1 propensity score-matched cohorts were conducted: rivaroxaban 20 mg (R20) vs. warfarin (n=15,584), rivaroxaban 15 mg (R15) vs. warfarin (n=11,554), and R20 vs. R15 (n=10,392). Hazard ratios (HRs) for ischemic stroke, intracranial hemorrhage (ICH), gastrointestinal (GI) bleeding, major bleeding, all-cause death, and composite clinical outcome were analyzed. Results Among the pooled total study population, mean age was 66.9±10.9 years, 62.2% were male, mean CHA2DS2-VASc score was 3.16±1.79, and mean CrCl was 83.6±42.0 mL/min (median 78.4 mL/min, IQR 67.7–91.0 mL/min). A substantial proportion (42.6%) of patients with CrCl ≥50 mL/min were prescribed off-label R15 for stroke prevention in the Korean AF population. Compared to warfarin, both R20 and R15 showed significantly lower risk for ischemic stroke, major bleeding (mainly through reduction of ICH), and all-cause death (Figure). Overall, both R20 and R15 had better results for the composite clinical outcome compared to warfarin (HR: 0.617, 95% CI: 0.550–0.691 for R20, and HR: 0.759, 95% CI: 0.675–0.853 for R15). Compared to off-label R15, on-label R20 showed a nonsignificant trend toward lower risks of ischemic stroke, hospitalization for GI bleeding, hospitalization for major bleeding, and all-cause death. Overall, on-label R20 had better results for the composite clinical outcome compared to off-label R15 in patients with CrCl ≥50 mL/min (HR: 0.852, 95% CI: 0.735–0.988). This benefit was consistently observed in patients aged ≥80 years and those &lt;50 kg. In patients with CrCl 50–60 mL/min, R20 showed a nonsignificant trend toward a higher risk of hospitalization for major bleeding compared to R15 (HR: 1.828, 95% CI 0.994–3.452). Conclusions Among Asians with AF and CrCl ≥50mL/min, both R20 and R15 were associated with reduced risk of ischemic stroke, ICH, major bleeding, and all-cause death without significantly increased risk of GI bleeding compared with warfarin. In patients with CrCl ≥50mL/min, on-label R20 showed better results for the composite clinical outcome compared to off-label R15.