Indications For Antithrombotic Therapy Research Articles

Bleeding Risk Prediction in Patients Treated with Antithrombotic Drugs According to the Anatomic Site of Bleeding, Indication for Treatment, and Time Since Treatment Initiation.

Background Reasons for the relatively poor performance of bleeding prediction models are not well understood but may relate to differences in predictors for various anatomical sites of bleeding. Methods We pooled individual participant data from four randomized controlled trials of antithrombotic therapy in patients with coronary and peripheral artery diseases, embolic stroke of undetermined source (ESUS), or atrial fibrillation. We examined discrimination and calibration of models for any major bleeding, major gastrointestinal (GI) bleeding, and intracranial hemorrhage (ICH), according to the time since initiation of antithrombotic therapy, and indication for antithrombotic therapy. Results Of 57,813 patients included, 1,948 (3.37%) experienced major bleeding, including 717 (1.24%) major GI bleeding and 274 (0.47%) ICH. The model derived to predict major bleeding at 1 year from any site (c-index, 0.69, 95% confidence interval [CI], 0.68-0.71) performed similarly when applied to predict major GI bleeding (0.71, 0.69-0.74), but less well to predict ICH (0.64, 0.61-0.69). Models derived to predict GI bleeding (0.75, 0.74-0.78) and ICH (0.72, 0.70-0.79) performed better than the general major bleeding model. Discrimination declined over time since the initiation of antithrombotic treatment, stabilizing at approximately 2 years for any major bleeding and major GI bleeding and 1 year for ICH. Discrimination was best for the model predicting ICH in the ESUS population (0.82, 0.78-0.92) and worst for the model predicting any major bleeding in the coronary and peripheral artery disease population (0.66, 0.65-0.69). Conclusion Performance of risk prediction models for major bleeding is affected by site of bleeding, time since initiation of antithrombotic therapy, and indication for antithrombotic therapy.

Antiplatelet and Anti-Coagulation Therapy for Left-Sided Catheter Ablations: What Is beyond Atrial Fibrillation?

Aim: International guidelines on the use of anti-thrombotic therapies in left-sided ablations other than atrial fibrillation (AF) are lacking. The data regarding antiplatelet or anticoagulation strategies after catheter ablation (CA) procedures mainly derive from AF, whereas for the other arrhythmic substrates, the anti-thrombotic approach remains unclear. This survey aims to explore the current practices regarding antithrombotic management before, during, and after left-sided endocardial ablation, not including atrial fibrillation (AF), in patients without other indications for anti-thrombotic therapy. Material and Methods: Electrophysiologists were asked to answer a questionnaire containing questions on antiplatelet (APT) and anticoagulation therapy for the following left-sided procedures: accessory pathway (AP), atrial (AT), and ventricular tachycardia (VT) with and without structural heart disease (SHD). Results: We obtained 41 answers from 41 centers in 15 countries. For AP, before ablation, only four respondents (9.7%) used antiplatelets and two (4.9%) used anticoagulants. At discharge, APT therapy was prescribed by 22 respondents (53.7%), and oral anticoagulant therapy (OAC) only by one (2.4%). In patients with atrial tachycardia (AT), before ablation, APT prophylaxis was prescribed by only four respondents (9.7%) and OAC by eleven (26.8%). At discharge, APT was recommended by 12 respondents (29.3%) and OAC by 24 (58.5%). For VT without SHD, before CA, only six respondents (14.6%) suggested APT and three (7.3%) suggested OAC prophylaxis. At discharge, APT was recommended by fifteen respondents (36.6%) and OAC by five (12.2%). Regarding VT in SHD, before the procedure, eight respondents (19.5%) prescribed APT and five (12.2%) prescribed OAC prophylaxis. At discharge, the administration of anti-thrombotic therapy depended on the LV ejection fraction for eleven respondents (26.8%), on the procedure time for ten (24.4%), and on the radiofrequency time for four (9.8%), with a cut-off value from 1 to 30 min. Conclusions: Our survey indicates that the management of anti-thrombotic therapy surrounding left-sided endocardial ablation of patients without other indications for anti-thrombotic therapy is highly variable. Further studies are necessary to evaluate the safest approach to these procedures.

Clinical characteristics and outcomes of patients admitted with atrial fibrillation/atrial flutter to the Emergency Department

Aim: To determine the clinical characteristics and outcomes of patients with atrial fibrillation/atrial flutter (AF) admitted to the Emergency Department (ED). Material and methods: Patients with AF at ED admission with cardiac palpitations only, thromboembolic complications, hemorrhagic complications, hemo¬dynamic instability, other non-traumatic diseases, and trauma. Demographics, vitals, comorbidities, ECG, laboratory findings, treatment, and survival were analyzed. Results: There were 247 patients (55.1% women, 44.9% men) admitted to the ED aged 73.8±13.0 . A total of 226 (79.8%) patients were brought to the ED by Emergency Medical Services, and 121 (49%) had palpitations as a reason for admission. The hospitalization rate was 34%. About 60% of patients were on antithrombotic treatment. Among 45 patients with AF discharged home who were not previously treated with anticoagulants, all but three patients without indications for antithrombotic therapy, received a recommendation to be treated with anticoagulants, but only half of them received a prescription. During the follow-up of 1025 (773-1197), days died 67 (27.1%) patients, and 30-day mortality was 5.3%. The lowest mortality was found in patients admitted due to cardiac palpitations. Conclusions:1. The patients with AF admitted to the ED constitute a group of patients with a high hospitalization rate. 2. The reason for the admission to the ED of patients with AF divides this population into subgroups with different outcomes in terms of mortality and hospitalization.3. The patients discharged home who did not have been earlier treated with anticoagulants received suitable recommendations, however, only about half of them received a prescription for an anticoagulant.

Protocol design and preliminary evaluation of the REAL-Health Triple Aim, an open-cohort CVD-care optimisation initiative

IntroductionEffective treatment of cardiovascular disease (CVD) in primary care could be improved. We aim to assess the efficacy of a scalable treatment optimisation programme in unselected community populations in South East England, with the triple aim of improved blood pressure control in people with hypertension, increased high-intensity statin use in people with CVD and reduced gastrointestinal bleeding in patients on antithrombotic medication.MethodThis observational study comprises an open cohort of approximately 200,000 adults at high cardiovascular risk registered with general practitioners in five South East England Clinical Commissioning Groups (CCGs). An intervention programme is planned in four of these CCGs with a further non-intervention CCG acting as a control group. The intervention will consist of: clinical guidelines and educational outreach; virtual patient-reviews software; peer-performance “dashboards” and, where available, financial incentives.The study will examine 3 primary outcomes: 1. Diagnosed hypertension with a blood pressure <140/90mmHg; 2. Diagnosed CVD on a high-intensity statin; 3. A cardiovascular indication for antithrombotic therapy with one or more factors for increased risk of gastrointestinal bleeding (e.g. age ≥65) on gastroprotection. A further 17 secondary outcomes related to these three aims will be assessed.AnalysisWe will use an interrupted time series analysis over 18 months, representing the pre-implementation, implementation and the post-implementation phases with comparison to the control CCG and applicable national Quality and Outcomes Framework and national prescribing statistics (e.g. OpenPrescribing). Secondary outcomes include an equity impact analysis with results stratified by age, gender, ethnic group and index of deprivation.Preliminary dataWe present preliminary data on Key Performance Indicators (KPIs) collected from 191 GP practices including [percentage achievement on 01/09/2019, on 01/09/2020]: 1. Patients with hypertension and most recent blood pressure ≤140/90mmHg [68.7%, 60.6%]. 2. Patients eligible for treatment with a high-intensity statin on such treatment [53.8%, 55.8%]. 3. Patients on antithrombotics with ≥1 risk factors for gastrointestinal bleeding on gastroprotection [59.0%, 60.1%]. We also present our virtual patient-review software tool and outcome visualisation dashboard.ConclusionThe REAL-Health Triple Aim initiative is a large-scale primary care cardiovascular risk reduction initiative which was launched almost contemporaneously with the United Kingdom's first SARS-CoV-2 related lockdown. Preliminary data justify the need for the Triple Aim initiative and give us an insight on the impact of the pandemic on its implementation.FUNDunding AcknowledgementType of funding sources: Other. Main funding source(s): Barts CharityBritish Heart Foundation

Anticoagulant and antiplatelet treatment in cancer patients with thrombocytopenia

A B S T R A C T Antithrombotic therapy (anticoagulation or antiplatelet therapy) is frequently prescribed in cancer patients for prior or new indications such as venous thromboembolism, secondary prevention of arterial thrombosis or atrial fibrillation. Therefore, it is not uncommon for thrombocytopenic cancer patients to have an indication for antithrombotic therapy. Thrombocytopenia does not reduce the risk of recurrent thrombosis. The bleeding risk with anticoagulation appears to increase when platelets are <50×109/L, but individual platelet counts are poor predictors of bleeding. Management options when platelets are <50×109/L include no change, temporarily withholding antithrombotic therapy, reducing dose, changing the regimen, and increasing the platelet transfusion threshold. There are currently no data on use of direct oral anticoagulants when platelets are below 50×109/L, and there is reason in restricting their use. Little is known on antiplatelet therapy in this setting, although recent data suggest the prognostic importance and apparent safety of aspirin in acute myocardial infarction and thrombocytopenia. This paper will review the evidence, guidelines, current practice and ongoing studies on anticoagulation and antiplatelet therapy in thrombocytopenic patients with cancer.

Sa1245 AN EVALUATION OF THE COMPLICATION RISKS FOLLOWING PERORAL ENDOSCOPIC MYOTOMY IN PATIENTS ON ANTITHROMBOTIC THERAPY

Approximately nine thousand per oral endoscopic myotomies (POEM) have been performed since the procedure was first described in 2007. POEM is a safe and effective treatment for achalasia with a low complication rate. However, one potential complication is post-procedural bleeding. There are currently no guidelines for anticoagulation management before and after POEM. This study sought to investigate the incidence, management, and outcomes of bleeding complications after POEM for patients on anticoagulation or antiplatelet therapy. All patients who underwent a POEM between January 2011 to October 2019 at a single academic institution were included. The charts of patients on antithrombotic therapy at the time of surgery were reviewed for complications. Aspirin alone was not considered antithrombotic therapy for this study. The indication for antithrombotic therapy, days antithrombotics were held prior to surgery, and post-operative days until antithrombotic therapy was resumed were recorded. All NSQIP post-operative complications, including readmission, perforation, and gastrointestinal bleeding were reviewed. 224 POEM procedures were performed during the study period. Thirteen patients (5.8%) were on antithrombotic therapy at the time of their POEM (table 1). Four of these patients (30.7%) required an extended admission or a readmission for a complication. Two of the four complications were delayed gastrointestinal bleeding after resuming dual antiplatelet therapy, consisting of clopidogrel and aspirin. One patient had a submucosal tunnel leak and peri-operative atrial fibrillation, while the other patient was readmitted for pneumonia. Two out of three of the patients on the combination of clopidogrel and aspirin had a bleeding event post-operatively, requiring readmission and transfusion. Endoscopic or surgical intervention was not required for hemostasis. 30.7% of patients on antithrombotic therapy suffered from a post-operative complication, of which 15.4% was post-operative bleeding. This is much higher than the expected complication rate of <10% and 0.2% bleeding risk quoted in the literature. Patients on antithrombotic therapy should be counseled regarding their higher complication risk. Particular attention should be paid to patients on dual antiplatelet therapy with clopidogrel and aspirin, as the only post-operative bleeds in this cohort occurred in these patients. Safe timing of post-operative resumption of antithrombotic medications remains a difficult decision that must be carefully considered by the endoscopist.

Abstract WP235: Risk of Arterial Ischemic Events After Non-Traumatic Subdural Hemorrhage

Introduction: To study the risk of arterial ischemic events after non-traumatic subdural hemorrhage (SDH). Methods: We performed a retrospective cohort study using inpatient and outpatient claims data from 2008-2015 from a nationally representative 5% sample of Medicare beneficiaries. The exposure was diagnosis of SDH. Our primary outcome was an arterial ischemic event defined as a composite of acute ischemic stroke and acute myocardial infarction (MI). Secondary outcomes were ischemic stroke alone and MI alone. We used validated ICD-9-CM diagnosis codes to identify our predictor and outcomes. We excluded patients who had an arterial ischemic event prior to SDH diagnosis. Using Cox regression and corresponding survival probabilities, adjusted for demographics and vascular comorbidities, we computed the hazard ratio (HR) in each 4-week interval after discharge for SDH. We performed secondary analyses stratified by strong indications for antithrombotic therapy (composite of atrial fibrillation, peripheral vascular disease, valvular heart disease and venous thromboembolism). Results: Among 1.7 million Medicare beneficiaries, 2,939 were diagnosed with SDH. Compared to patients without SDH, those with SDH were more often older, male, and had more vascular risk factors. In the 4 weeks after SDH, patients’ risk of an arterial ischemic event was substantially increased (HR, 4.2; 95% CI, 2.2-6.7). There was no association between SDH diagnosis and arterial ischemic event risk beyond 4 weeks. In secondary analysis, during the 4 weeks after SDH, patients’ risk of ischemic stroke was increased (HR, 5.6; 95% CI, 3.6-9.7) but not their risk of MI (HR, 0.8, 95% CI, 0.2-1.7). Patients with strong indications for antithrombotic therapy had similarly increased risks for arterial ischemic events as compared to patients in the primary analysis; patients without strong indications for antithrombotic did not demonstrate an increased risk for arterial ischemic events. Conclusions: Among Medicare beneficiaries, we found a heightened risk of arterial ischemic events, particularly ischemic stroke, in the four weeks after SDH. This increased risk may be driven by withholding of antithrombotic therapy after SDH diagnosis.

Issue Highlights

Issue Highlights

Stroke : Highlights of Selected Articles

<i>Stroke</i> : Highlights of Selected Articles

Popliteal vein aneurysm: Is it necessary to apply anticoagulants after a surgery?

SummaryAim: This study is intended to evaluate indications for antithrombotic therapy in patients with tangentially resected popliteal vein aneurysm.Methods: Evaluation of the course of therapy in a patient with popliteal vein aneurysm. Literature review covered literature data published within the last decade. Studies were identified by searching Medline and PubMed databases for the following phrases: ”popliteal venous aneurysm” and ”popliteal vein aneurysm”.Results: The case study and literature review revealed that thromboembolic risk cannot be entirely eliminated by means of tangential resection of popliteal vein aneurysm. Vein suture and residual postoperative dilatation of the popliteal vein can be considered predisposing factors to thromboembolic complications.Conclusion: Patients with tangentially resected popliteal vein aneurysm involving vein suture can be administered oral antithrombotic therapy within three months postoperatively. Therapy extension should be made conditional on the degree of vein dilation reduction. Where the diameter at surgical site is larger than 20 mm, it appears appropriate to continue antithrombotic therapy and to repeat assessment in six months time.

LEFT ATRIAL APPENDAGE MORPHOLOGY AND RISK OF STROKE IN PATIENTS WITH AF AND CHADS2 SCORE 0-1: IS THERE AN ASSOCIATION?

In pts with atrial fibrillation (AF) and CHADS2 score 0-1 the indication for antithrombotic therapy is controversial. We evaluated different LAA morphologies by computed tomography (CT) and by magnetic resonance imaging (MRI) in pts with CHADS2 score 0-1 and AF to correlate the different

Antithrombotic Treatment in Neonatal Cerebral Sinovenous Thrombosis: Results of the International Pediatric Stroke Study

To identify predictors of antithrombotic treatment in neonates with cerebral sinovenous thrombosis (CSVT) in a large multinational study. Neonates with CSVT from 10 countries were enrolled in the International Pediatric Stroke Study from 2003 through 2007. Term neonates with CSVT who presented with neurologic symptoms or signs of systemic illness and neuroimaging evidence of thrombus or flow interruption within cerebral venous system were included. Of 341 neonates enrolled, 84 had isolated CSVT. Neuroimaging findings, available in 67/84 neonates, included venous ischemic infarction in 5, hemorrhagic infarction or other intracranial hemorrhage in 13, both infarction and hemorrhage in 26, and no parenchymal lesions in 23. Treatment data, available in 81/84 neonates, included antithrombotic medications in 52% (n = 43), comprising heparin (n = 14), low molecular weight heparin (n = 34), warfarin (n = 1), and aspirin (n = 2). By univariate logistic regression analysis, deep venous system thrombosis (P = .05) and location in the United States (P = .001) predicted nontreatment. Presence of infarction, hemorrhage, dehydration, systemic illness, and age did not predict treatment or nontreatment. In multivariate analysis only geographic location remained significant. In neonatal CSVT, regional antithrombotic treatment practices demonstrate considerable variability and uncertainty about indications for antithrombotic therapy. Additional studies are warranted.

Indication for antithrombotic therapy for atrial fibrillation: reconciling the guidelines with clinical practice

Cardioembolic stroke secondary to atrial fibrillation (AF) is an urgent public-health problem. On the basis of the data from several randomized controlled clinical trials and pooled analyses, several guidelines have been published to promote the use of anticoagulant treatment to prevent stroke in patients with AF. Current evidence-based guidelines recommend long-term anticoagulation for most patients with AF. However, only a small proportion of patients with AF whom best-practice guidelines identify as eligible for oral anticoagulant therapy actually receive it. One explanation for this low implementation is attributed to the high selection criteria of patients in randomized clinical studies, which often included patients with a lower risk of bleeding than those treated in clinical practice. Indeed, the fear of bleeding is a major consideration when implementing anticoagulation therapy as the risk of bleeding may be higher than the risk of stroke for some patients, which may explain why some physicians do not perceive the guidelines to be fully justified in clinical practice. Considering the complexities surrounding prescribing oral anticoagulation in patients with AF, new drugs with a better benefit/risk ratio are therefore required in the armamentarium for the prevention of thromboembolic events in patients with AF.

Alterations of platelet, coagulation, and fibrinolysis markers in patients with acute ischemic stroke.

Alterations of platelet, coagulation, and fibrinolysis markers were investigated to determine the indications for antithrombotic therapy in patients with different clinical categories of acute cerebral infarction. Marked platelet activation was observed in platelet function tests, including measurements of platelet-specific proteins and platelet survival, platelet scintigraphy in the brain, and platelet fibrinogen binding assay, in patients with atherothrombotic stroke. Among patients with atherothrombotic stroke, increases of thrombin-antithrombin III complex (TAT) and D-dimer were frequent in addition to the findings of platelet activation in patients showing progressing stroke. Patients with cardioembolic stroke demonstrated marked elevation of coagulation markers, TAT and fibrinopeptide A, and fibrinolysis markers, D-dimer and plasmin-alpha2-plasmin inhibitor complex, as well as platelet activation. In contrast, neither activation was seen in patients with lacunar stroke. On the basis of these findings, antiplatelet therapy is indicated for stable or improving stroke, whereas anticoagulant therapy is indicated for progressing stroke among patients with atherothrombotic stroke. In patients with cardioembolic stroke, anticoagulant therapy should be started as soon as possible, or should be followed by thrombolytic therapy in the hyperacute phase. However, further investigation appears necessary for recommendations for patients with lacunar stroke.