Initiation Of Anticoagulant Therapy Research Articles

ATRIAL FIBRILLATION IN A CIED POPULATION: RESULTS FROM A TELEMONITORING FOLLOW–UP

Abstract Background Telemedicine has emerged as a crucial tool in managing patients with Cardiac Implantable Electronic Devices (CIED), addressing the common challenge of the Atrial Fibrillation (AF) in cardiology. The incidence of AF in CIED recipients varies widely (30–70%), influenced by implant indication, device type, and population characteristics. This study aims to evaluate AF in an unselected, real–world CIED population, considering patients’ characteristics and the remote follow–up. Methods and Results 808 consecutive CIED recipients were evaluated between 2021 and 2023 in two Italian Division of Cardiology by collecting patients’ baseline characteristics and the scheduled remote follow–up data. Mean age was 75.6±12.6 years, 42% were females. 16.7% of the population was working actively and 73% of individuals were assisted by at least one caregiver, reflecting a diminished quality of life (EQ–5D score 8.9±4.3). Over a median follow–up of 20.6 months, 8.9% of patients died. 68.8% of the patients received a pacemaker, 19.3% an ICD and 11.9% a loop recorder. History of AF was present in 40.1% of the population, with a prevalence of permanent AF (46.6%). Ongoing anticoagulant therapy was documented in 303 patients (37.5%), 71% of whom were taking direct oral anticoagulants. Baseline CHA2DS2–VASC score was ≥3 in 79.7%, and the median HAS–BLED score was 1. During the observation period, scheduled remote transmissions revealed 719 AF episodes (15.7 episodes/patient/year), causing 21% of the overall remote alarms. Among patients without AF history, 69 (14.3%) experienced AF episodes (4.8 episodes/patient/year). Notably, 21.8% of the AF episodes lasted less than 10 minutes. Conclusions The wide spreading of heart rhythm monitoring technologies reveals the challenge of the subclinical AF in healthcare systems. This study, encompassing an unselected CIED population of elderly and frail patients with high AF prevalence, highlights AF as a primary cause of remote alerts and a substantial burden in telemonitoring controls. Telemedicine facilitated new AF diagnoses in 14.3% of individuals without a prior AF history and resulted a valuable tool considering the significant cardioembolic risk in these patients. However, the initiation of anticoagulation therapy remains debatable, especially for episodes of brief duration which in our experience exceeded 20% of the cases.

Screening and diagnosis of atrial fibrillation using wearable devices.

In recent years, the development and use of various devices for the screening of atrial fibrillation (AF) have significantly increased. Such devices include 12-lead electrocardiogram (ECG), photoplethysmography systems, and single-lead ECG and ECG patches. This review outlines several studies that have focused on the feasibility and efficacy of such devices for AF screening, and summarizes the risks and benefits involved in the initiation of anticoagulant therapy after early detection of AF. We also describe several ongoing trials on unresolved issues associated with AF screening. Overall, this review provides a comprehensive summary of the current state of AF screening and its implications for patient care.

Determining The Risk of Atrial Fibrillation Paroxysm in Patients With Chronic Heart Failure With Intact and Reduced Ejection Fraction.

To determine predictors for the development of atrial fibrillation (AF) in patients with chronic heart failure (CHF) with preserved and reduced ejection fraction by echocardiography (EchoCG) according to an extended protocol with determination of diastolic function and left atrial global strain. Data of 168 patients with stage I-III CHF without a history of AF were analyzed. All patients underwent echocardiography according to an extended protocol with the determination of diastolic dysfunction (DD), left atrial ejection fraction (LA EF), and left atrial global strain (LA GS). Tissue Doppler imaging (TDI) was used to evaluate the early (E) and late (A) LV filling velocity and the early (E') and late (A') diastolic mitral annular velocity. In all patients, Holter ECG monitoring (HM ECG) of heart rhythm was performed for 3 days, and ECG monitoring with telemedicine technologies was performed for 7 days, 3 times a day for 3 minutes. The follow-up period was 3 months or until an AF episode. During the study, paroxysmal AF (pAF) was detected in 41 (24.4%) patients using various methods of heart rhythm monitoring. Complaints of palpitations were noted for 10 (24.4%) patients during pAF, which was recorded using a CardioQVARK® device, HM ECG or a 12-lead ECG. In 5 (12.2%) patients, daily ECG monitoring revealed pAF without associated complaints. HM ECG detected 8, 2, 4 (19.5%, 4.8%, and 9.7%) cases during 24, 48 and 72 hours, respectively; a single-channel CardioQVARK® detected 30 (73.2%) cases when used 3 times a day for 7 days. These results showed that AF frequently develops in CHF without accompanying symptoms. The method for detecting pAF with CardioQVARK® showed good results: it was twice more effective than HM ECG and three times more effective than 12-lead ECG. Also, according to ultrasound data, significant changes in the following parameters were noted in patients with AF: LA EF <36% (OR 1.04, 95% CI: 1.02-1.08), p=0.003; LA GS <9.9% (OR 1.16, 95% CI: 1.02-1.38), p<0.001; TDI E med <5.7 cm/s (OR 0.97, 95% CI: 0.94-1.00), p=0.026. Grade 2 DD did not show statistically significant results (OR 1.1, 95% CI: 0.7-1.5, p=0.54). However, it was detected more frequently in patients with AF, in 34% of cases, compared to 29% of cases in patients without AF, which requires further study on a larger patient sample. Patients with CHF have a high risk of developing pAF (24.4%). 75% of patients with AF do not feel the development of paroxysm. All CHF patients should undergo EchoCG with assessment of LA EF, TDI E med and LA GS to identify a group at risk for the development of AF. Heart rhythm remote monitoring with CardioQVARK® devices can be considered a reliable method for early detection of pAF and timely initiation of anticoagulant therapy in patients with CHF.

Acute Kidney Injury in Different Anticoagulation Strategies: A Large-Scale Pharmacoepidemiologic Study Using Real-World Data.

Acute kidney injury (AKI) following anticoagulant application has received growing attention as a significant emerging complication of anticoagulation. Nevertheless, there remains a lack of real-world studies to compare the incidence, clinical features, and prognosis of AKI across different anticoagulant regimens. Disproportionality analysis and Bayesian analysis were used to identify suspected AKI cases after different anticoagulant use within the Food and Drug Administration's Adverse Event Reporting System from January 2004 to March 2023. The time to onset, fatality, and hospitalization rates of anticoagulant-associated AKI were also investigated. We identified 9313 anticoagulant-associated AKIs, which appeared to influence mostly patients over 65 years old (65.37%). Lepirudin displayed a stronger AKI association than others, based on the highest reporting odds ratio (ROR = 6.66, 95% CI = 3.97-11.18), proportional reporting ratio (PRR = 6.08, χ2 = 69.12), and empirical Bayes geometric mean (EBGM = 6.08, the lower 90% one-sided CI = 3.95). Warfarin showed the slightest association with AKI in oral anticoagulants, lower than any direct oral anticoagulants excluding apixaban. Edoxaban exhibited the highest potential renal risk among direct oral anticoagulants, with an ROR of 3.32 (95% CI = 2.95-3.72). The median time to AKI onset was 36 (IQR 7-205) days following the initiation of anticoagulation therapy, and most AKI cases occurred within the first month. Particular attention should be directed toward monitoring renal function in individuals receiving anticoagulants, including warfarin and direct oral anticoagulants, as well as other anticoagulant agents. This diligence is particularly imperative within the first month after anticoagulant administration for individuals with a tendency for AKI.

A Tale of 2 Morbid Complications in a Patient With Takotsubo Cardiomyopathy.

A 66-year-old female was found hypotensive in ventricular tachycardia (V-tach). Workup confirmed septic shock and takotsubo cardiomyopathy (TCM) with left ventricular (LV) thrombus. Despite the initiation of anticoagulation therapy, she developed an embolic stroke on day 14. Malignant ventricular arrhythmia and LV thrombosis are rare complications of TCM. However, there is no specific guideline regarding prophylactic anticoagulation.

Atrial Fibrillation Prevalence and Its Management in Transfusion-Dependent Thalassemias: The Fathal Study

Atrial fibrillation (AF) represents an emerging issue in the thalassemia population related to increased life expectancy. However, data on AF in these patients are limited, and the current management is based on the guidelines for the general population. Nevertheless, AF in these patients has distinctive features that could require specific management. We conducted a multicentric retrospective study supported by the Italian Society of Thalassemia and Hemoglobinopathies (SITE) to elucidate the prevalence of AF in transfusion-dependent thalassemia (TDT) adults in Italy and to study its management, particularly the use of transcatheter ablation and anticoagulation management. Patients followed between June 1, 2003 and May 31, 2023 with a diagnosis of alpha- or beta-transfusion-dependent thalassemia with at least one episode of AF were included in the study. Clinical data of patients have been retrospectively collected with dedicated digital case report form (CRF). So far, 3 centers (Cagliari, Ferrara, Milano) have participated in the study. Eight-hundred-sixty-one adult TDT patients are regularly followed in the participating centers. Data from 130 adult TDT with AF were included. At enrollment, 119 patients were alive (71 males, 60%), the mean age at enrollment was 51.9 years, and 71% were splenectomized. Almost all (98%) had beta-thalassemia, of which 20% had thalassemia intermedia and became transfusion dependent during their life. The mean age at the first AF episode was 39.7 yr. Overall, AF prevalence in TDT was 13.8%, with a significant rise above the age of 50 (age 51-65: prevalence 26.4%, age>65 33.3%), differently from the general population in which the prevalence is 2-4%, and patients are older. As in the general population, prevalence was higher in males (18.2% vs 10.2%). Among the known risk factors for AF, the most frequent were diabetes (16%, n=111) and previous heart failure (22%, n=111). Regarding disease-specific factors contributing to the pathophysiology of AF, cardiac iron overload, defined as at least one between T2*<20 ms and serum ferritin>2500 ng/ml, was present in half of the patients (48.7%, n=76) at any time before AF and in approximately one-third (29%, n=93) at the time of the first event. Thirty-eight patients did not show cardiac iron overload before or at the time of the first AF episode. Most subjects had left atrial dilatation (58.1%), which can result from chronically increased cardiac output due to anemia. In most patients (87%), a rhythm control strategy was chosen at any time. Amiodarone was the most widely used drug. Transcatheter ablation was performed in 29 patients (22%), with a total of 39 procedures, and 20 (77%) patients reported improvement in symptoms after the last ablation. CHA 2DS 2-VASc score at the first AF episode detected a low risk of thromboembolism in 66 (50.8%) patients and a high risk in 19 (14.6%). However, 72 patients, including 40 low-risk subjects, initiated anticoagulation after the first episode. Four patients had a hemorrhagic event (3.1%), but only one had major bleeding during anticoagulant therapy without significant sequelae. Interestingly, management was heterogenous between different centers for both transcatheter ablation use and anticoagulation strategy. The prevalence of stroke in TDT AF patients was 5%, rising to 7.6% when also considering transient ischemic attacks. Compared to the literature, this prevalence is at least 10-fold higher than the general TDT population. Of note, splenectomy, a well-known risk factor for thrombosis, was present in all patients with stroke at the time of the event. In conclusion, AF represents significant morbidity in adult TDT, and its management is heterogeneous. It generally occurs at a younger age than the general population, and iron overload and atrial dilatation play a central role in its genesis. For symptomatic patients, we propose a rhythm control strategy to improve their quality of life, among which ablation could be the best option. Moreover, because stroke represents a major and frequent complication in TDT patients with AF, early detection of AF and prompt initiation of anticoagulant therapy, irrespective of CHA 2DS 2-VASc, which does not capture potential disease-specific risk factors, including splenectomy, should be considered. Further studies to support our approach are needed.

Does early initiation of anticoagulant therapy minimize the need for maternal respiratory support in COVID-19 positive pregnant women?

Does early initiation of anticoagulant therapy minimize the need for maternal respiratory support in COVID-19 positive pregnant women?

Dynamic change in anticoagulation pattern at age 65 years in patients with atrial fibrillation and prior low thromboembolic risk

Abstract Background Atrial Fibrillation (AF) is common in elderly patients. Age ≥65 years is an independent thromboembolic risk factor in patients with AF and is an indication for the initiation of anticoagulant therapy based on CHA2DS2VASc scale. Despite this, it may be controversial to justify an arbitrary cut-off for a continuous variable to determine that risk. Objectives The primary endpoint was to assess whether the initiation of anticoagulation therapy in patients who were 65 years old prevents ischemic stroke events in low thromboembolic risk individuals at baseline (CHA2DS2VASc 0 points in male and 1 in women). Another aim was to evaluate whether there were differences in major bleeding events in this population. Methods We used data from the CardioCHUVI-AF registry that included 16202 patients with a diagnosis of AF from the Vigo Health Area between January 2014 and January 2018 Of these, 861 individuals (5.3%) had low embolic risk at baseline. Eight patients with Hypertrophic Cardiomyopathy, 26 with mechanical prostheses and 3 with mitral stenosis were excluded. Of the remaining 824 patients, 389 (2.4%) ceased to belong to this low embolic risk group due to age (≥65 years) during the follow-up period. Univariate analysis was performed with age ≥65 years to compare the incidence of ischemic stroke and major bleeding events in anticoagulated patients with those in non-anticoagulated patients. Results A total of 389 patients with a diagnosis of AF and initial low embolic risk were followed for 8.1±1.5 years (median 8.9, IQR 7.8-9.0 years). The mean age at the start of follow-up was 60.9±2.7 years. Before the age of 65, 187 patients (48.1%) were anticoagulated. A total of 261 patients were under anticoagulant treatment after turn to 65 years (67.1%, an increase of 19.0% in the rate of anticoagulation). Therefore, 32.9% of the individuals were not anticoagulated despite the fact that they had an indication at that time. In the Kaplan-Meier curves of our study population before reaching 65 years of age, no significant differences were observed in the rate of ischemic stroke events between anticoagulated and non-anticoagulated patients [HR, 1.22; 95%CI 0.41-3.64; p=0.718] or in the rate of major bleeding [HR 1.03, 95%CI 0.36-2.95; p=0.949]. However, in the same population that had already reached 65 years of age at the end of follow-up, statistically significant differences were observed in favor of anticoagulated patients in the incidence of ischemic stroke [HR 0.19, 95%CI 0.05-0.77; p=0.020] without an increase in the rate of hemorrhagic events [HR 0.85, 95%CI 0.32-2.27; p=0.745]. Conclusions Our registry highlights the dynamic nature of the CHA2DS2VASc scale based on age. Thus, patients with a CHA2DS2VASc score of 0 points (1 if they are women) who are close to 65 years should be evaluated periodically, starting anticoagulation therapy at that age.

Reduced fibrin clot permeability on admission and elevated E-selectin at 3 months as novel risk factors of residual pulmonary vascular obstruction in patients with acute pulmonary embolism

BackgroundResidual pulmonary vascular obstruction (RPVO) is common following pulmonary embolism (PE) but its association with fibrin clot properties is poorly understood. We investigated whether prothrombotic state and hypofibrinolysis markers can identify patients with RPVO.MethodsIn 79 normotensive noncancer patients (aged 56 ± 13.3 years) with acute PE, we determined fibrin clot permeability (Ks), clot lysis time (CLT), endogenous thrombin potential (ETP), fibrinolysis proteins, oxidative stress markers, and E-selectin on admission before initiation of anticoagulant therapy, after 5–7 days, and 3 months of anticoagulation. RPVO was diagnosed using computed tomography angiography 3–6 months since PE.ResultsPatients with RPVO (n = 23, 29.1%) had at baseline higher simplified Pulmonary Embolism Severity Index (sPESI) (P = 0.004), higher N-terminal brain natriuretic propeptide (P = 0.006) and higher D-dimer (P = 0.044). Patients with versus without RPVO had lower Ks (P < 0.001) and longer CLT (P < 0.05), both at baseline and 5–7 days since admission, but not at 3 months. Patients with RPVO showed 40.6% higher E-selectin (P < 0.001) solely at 3 months. By multivariable logistic regression, baseline Ks (odds ratio [OR] 0.010, 95% confidence interval [CI] 0.001–0.837, P = 0.042, per 10− 9 cm2), baseline D-dimer (OR 1.105, 95% CI 1.000-1.221, P = 0.049, per 100 ng/ml), and E-selectin levels after 3 months (OR 3.874, 95% CI 1.239–12.116, P = 0.020, per 1 ng/ml) were associated with RPVO.ConclusionsRPVO patients despite anticoagulation characterize with the formation of denser fibrin clots on admission and higher E-selectin at 3 months. Those parameters could be the potential novel RPVO risk factors that warrant further evaluation in an independent cohort.Graphical

Incidence of Documented Atrial Arrhythmias in Patients with Dual Chamber Cardiac Implantable Devices

Abstract Background Atrial fibrillation (AF) is the most common sustained atrial arrhythmia, and is associated with increased risks of morbidity and mortality. Integrated management including anticoagulation therapy in patients with AF is increasingly recognized, but there are still a substantial number of AF patients admitted with stroke, heart failure, and other complications. This can be to some extent due to asymptomatic nature of AF as approximately one-third of patients did not report any symptoms commonly attributable to AF (e.g., palpitations, shortness of breath, or chest pain), leading to a prolonged delay in AF diagnosis and timely initiation of anticoagulation therapy. In many cases, asymptomatic AF is diagnosed only after the onset of complications such as ischemic stroke or congestive heart failure has occurred. Objective This work aims at documenting atrial arrhythmias in patients with dual chamber cardiac implantable devices. Patients and Methods This study included 200 patients who were undergoing follow up of dual chamber cardiac implantable devices. The study was carried out in pacemaker follow up clinics at Ain Shams University hospitals and National Heart Institute. Results According to the results of the current study we concluded diabetes Mellitus, ischemic heart diseases, decreased function (EF ≤ 48%) and dilated LA &amp; LV dimensions (LVIDd &amp;gt;48 mm, LVIDs &amp;gt;41 mm, LA diameter &amp;gt;52 mm), are significant factors associated with AHREs in patients with dual chamber cardiac implantable devices. But unfortunately we cannot assess precisely the impact of AHRE on stroke or thromboembolism development in such patients due to the relatively small number of patients were included in the present study, which may have reduced the detection power and possibly influenced the validity of some results. Conclusion Diabetes Mellitus, ischemic heart diseases, decreased function (EF ≤ 48%) and dilated LA &amp; LV dimensions (LVIDd &amp;gt;48 mm, LVIDs &amp;gt;41 mm, LA diameter &amp;gt;52 mm), are significant factors associated with AHREs in patients with dual chamber cardiac implantable devices. Abbreviations AF: Atrial fibrillation; AHRE: Atrial high rate episodes; AT: Atrial Tachycardia; BMI: Body mass index; CI: Confidence intervals; CIED: Cardiac implantable electronic devices; CRT: Cardiac resynchronization therapy; DDD: Dual chamber Device DM: Diabetes Mellitus; ECG: Electrocardiogram; EF: Ejection Fraction; HbA1c: Hemoglobin A1c; HR: Hazard Ratio; ICD: Implantable cardioverter defibrillator; IHD: Ischemic heart disease; INR: International Normalized Ratio; LA: Left atrium; LVIDd: Left ventricular internal dimensions (Diastole); LVIDs: Left ventricular internal dimensions (Systole); MOST: Mode Selection Trial; OR: Odds ratio; ROC: Receiver operating characteristic curve; AUC: Area Under Curve; SCAF: Subclinical AF

Comparison of early and delayed anticoagulation therapy after ischemic stroke in patients with atrial fibrillation: a systematic review and meta-analysis.

The optimal initiation timing of oral anticoagulants (OACs) remains controversial in patients with atrial fibrillation (AF)-related acute ischemic stroke (AIS). The aim of this study is to compare the efficacy and safety of early OACs initiation with that of the delayed initiation for AIS and AF.We searched systematically the following mainstream databases: PubMed, Embase, and Web of Science from the inception to July 2023 for studies that compared the early initiation with the delayed initiation of OACs for AF-related AIS patients. Outcome measures were the incidence of hemorrhagic events, ischemic events, and combined outcomes, as well as all-cause mortality.There were 12 eligible articles included (10 cohort studies and 2 RCT), involving 11421 patients (5690 patients in the early-initiation group and 5731 in the delayed-initiation group). Meta-analysis revealed that patients receiving OACs at the early stage of stroke had a lower incidence of ischemic events (OR: 0.68; 95% CI: 0.55,0.84; p = 0.0003) and combined outcomes (OR=0.74, 95% CI (0.57,0.95), p=0.02). No significant differences were identified in the incidence of hemorrhagic events (p = 0.26) and all-cause mortality ( p = 0.20) between the groups.Early initiation of anticoagulation therapy would be preferable in lowering the incidence of ischemic events and combined outcomes in AIS patients with AF. It is safe compared to the delayed-initiation strategy. However, the conclusion of this study needs to be further validated by more well-designed RCTs.

Anaesthetic management of an infant with severe protein C deficiency and septal cardiac defects—a case report

BackgroundProtein C deficiency is a rare genetic disorder with varying severity of symptoms and disease. The disorder may vary in presentation from a complete symptomless state to a less severe form like venous thromboembolism. The most severe form of disease is a rare condition called neonatal purpura fulminans (NPF) which is characterized with sudden progressive dermal hemorrhage and necrosis due to vascular thrombosis and disseminated intravascular coagulation. In contrast, congenital atrial and ventricular septal defects are the commonest congenital heart diseases found in pediatric population. An infant presenting with systemic vascular thromboembolism secondary to protein C deficiency along with the cardiac septal defects posted for surgery will be a very challenging task to manage in perioperative period. Also, physiological mechanisms during perioperative period and surgery will promote thromboembolism leading to worsening of the situation further. So, perioperative management of such patient pose a great challenge to the anaesthesiologist. Due to rarity of the condition, there is very limited literature available.Case presentationWe report the perioperative management of a 2-month-old child suffering with neonatal purpura fulminans with atrial and ventricular septal cardiac defect, scheduled for bilateral foot amputation. The patient was a diagnosed with complete occlusion of abdominal aorta leading to foot gangrene. After initiation of anticoagulant therapy, symptoms were relieved and patient was posted for amputation of gangrenous feet.ConclusionsThere could be an increased risk of thromboembolism and bleeding due to protein C abnormality along with the chances of shunt reversal, paradoxical embolism, and other cardiac morbidities secondary to septal defects. Wise selection of anaesthetic agents like limiting the use of nitrous oxide, ketamine as much as possible to be considered. Conditions like tachycardia, hypotension, and hypothermia should also be prevented perioperatively as these could increase the chances of thrombosis.

Clinical course and diagnosis of cerebral vein and sinus thrombosis associated with COVID-19 in young and middle-aged patients

Cerebral venous thrombosis (CVT) is a form of cerebrovascular disorders that is difficult to recognize, it is potentially a life threatening condition and requires timely anticoagulant therapy. In the era of the COVID-19 pandemic, there is a steady increase in CVT (4.2% vs. 0.5–1%). At the same time, mortality in patients with CVT on the background of COVID-19 significantly exceeds the mortality in patients with CVT without COVID-19 (45.5% vs. 15%). Objective: to study the clinical course of CVT, to determine the diagnostic value of radiological methods and the significance of genetic risk factors for thrombosis in the development of CVT in young and middle-aged patients against the background of COVID-19. Material and methods. Seven patients were examined: six women (five of them of reproductive age) and one man, aged 26 to 57 years (mean age 37 years). The main clinical and neurological manifestations of CVT, the results of laboratory examination, neuroimaging, and the data of molecular genetic analysis of risk factors for thrombosis were analyzed. Results. The course of COVID-19 was severe in one case, and moderate in the rest of cases. The interval between the onset of COVID-19 symptoms and the development of CVT ranged from 7 to 25 days. In three cases CVT had an acute course and was accompanied by the development of a stroke (in two cases, hemorrhagic stroke was noted, in one case, multifocal ischemic stroke), in other cases, a subacute course of CVT was noted. Genetic risk factors for thrombosis were identified in all patients.Conclusion. The diagnosis of CVT in the era of the COVID-19 pandemic is particularly difficult, since the most common symptom of CVT – headache (90%) – can be regarded as a manifestation of COVID-19. At the same time, timely diagnosis of CVT and immediate initiation of anticoagulant therapy are associated with a relatively favorable prognosis.

Progress in the treatment of acute pulmonary embolism and chronic thrombo-embolic pulmonary hypertension/disease.

The combination of an initial clinical approach aimed at evaluating the early risk of mortality with subsequent diagnostic and therapeutic approaches articulated on the overall patient's profile is recommended in acute pulmonary embolism (PE). The presence of pulmonary hypertension associated with the persistence of chronic vascular obstructions in the pulmonary arteries after one or more acute thrombo-embolic events identifies a condition defined as chronic thrombo-embolic pulmonary hypertension (CTEPH). The evolution of technology and knowledge in the field of imaging has allowed us to qualify the computed tomography angiography of the pulmonary arteries as the gold standard for the diagnostic confirmation of both acute PE and CTEPH. In both these conditions, the first therapeutic step is the immediate initiation of anticoagulant therapy. In acute high-risk PE, in addition to anticoagulant therapy, thrombolytic therapy is recommended; in the event of contraindications to thrombolysis, surgical embolectomy or percutaneous catheter-directed treatment represents viable treatment options. In CTEPH, the combination of data collected from cardiac catheterization, computed tomography angiography, and conventional angiography of pulmonary arteries allows a team of experts to identify candidates for pulmonary endarterectomy surgery. Inoperable patients should be considered for percutaneous balloon angioplasty of the pulmonary arteries which can improve patients' symptoms, quality of life, and prognosis.

Ability to remotely monitor atrial high-rate episodes using a single-chamber implantable cardioverter-defibrillator with a floating atrial sensing dipole.

To allow timely initiation of anticoagulation therapy for the prevention of stroke, the European guidelines on atrial fibrillation (AF) recommend remote monitoring (RM) of device-detected atrial high-rate episodes (AHREs) and progression of arrhythmia duration along pre-specified strata (6 min…<1 h, 1 h…<24 h, ≥ 24 h). We used the MATRIX registry data to assess the capability of a single-lead implantable cardioverter-defibrillator (ICD) with atrial sensing dipole (DX ICD system) to follow this recommendation in patients with standard indication for single-chamber ICD. In 1841 DX ICD patients with daily automatic RM transmissions, electrograms of first device-detected AHREs per patient in each duration stratum were adjudicated, and the corresponding positive predictive values (PPVs) for the detections to be true atrial arrhythmia were calculated. Moreover, the incidence and progression of new-onset AF was assessed in 1451 patients with no AF history. A total of 610 AHREs ≥6 min were adjudicated. The PPV was 95.1% (271 of 285) for episodes 6min…<1 h, 99.6% (253/254) for episodes 1 h…<24 h, 100% (71/71) for episodes ≥24 h, or 97.5% for all episodes (595/610). The incidence of new-onset AF was 8.2% (119/1451), and in 31.1% of them (37/119), new-onset AF progressed to a higher duration stratum. Nearly 80% of new-onset AF patients had high CHA2DS2-VASc stroke risk, and 70% were not on anticoagulation therapy. Age was the only significant predictor of new-onset AF. A 99.7% detection accuracy for AHRE ≥1 h in patients with DX ICD systems in combination with daily RM allows a reliable guideline-recommended screening for subclinical AF and monitoring of AF-duration progression.

Antithrombotic therapy and bleeding risk in the era of aggressive lipid-lowering: current evidence, clinical implications, and future perspectives.

The clinical efficacy of proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) in reducing major cardiovascular adverse events related to atherosclerotic cardiovascular disease (ASCVD) has been well established in recent large randomized outcome trials. Although the cardiovascular and all-cause mortality benefit of PCSK9i remains inconclusive, current cholesterol management guidelines have been modified toward more aggressive goals for lowering low-density lipoprotein cholesterol (LDL-C). Consequently, the emerging concept of "the lower the better" has become the paradigm of ASCVD prevention. However, there is evidence from observational studies of a U-shaped association between baseline LDL-C levels and all-cause mortality in population-based cohorts. Among East Asian populations, low LDL-C was associated with an increased risk for hemorrhagic stroke in patients not on antithrombotic therapy. Accumulating evidence showed that low LDL-C was associated with an enhanced bleeding risk in patients on dual antiplatelet therapy following percutaneous coronary intervention. Additionally, low LDL-C was associated with a higher risk for incident atrial fibrillation and thereby, a possible increase in the risk for intracranial hemorrhage after initiation of anticoagulation therapy. The mechanism of low-LDL-C-related bleeding risk has not been fully elucidated. This review summarizes recent evidence of low-LDL-C-related bleeding risk in patients on antithrombotic therapy and discusses potential measures for reducing this risk, underscoring the importance of carefully weighing the pros and cons of aggressive LDL-C lowering in patients on antithrombotic therapy.

D-Dimer beyond Diagnosis of Pulmonary Embolism: Its Implication for Long-Term Prognosis in Cardio-Oncology Era.

Venous thromboembolism (VTE) is a common comorbidity of cancer, often referred to as cancer-associated thrombosis (CAT). Even though its prevalence has been increasing, its clinical picture has not been thoroughly investigated. In this single-center retrospective observational study, 259 patients who were treated for pulmonary embolism (PE) between January 2015 and December 2020 were available for analysis. The patients were divided by the presence or absence of concomitant malignancy, and those with malignancy (N = 120, 46%) were further classified into active (N = 40, 15%) and inactive groups according to the treatment status of malignancy. In patients with malignancy, PE was more often diagnosed incidentally by computed tomography or D-dimer testing, and the proportion of massive PE was lower. Although D-dimer levels overall decreased after the initiation of anticoagulation therapy, concomitant malignancy was independently associated with higher D-dimer at discharge despite the lower severity of PE at onset. The patients with malignancy had a poor prognosis during post-discharge follow-up. Active malignancy was independently associated with major adverse cardiovascular events (MACE) and major bleeding. D-dimer at discharge was an independent predictor of mortality even after adjustment for malignancy. This study's findings suggest that CAT-PE patients might have hypercoagulable states, which can potentially lead to a poorer prognosis.

Magnitude of hemorrhagic complications and its associated factors among patients on anticoagulant therapy at University of Gondar Comprehensive and Specialized Hospital, Northwest Ethiopia

BackgroundDespite the well-established effectiveness of anticoagulants, the risk of their hemorrhagic complications withheld many patients from being maintained on anticoagulant therapy. However, there is no sufficient data on the magnitude and factors associated with anticoagulant-related hemorrhagic complications in resource-constrained settings. Thus this study aimed to assess the magnitude of hemorrhagic complications and associated factors related to anticoagulant therapy among patients at the University Of Gondar Comprehensive and Specialized Hospital. MethodsA retrospective follow-up study was done on 154 individuals starting from June 2018 to June 2019 on adult patients who had completed their anticoagulant therapy at the University of Gondar specialized and comprehensive hospital. They were selected using a systematic random sampling technique among all patients who had completed their anticoagulant therapy which is heparin, warfarin, or both. A retrospective data after the initiation of anticoagulant therapy was collected. The data collection was conducted from July 1 to August 30, 2019. Bivariable and multivariable logistic regression was used to identify factors. Variables with p < 0.05 were considered statistically significant. ResultsOut of 154 patients who received anticoagulant therapy during the study period, more than half 83 (53.9%) of the participants were female, and the mean age of participants was 54.8 ± 21.1 years. A quarter of patients, 38 (24.7%), 95% CI (17.8, 31.6) who had been on anticoagulant therapy experienced bleeding complications. Being female (AOR = 6.12, 95% CI: 1.81, 20.71, P = 0.004) Aspirin use (AOR = 7.71, 95% CI: 2.24, 26.53, P = 0.001), type of anticoagulant (AOR = 4.94, 95% CI: 1.58, 15.49, P = 0.006), and number of co-morbidities(AOR = 4.99, 95% CI: 1.47, 16.95, P = 0.010) were found to be significantly associated with hemorrhagic complications. ConclusionsHemorrhagic complications related to anticoagulant therapy are not rare. Therefore close monitoring of coagulation profiles as well as minimization of risk factors is crucial and needs collaborated work of all health care professionals and decision-makers.

Neonatal Cerebral Sinovenous Thrombosis Post–Therapeutic Hypothermia in Perinatal Asphyxia: A Case Report

AbstractCerebral sinovenous thrombosis (CSVT) is an uncommon condition in neonates and often leads to adverse neurodevelopmental outcomes. A high index of suspicion for CSVT is mandated for asphyxiated infants, especially following therapeutic hypothermia (TH). Magnetic resonance venography can assist in the early detection of CSVT in suspected cases. Timely initiation of anticoagulation therapy prevents thrombus propagation and allows recanalization at around 6 to 12 weeks. Long-term follow-up is essential as cognitive impairment, motor dysfunctions, and epilepsy are common complications. Herein, we describe the clinical course of a term infant who developed CSVT in the first week of life following TH for perinatal asphyxia, its management strategies, and short-term follow-up till infancy.

Beyond the Guidelines: Anticoagulant Treatment of Patients with Recent Portal Vein Thrombosis in the Setting of Liver Cirrhosis

Abstract Portal vein thrombosis, in the clinical setting of liver cirrhosis, is a complication which increases mortality rate by leading to specific complications. Its presence also serves as a negative prognostic factor for these patients. Specialized literature, although rich in papers on this subject, presents loose and sometimes contradictory information regarding its prognosis and specific treatment. This paper brings into discussion the issue of recent portal vein thrombosis in cirrhotic patients, with emphasis on indications for initiation of anticoagulant therapy and the optimal drug of choice. It also highlights the utility of using correct terminology for facilitating clinical approach of guideline recommendations as well as increasing the quality of published scientific papers. The coagulation homeostasis of the cirrhotic patient presents many particularities that can make the optimal therapeutic choice extremely difficult when portal vein thrombosis is established. Absence of randomized clinical trials and lack of consensus regarding anticoagulant treatment in these patients leaves it up to the clinician to decide when and what anticoagulant to use. Analysis of the newest guidelines and recent meta-analysis made it possible to identify the right context for initiating therapy with the most used anticoagulants currently: low molecular weight heparin, vitamin K antagonists and direct oral anticoagulants.