Initiation Of Anticoagulation Research Articles

Facilitating active participation in anticoagulant decisions in advanced kidney disease: co-production of a question prompt list

BackgroundPeople with chronic kidney disease are at increased risk of thrombotic and bleeding episodes making anticoagulant treatment decisions challenging. Currently, there are no support tools for people with chronic kidney disease regarding anticoagulant therapy decisions. This work aimed to co-produce materials to support shared-decision making when considering anticoagulant use in advanced chronic kidney disease.MethodsFocus groups were undertaken to explore the views of people with kidney disease towards anticoagulant prescribing. Data was thematically analysed based on Makoul and Clayman’s model of shared-decision making. Co-production methods were used to develop a question prompt list based on themes from the focus groups in conjunction with people with kidney disease over three meetings.ResultsA question prompt list, to be used by patients when initiated on anticoagulant therapy, was co-produced. These questions were based upon participants’ experiences of the various stages of shared-decision making within the context of anticoagulant use in advanced chronic kidney disease. Of particular importance to participants was the individualised discussion around treatment risks and follow up arrangements.ConclusionShared-decision making is important when initiating medication to ensure the best outcomes for patients, yet it can be difficult to engage in shared-decision making without prompts or guidance. This co-produced question prompt list could be included as part of national guideline to support shared-decision making for anticoagulant initiation in patients with advanced chronic kidney disease.

Improving Atrial Fibrillation or Flutter Detection and Management by Smartphone-Based Photoplethysmography Rhythm Monitoring Following Cardiac Surgery: A Pragmatic Randomized Trial.

Atrial fibrillation (AF) or atrial flutter (AFL) after cardiac surgery are common and associated with adverse outcomes. The increased risk related to AF or AFL may extend beyond discharge. This study aims to determine whether photoplethysmography (PPG)-based smartphone monitoring to detect AF or AFL after hospital discharge following cardiac surgery improves AF management. The intervention group performed one-minute rhythm checks three times daily using a smartphone-based PPG application during six weeks after hospitalization for cardiac surgery. The primary outcome involved AF management interventions by independent physicians, including initiation of oral anticoagulation (OAC), direct cardioversion and up-titration or initiation of antiarrhythmic drugs. The study included 450 patients (mean [SD] age, 64.1 [9.2] years; 96 women [21.3%]; 130 patients with AF history [28.9%]; median [IQR] CHA2DS2-VASc score, 2 [1-3]), of whom 238 were randomized to PPG-based monitoring and 212 to usual care. AF/AFL was detected with PPG or electrocardiography in 44 patients (18.5%) in the monitoring group and 4 patients (1.9%) in the usual care group (OR 11.8; 95%CI, 4.2-33.3; P<.001), these were new detections in respectively 22 patients (9.2%) and 1 patient (0.5%) (OR 21.3; 95%CI, 2.9-166.7; P=.003). AF management interventions occurred in 24 patients (10.1%) in the monitoring group compared to 5 patients (2.4%) in the usual care group (odds ratio [OR]), 5.1; 95%CI, 1.8-14.4; P=.002). In unselected patients discharged home following cardiac surgery, PPG-based smartphone monitoring revealed significantly more AF/AFL which led to significantly more optimization of AF management.

Early vs Late Anticoagulation After Ischemic Stroke in Patients With Atrial Fibrillation and Covert Brain Infarcts.

Covert brain infarcts (CBIs) in patients with first-ever ischemic stroke (IS) and atrial fibrillation (AF) are associated with an increased risk of stroke recurrence. We aimed to assess whether CBIs modify the treatment effect of early vs late initiation of direct oral anticoagulants (DOACs) in patients with IS and AF. We conducted a post hoc analysis of the international, multicenter, randomized-controlled ELAN trial, which compared early (<48 hours after ischemic stroke for minor and moderate stroke, 6-7 days for major stroke) vs late (>48 hours for minor, 3-4 days for moderate, 12-14 days for major stroke) initiation of DOACs in patients with IS and AF. The primary outcome was a composite of recurrent IS, symptomatic intracranial hemorrhage (sICH), major extracranial bleeding, systemic embolism, or vascular death within 30 days after stroke; secondary outcomes were the individual components. We estimated outcomes based on the presence of CBIs (any CBI vs no CBI) on prerandomization imaging (core-lab rating) using adjusted risk differences (aRDs) between treatment arms. Point estimates and 95% CIs are presented without reporting p values. Of the 1,694 participants with first-ever IS included (median age: 77 years, 45.9% female), 678 (40.0%) had CBI. The imaging core-lab interrater reliability for the presence of CBI was 0.87 (0.81-0.94). The primary outcome occurred in 8 (2.3%; recurrent IS: 3/342) of 342 participants with CBI assigned to the early treatment arm vs 20 (6.0%; recurrent IS: 12/336) of 336 assigned to the late treatment arm (aRD: -3.6%, 95% CI -6.6 to -0.6) (p for interaction: 0.063). With early DOAC treatment, IS recurrence risk was lower in participants with CBI (aRD: -2.7%, 95% CI -5.0 to -0.4), but not in participants without CBI (aRD: -0.4, 95% CI -2.1 to 1.2). No sICH was observed in the early treatment group. The presence of CBI may indicate a subgroup of patients with first-ever IS and AF who particularly benefits from early DOAC initiation to prevent ischemic event recurrence, without increasing harm. Our findings should be considered in clinical decision making regarding timely DOAC treatment in patients with stroke and AF. This study provides Class II evidence that in patients with covert brain infarcts, atrial fibrillation, and first-ever ischemic stroke, early (vs late) initiation of DOACs is associated with lower risk of recurrent stroke with no increase in harm. URL: clinicaltrials.gov/study/NCT03148457; Unique identifier: NCT03148457; submitted: April 7, 2017; first patient enrolled: November 6, 2017.

Early versus delayed anticoagulation treatment for people with non-valvular atrial fibrillation-related acute ischaemic stroke.

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the benefits and risks of early versus late initiation of oral anticoagulation (vitamin K antagonists or NOACs) in people with non-valvular atrial fibrillation-related ischaemic stroke.

Bridging the Gaps in Atrial Fibrillation Management in the Emergency Department.

Atrial fibrillation (AF) frequently presents in emergency departments (EDs), contributing significantly to adverse cardiovascular outcomes. Despite established guidelines, ED management of AF often varies, revealing important gaps in care. This review addresses specific challenges in AF management for patients in the ED, including the nuances of rate versus rhythm control, the timing of anticoagulation initiation, and patient disposition. The updated 2024 European Society of Cardiology (ESC) guidelines advocate early rhythm control for select patients while recommending rate control for others; however, uncertainties persist, particularly regarding these strategies' long-term impact on outcomes. Stroke prevention through timely anticoagulation remains crucial, though the ideal timing, especially for new-onset AF, needs further research. Additionally, ED discharge protocols and follow-up care for AF patients are often inconsistent, leaving many without proper long-term management. Integration of emerging therapies, including direct oral anticoagulants and advanced antiarrhythmic drugs, shows potential but remains uneven across EDs. Innovative multidisciplinary models, such as "AF Heart Teams" and observation units, could enhance care but face practical challenges in implementation. This review underscores the need for targeted research to refine AF management, optimize discharge protocols, and incorporate novel therapies effectively. Standardizing ED care for AF could significantly reduce stroke risk, lower readmission rates, and improve overall patient outcomes.

Suprasternal aortic arch echocardioscopy as a potential tool in detection and follow-up of mobile thrombi in patients with ischemic stroke.

Severe or complicated atheromatosis of the aortic arch represents an important and often underdiagnosed embolic source in patients with ischemic stroke. The presence of a floating thrombus has significant clinical relevance, as it is associated with a high risk of early recurrence. The aim of this study was to analyze the potential of echocardiographic examination through the suprasternal window in both the detection of embolic sources and the monitoring of the response to anticoagulant treatment in patients with mobile thrombi. This case series study included ten consecutive patients with a mobile floating aortic arch thrombus associated with an atheromatous plaque, detected by focused echocardiography and confirmed by Computed Tomography Angiography (CTA). Epidemiological, clinical, radiological, and ultrasound characteristics were analyzed. Clinical and ultrasound follow-up was performed after initiation of anticoagulation as secondary prevention to assess the efficacy and safety of this treatment. Ten patients (seven female) with a mean age of 76 years were identified. After anticoagulation, a complete resolution of the mobile thrombus was observed in eight of them during ultrasound follow-up. One patient suffered an ischemic recurrence. Two patients receiving associated antiplatelet therapy presented severe hemorrhagic complications, one of which was fatal. Once the disappearance of the mobile thrombus was detected, anticoagulation was discontinued, and no further ischemic recurrences were observed. Floating thrombus of the aortic arch is an underdiagnosed but clinically relevant condition. The study of the aortic arch with echocardiography through the suprasternal window is a highly available and harmless technique, that may be highly useful for the detection and monitoring of response to treatment of this pathology. Furthermore, early anticoagulation could be an effective and safe treatment in these patients.

Net Benefit of Early Anticoagulation for Stroke With Atrial Fibrillation: Post Hoc Analysis of the ELAN Randomized Clinical Trial.

The net clinical effect of early vs later direct oral anticoagulant (DOAC) initiation after atrial fibrillation-associated ischemic stroke is unclear. To investigate whether early DOAC treatment is associated with a net clinical benefit (NCB). This was a post hoc analysis of the Early Versus Late Initiation of Direct Oral Anticoagulants in Post-Ischaemic Stroke Patients With Atrial Fibrillation (ELAN) open-label randomized clinical trial conducted across 103 sites in 15 countries in Europe, the Middle East, and Asia between November 6, 2017, and September 12, 2022, with a 90-day follow-up. Participants included patients with atrial fibrillation-associated acute ischemic stroke, excluding those with therapeutic anticoagulation at stroke onset or with severe hemorrhagic transformation of the ischemic infarct. Early DOAC initiation (<48 hours after minor and moderate stroke, 6-7 days after major stroke) vs later initiation (3-4 days after minor stroke, 6-7 days after moderate stroke, and 12-14 days after major stroke). The main measure was the NCB of early treatment over later treatment, calculated by subtracting the weighted rate of excess bleeding events (major extracranial or intracranial hemorrhage) attributable to early treatment from the rate of excess ischemic events (recurrent stroke or systemic embolism) possibly prevented by early treatment within 30 days (main analysis) or 90 days (ancillary analysis). An established weighting scheme was used to account for the different clinical impact of bleeding relative to ischemic outcomes. Event rates were derived from adjusted logistic models. The analysis included all evaluable randomized ELAN participants. Of the original 2013 ELAN participants, 1966 were eligible for analysis (977 [49.7%] assigned to early DOAC initiation, 989 [50.3%] assigned to later DOAC initiation; median [IQR] age 77 [70-84] years; 1075 [54.7%] male). The 30-day NCB of early treatment over later treatment ranged from 1.73 (95% CI, 0.06-3.40) to 1.72 (95% CI, -0.63 to 3.98) weighted events possibly prevented per 100 participants for intracranial hemorrhage weights 1.5 to 3.3. The 90-day NCB ranged from 2.16 (95% CI, 0.30-3.87) to 2.14 (95% CI, -0.26 to 4.41) weighted events per 100 participants. This post hoc analysis of a randomized clinical trial estimated a sizeable NCB of early anticoagulation for patients after atrial fibrillation-associated ischemic stroke. Although estimates cannot exclude the possibility of no benefit or small net harm, the findings suggest that early treatment may be more favorable. ClinicalTrials.gov Identifier: NCT03148457.

Integration of a specialist pharmacist-led multidisciplinary team in primary care: preventing strokes in people with atrial fibrillation across North East London

Public Health England outlines a national ambition of anticoagulating 90% of eligible patients with atrial fibrillation (AF) by 2029. In 2019/2020, two out of three boroughs reviewed in this study...

Ischemic Stroke Prevention in Patients Atrial Fibrillation and a Recent Ischemic Stroke, TIA, or Intracranial Hemorrhage; a World Stroke Organisation (WSO) Scientific Statement.

Secondary stroke prevention in patients with atrial fibrillation (AF) is one of the fastest growing areas in the field of cerebrovascular diseases. This Scientific statement from the World Stroke Organization Brain & Heart Task Force provides a critical analysis of the strength of current evidence this topic, highlights areas of current controversy, identifies knowledge gaps, and proposes priorities for future research. We select topics with the highest clinical relevance and perform a systematic search to answer specific practical questions. Based on the strength of available evidence and knowledge gaps, we identify topics that need to be prioritized in future research. For this purpose, we adopt a novel classification of evidence strength based on the availability of publications in which the primary population is patients with recent (<6 months) cerebrovascular events, whether the primary study endpoint is a recurrent ischemic stroke, and the quality of the studies (e.g., observational vs. randomized controlled trial). Priority areas include AF screening, molecular biomarkers, AF subtype classification, anticoagulation in device-detected AF, timing of anticoagulation initiation, effective management of breakthrough strokes on existing anticoagulant therapy, the role of left atrial appendage closure, novel approaches, and antithrombotic therapy post-intracranial hemorrhage. Strength of currently available evidence varies across the selected topics, with early anticoagulation being the one showing more consistent data. Several knowledge gaps persist in most areas related to secondary stroke prevention in AF. Prioritizing research in this field is crucial to advance current knowledge and improve clinical care.

AGA Clinical Practice Update on Management of Portal Vein Thrombosis in Patients With Cirrhosis: Expert Review.

Portal vein thromboses (PVTs) are common in patients with cirrhosis and are associated with advanced portal hypertension and mortality. The treatment of PVTs remains a clinical challenge due to limited evidence and competing risks of PVT-associated complications vs bleeding risk of anticoagulation. Significant heterogeneity in PVT phenotype based on anatomic, host, and disease characteristics, and an emerging spectrum of therapeutic options further complicate PVT management. This Clinical Practice Update (CPU) aims to provide best practice advice for the evaluation and management of PVT in cirrhosis, including the role of direct oral anticoagulants and endovascular interventions. This expert review was commissioned and approved by the American Gastroenterological Association (AGA) Institute CPU Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Gastroenterology. These Best Practice Advice statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these Best Practice Advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: Asymptomatic patients with compensated cirrhosis do not require routine screening for PVT. BEST PRACTICE ADVICE 2: Patients with cirrhosis with PVTs identified on Doppler ultrasound should undergo cross-sectional imaging with computed tomography or magnetic resonance imaging to confirm the diagnosis, evaluate for malignancy, and document the degree of lumen occlusion, clot extent, and chronicity. BEST PRACTICE ADVICE 3: Patients with cirrhosis and PVT do not require a hypercoagulable workup in the absence of additional thromboemboli or laboratory abnormalities or family history suggestive of thrombophilia. BEST PRACTICE ADVICE 4: Patients with cirrhosis and PVT with evidence of intestinal ischemia require urgent anticoagulation to minimize ischemic injury. If available, these patients should be managed by a multidisciplinary team, including gastroenterology and hepatology, interventional radiology, hematology, and surgery. BEST PRACTICE ADVICE 5: Consider observation, with repeat imaging every 3 months until clot regression, in patients with cirrhosis without intestinal ischemia and recent (<6 months) thrombosis involving the intrahepatic portal vein branches or when there is <50% occlusion of the main portal vein, splenic vein, or mesenteric veins. BEST PRACTICE ADVICE 6: Anticoagulation should be considered in patients with cirrhosis without intestinal ischemia who develop recent (<6 months) PVT that is >50% occlusive or involves the main portal vein or mesenteric vessels. Patients who have increased benefit of recanalization include those with involvement of more than 1 vascular bed, those with thrombus progression, potential liver transplantation candidates, and those with inherited thrombophilia. BEST PRACTICE ADVICE 7: Anticoagulation is not advised for patients with cirrhosis with chronic (>6 months) PVT with complete occlusion with collateralization (cavernous transformation). BEST PRACTICE ADVICE 8: Patients with cirrhosis and PVT warrant endoscopic variceal screening if they are not already on nonselective beta-blocker therapy for bleeding prophylaxis. Avoid delays in the initiation of anticoagulation for PVT, as this decreases the odds of portal vein recanalization. BEST PRACTICE ADVICE 9: Vitamin K antagonists, low-molecular-weight heparin, and direct oral anticoagulants are all reasonable anticoagulant options for patients with cirrhosis and PVT. Decision making should be individualized and informed by patient preference and Child-Turcotte-Pugh class. Direct oral anticoagulants may be considered in patients with compensated Child-Turcotte-Pugh class A and Child-Turcotte-Pugh class B cirrhosis and offer convenience as their dosages are independent of international normalized ratio monitoring. BEST PRACTICE ADVICE 10: Patients with cirrhosis on anticoagulation for PVT should have cross-sectional imaging every 3 months to assess response to treatment. If clot regresses, anticoagulation should be continued until transplantation or at least clot resolution in nontransplantation patients. BEST PRACTICE ADVICE 11: Portal vein revascularization with transjugular intrahepatic portosystemic shunting may be considered for selected patients with cirrhosis and PVT who have additional indications for transjugular intrahepatic portosystemic shunting, such as those with refractory ascites or variceal bleeding. Portal vein revascularization with transjugular intrahepatic portosystemic shunting may also be considered for transplantation candidates if recanalization can facilitate the technical feasibility of transplantation.

Medical Management of Acute Stroke based on Japan Stroke Society Guidelines and the Japan Stroke Data Bank.

Stroke is a leading cause of death and disability in Japan, necessitating standardized treatment guidelines. The Japan Stroke Society (JSS) periodically revises its guidelines to incorporate new research. This review provides a short overview of acute stroke management based on JSS Guideline 2021 (revised 2023) and the Japan Stroke Data Bank (JSDB), and discusses future directions in stroke management. Acute stroke management emphasizes systemic support and complication management. Risk factor control during acute hospitalization is also crucial for preventing recurrent strokes in the chronic phase.In ischemic stroke, super-acute recanalization therapies, including intravenous thrombolysis and mechanical thrombectomy, are the most important and effective. Antiplatelet therapy, particularly aspirin and clopidogrel, is recommended for noncardiogenic stroke and high-risk transient ischemic attack. In cardioembolic stroke, early initiation of direct oral anticoagulants might be considered according to stroke severity.For brain hemorrhage, early blood pressure management is recommended. Specific reversal agents are advised for patients on anticoagulant therapy. Minimally invasive hematoma removal may improve outcomes for intracerebral hemorrhage.Subarachnoid hemorrhage treatments reported from Japan include intravenous drugs to prevent vasospasm.The JSDB revealed improvements in functional outcomes in patients with ischemic stroke over the past 20 years, although patients with hemorrhagic stroke showed no clear improvement. The evolving guidelines and research underscore the importance of stratified and timely intervention in stroke care.

Optimal timing of oral anticoagulation initiation in patients with acute ischaemic stroke and atrial fibrillation: a comprehensive meta-analysis and systematic review

The optimal timing for initiating direct oral anticoagulants (DOACs) for secondary stroke prevention in patients with atrial fibrillation and acute ischaemic stroke remains controversial due to concerns about haemorrhagic transformation....

Fracture in Association with Anticoagulant Therapy in Patients with CKD and Atrial Fibrillation.

Key Points In patients with CKD and atrial fibrillation, we observed no difference in the rates of fracture between initiators of direct oral anticoagulant and warfarin.However, direct oral anticoagulant use relative to warfarin was associated with a lower risk of all-cause mortality. Background Direct oral anticoagulant (DOAC) use has been associated with a lower risk of adverse events relative to warfarin in patients with atrial fibrillation. Little is known about the risk of fracture in association with anticoagulant therapy in patients with CKD. Methods We conducted a new user, active comparator cohort study in a United States-based commercial claims database spanning 2013 through 2020 to quantify the comparative risk of fracture associated with select DOACs (apixaban or rivaroxaban) versus warfarin. Individuals were required to have International Classification of Diseases diagnosis codes for CKD (stages 3–5) and atrial fibrillation during the 365-day baseline period before anticoagulant initiation. Primary analyses quantified nonvertebral fracture risk between patients initiating DOACs and warfarin using a 1:1 propensity score-matched design. Cox proportional hazards regression was used to obtain hazard ratios (HRs) and 95% confidence intervals (CIs) of nonvertebral fracture. Secondary analyses evaluated risks of hip fracture and all-cause mortality. Results The 1:1 propensity score-matched population included 14,370 DOAC initiators and 14,370 warfarin initiators. The mean age at anticoagulant initiation was 77 years, and 45% were female. The HR for nonvertebral fracture comparing DOACs with warfarin was 1.12 (95% CI, 0.95 to 1.32), and the corresponding incidence rate difference per 1000 person-years was 3.55 (95% CI, −1.67 to 8.76). The HR and incidence rate difference comparing DOACs with warfarin were 0.98 (95% CI, 0.68 to 1.41) and −0.13 (95% CI, −2.52 to 2.25), respectively, for hip fracture and 0.91 (95% CI, 0.85 to 0.98) and −17.23 (95% CI, −29.49 to −4.96), respectively, for all-cause mortality. Conclusions In patients with CKD and atrial fibrillation, we did not observe a difference in the rates of fracture between DOAC and warfarin initiators. DOAC use relative to warfarin was associated with a lower risk of all-cause mortality.

Abstract 4123563: High Prevalence of Unrecognized Actionable Cardiac Arrhythmias in Patients with Moderate to Severe Chronic Obstructive Pulmonary Disease

Background: Patients with chronic obstructive pulmonary disease (COPD) are at high risk for developing arrhythmias due to hypoxemia, right heart failure and use of beta-agonists inhalers. Symptoms related to arrhythmias can often be masked or confounded by symptoms related to COPD exacerbation and remain undiagnosed. Objective: To identify the incidence of actionable arrhythmias in patients with no prior cardiology follow-up and moderate–severe COPD with continuous monitoring. Methods: An automatic referral for electrophysiology (EP) consult was generated in patients with moderate-severe COPD if they answered yes to one of the following: palpitations, dizziness, abnormal ECG, near syncope. Upon consultation with EP specialist, implantation of loop reorder was discussed (ILR) with the patient. Patients were then monitored for 12 months via remote monitoring. Actionable arrhythmia was defined the arrhythmia that correlated with symptoms triggered by the patient, necessitated adjustment of medications (including initiation of anticoagulation), catheter ablation and implantation of implantable cardiac defibrillator (ICD) or permanent pacemaker (PPM). Results: Out of 62 patients referred 22 (35.5%) agreed to undergo ILR implantation. Of the 22 (50.0% female, 62 ± 9.5 years) patients implanted with an ILR, 15 (68.2%) had an actionable arrhythmia after a mean follow-up of 2.7± .3 months. These included 14 symptomatic events requiring medication adjustment (10 atrial tachycardias, 4 ventricular events), 7 cases of atrial fibrillation (requiring initiation of anticoagulation in all cases and catheter ablation in 1), 1 case of sinus node dysfunction requiring pacemaker implantation, and 1 episodes of sustained ventricular tachycardia requiring ICD implantation. Conclusion: Continuous monitoring had high yield in diagnosing significant arrhythmic events in patients with moderate-severe COPD. Awareness should be raised about the high arrhythmic risk of this population and the role of continuous monitoring should be sought in larger studies.

Abstract 4113263: Serum Metabolomics Adds Predictive Value to Clinical and Polygenic Risk Scores for Atrial Fibrillation: A UK Biobank study of &gt;240,000 Patients

Background: Atrial fibrillation (AF) poses substantial morbidity and mortality burdens globally. It is critical to identify individuals at high-risk for AF to implement both lifestyle modifications and close monitoring for initiation of oral anticoagulants. Currently, risk prediction in AF relies on clinical scores such as CHARGE-AF. Small molecule metabolites are thought to play a role in AF pathogenesis, but the additional predictive value of metabolomics over clinical and genetic risk factors is unknown. Using the UK Biobank (UKBB), we sought to perform this evaluation. Methods: We included all UKBB participants with complete 1 H-NMR metabolite measurements. We excluded participants with prior history of AF or with incomplete AF Polygenic Risk Score (AF-PRS) or CHARGE-AF components. The final cohort included 240,628 patients. In-patient records, primary care notes, and death registries were queried to identify patients who had developed incident AF within 5 years of enrollment. The cohort was divided into a 80/20:Train/Test split. We compared the performance of an Elastic-Net regularized Cox Proportional Hazards (EN-CPH) model trained on CHARGE-AF, AF-PRS, and the full 170 metabolite panel to a CPH model trained only on CHARGE-AF and AF-PRS. Results: Within 5 years, 4,174 (1.7%) patients developed AF. Compared to the control population, the incident AF cases were more likely to be older (62 vs. 56, p&lt;0.001), male (65% vs 45%, p&lt;0.001), and have higher CHARGE-AF and AF-PRS scores (p&lt;0.001). After training the EN-CPH model on CHARGE-AF, AF-PRS, and 170 metabolites, the final model included 8 metabolites on top of CHARGE-AF (HR: 1.28) and AF-PRS (HR: 1.11). After adjusting for CHARGE-AF and AF-PRS, creatinine level was associated with increased risk of AF (HR: 1.01) while linoleic acid level (HR: 0.985) was associated with decreased risk. Furthermore, total cholesterol, esterified cholesterol, free cholesterol, cholesteryl esters in IDL, omega-6 fatty acids, and cholesterol in large LDL were associated with HR 0.993-0.999. The EN-CPH model out-performed the CPH model without metabolomics on the test set (AUC 0.786 vs 0.753, p &lt; 0.001). Conclusions: The addition of metabolomics to clinical and genomic risk scores improves prediction of 5-year incident AF within a general population. This study highlights the significance of the metabolome as an independent prognosticator of AF risk. Further study of the mechanisms by which selected metabolites alter AF risk is needed.

Decision Support Intervention and Anticoagulation for Emergency Department Atrial Fibrillation

Oral anticoagulation for adults with atrial fibrillation or atrial flutter (AFF) who are at elevated stroke risk reduces the incidence of ischemic stroke but remains underused. Efforts to increase anticoagulation initiation on emergency department (ED) discharge have yielded conflicting results. To evaluate the effectiveness of a multipronged intervention supporting anticoagulation initiation for eligible adult ED patients. The Clinical Decision Support to Optimize Care of Patients With Atrial Fibrillation or Flutter in the Emergency Department (O'CAFÉ) pragmatic, stepped-wedge cluster randomized clinical trial was conducted from July 1, 2021, through April 30, 2023, at 13 community medical centers (in 9 clusters) of an integrated health system in Northern California. The study included adult ED patients with primary AFF eligible for anticoagulation initiation when discharged home. Clusters were randomly assigned to staggered dates for 1-way crossover from the control phase (usual care) to the intervention phase. Physician education, facility-specific audit and feedback, and access to decision support, which identified eligible patients and recommended shared decision-making, anticoagulation initiation (if suitable), and timely follow-up. The main outcome was a composite of anticoagulation on discharge or within 30 days. A primary intention-to-treat analysis (decision support access regardless of use) and a secondary per-protocol analysis (decision support use) were performed. Multivariable analyses adjusted for intervention and exposure months with random effects, accounting for clustering by facility and patient. A total of 3388 eligible patients with atrial fibrillation were discharged home: 2185 (64.5%) were receiving pre-ED arrival anticoagulation and 1203 (35.5%) were eligible for anticoagulation. Among the 1203 patients with an initiation-eligible encounter, the median age was 74.0 (IQR, 68.0-82.0) years and approximately half (618 [51.4%]) were men. Among the 387 patients with an initiation-eligible control encounter, 244 (63.0%) received anticoagulation (190 [49.0%] at discharge and 54 [14.0%] within 30 days). Among the 816 patients with an initiation-eligible intervention encounter, 558 (68.4%) received anticoagulation (428 [52.5%] on discharge and 130 [15.9%] within 30 days). There was no statistically significant change in initiation of anticoagulation associated with the intervention (adjusted odds ratio, 1.33 [95% CI, 0.75-2.35]; P = .13). Decision support was used for 217 eligible case patients (26.6%) (per protocol) and was associated with a statistically significant change in anticoagulation initiation when compared with 599 patients for whom decision support was not used (164 [75.6%] vs 394 [65.8%]; P = .008). In this trial, a multipronged intervention to facilitate thromboprophylaxis among eligible ED patients with AFF did not significantly increase anticoagulation initiation. Opportunities exist to further improve stroke prevention among ED patients with primary AFF. ClinicalTrials.gov Identifier: NCT05009225.

Abstract 411: Starting anticoagulation within 24 hours of primary Middle Meningeal artery embolization for chronic subdural hematoma (SDH) is safe and allows for chronic SDH resorption.

Introduction Middle Meningeal artery (MMA) embolization has emerged as an effective treatment for the resorption of chronic subdural hematoma (cSDH), by occluding the blood supply to the subdural hematoma membrane; thereby preventing leakage of blood into the subdural space. Limited data is available for initiating anticoagulation within 24 hours post primary MMA embolization and maintaining the anticoagulation treatment, with regards to its effect on the cSDH. Methods A prospective collection of patients requiring MMA embolization for cSDH was maintained from a single center between 2019 and 2023. Patients that received full strength anticoagulation within 24 hours of primary MMA embolization were included in this study. All patients were treated with 100‐300 micron embospheres for distal penetration. Some patients received ONYX embolization at the proximal portion of the Middle Meningeal artery. Alternatively, some patients had the proximal portion of the MMA occluded using coils. A successful outcome is defined as complete resolution of the subdural hematoma and/or trace residual (less than or equal to 4 mm) between 1 and 6 months post treatment, while maintaining medication compliance to the anticoagulation treatment. Subdural hematoma expansion, need for surgical treatment (burr hole and/or craniotomy) and mortality were documented. Results 39 out of 148 patients (26%) were treated with primary MMA embolization (25 male). Anticoagulation was required for atrial fibrillation (36 patients) and DVT/PE (3 patients). All patients that followed up in clinic confirmed anticoagulation medication compliance. Complete subdural hematoma resolution was seen in 17 (43.5%) patients (mean age 74). 7 patients (18%) demonstrated trace residual (less than or equal to 4 mm) subdural hematoma on the three month follow up CT scan, but they all did not have a six month follow up CT scan. Burr hole evacuation was required in 1 patient (2.5%) due to hematoma expansion. There were no patient deaths or neurologic deficits related to subdural hematoma expansion on anticoagulation following embolization. Following the initial embolization, 8 patients (22%) demonstrated reduced/stable subdural hematoma on their approximate one month follow up imaging, but they had incomplete follow up imaging. Following the initial embolization, 6 patients (15%) have no follow up imaging. The COVID pandemic created an environment that limited access to the hospital for many patients. Conclusion Initiation of anticoagulation within 24 hours of primary MMA embolization is safe and can lead to complete resorption of the chronic subdural hematoma. Further studies are required to identify patient characteristics that may lead to hematoma expansion following embolization and the initiation of anticoagulation.

Abstract 172: A Machine Learning Model for Prediction of Short‐Term Functional Outcomes in Cerebral Venous Thrombosis

Background Dural Sinus and Cerebral Vein Thrombosis (CVT) represents a rare yet significant cause of stroke, with distinct pathophysiological mechanisms compared to arterial strokes. Despite the progress in machine learning‐based predictive models for arterial stroke, which have significantly advanced prognostication and treatment strategies, there remains a notable absence of similar models for CVT. Methods A single‐center, retrospective cohort study of adult patients diagnosed with acute CVT confirmed on contrast‐enhanced CT/MR Imaging at admission was carried out at a specialized tertiary care center. Patients with a known history of recent or active infections or inflammatory conditions or missing data were excluded. Baseline clinical and demographic data, laboratory data including blood cell counts, Serum Homocysteine and Folate levels measured before the initiation of anticoagulation, and modified Rankin Scale (mRS) scores at discharge were collected. To study short‐term functional outcomes, patients were dichotomized into good (mRS 2 or less, encoded as output class 1) and poor (mRS &gt;2 encoded as output class 0) functional outcome groups. Machine learning models were built in order to predict if patients belonged to good or poor function outcome groups (mRS2). The classifiers were validated using K‐fold cross validation to pick the best hyperparameters and were tested using a holdout data. The classifiers built include Support Vector Machine (SVM), Logistic Regression Regression (LR), Random Forests (RF) and Gradient Boosting. The performance of the classifiers are compared based on the Area Under the Receiver Operating Characteristic (AUROC) and Sensitivity. Results 162 patients were included in the final dataset, 32 of whom had a significant disability (mRS&gt;2) at discharge. The top variables for predicting the functional outcome groups were Platelet count, Serum Homocysteine, Neutrophil‐to‐Lymphocyte ratio, and Total Leucocyte Count at the time of admission. Support Vector Machine (SVM) was found to be the best‐performing algorithm with an accuracy of 0.86 and AUC of 0.643. Conclusion Using the SVM machine learning algorithm, a predictive model consisting of baseline platelet count, serum homocysteine, total leucocyte count, and the inflammatory marker Neutrophil‐to‐Lymphocyte Ratio was developed to predict short‐term functional outcomes in acute CVT. The high value of accuracy (0.86) indicates that the algorithm is able to reliably detect short‐term functional outcomes.

Abstract 361: Papillary fibroelastoma as a rare cause of recurrent strokes in a young female: when to intervene?

Introduction Primary cardiac tumors including papillary fibroelastomas are rare, with an incidence as low as 0.1%, but they pose considerable embolic risk. When untreated, cardiac fibroelastomas can present with embolic stroke in about 30% of patients. While larger, mobile fibroelastomas may be thought to carry a greater risk of cerebral embolism, observational data indicate no single echocardiographic feature to be sufficiently predictive of stroke. We present a case of a young female who presented with recurrent strokes in the setting of a small, untreated papillary fibroelastoma. Case presentation A 41‐year‐old Black female with past medical history significant for three ischemic strokes (2020, 2021) without residual deficits, presented in June 2024 to our institution with new left‐sided weakness and dysarthria over 24 hours. NIHSS was 7 for left facial droop, dysarthria, and left‐sided weakness. Initial imaging (CT head, CTA head/neck, CT perfusion) demonstrated chronic, known cortical infarcts without large‐vessel occlusion or perfusion deficit. MRI brain without contrast demonstrated multiple small, acute infarcts in the right perirolandic region and FLAIR changes consistent with prior infarcts in the left MCA, right occipital and right cerebellar regions. A transthoracic echocardiogram demonstrated no structural abnormalities, normal left ventricular ejection fraction, and normal left atrial volume index. However, a transesophageal echocardiogram demonstrated a rounded mobile echodensity measuring 0.48cm x 0.13cm attached to the commissure of left and right cusps on the aortic valve, consistent with a papillary fibroelastoma. Transthoracic echocardiogram in 2020 during her first stroke admission demonstrated a similarly sized, mobile echodensity (~0.3 times 0.2cm) of the aortic valve concerning for fibroelastoma. At the time, this fibroelastoma was thought to be too small to be causative of her ischemic stroke, therefore therapeutic anticoagulation or surgical intervention was deferred. She was discharged with aspirin 81mg daily, and was switched to clopidogrel 75mg daily after her second stroke in 2021. Again, surgery was deferred. Hypercoagulability workup (anticardiolipin, beta‐2 glycoprotein, protein C, protein S, homocysteine, Factor V Leiden, antithrombin 3) was normal. There was no evidence of atrial fibrillation during any of her four inpatient stroke admissions. Given that this was her fourth ischemic stroke without an alternative mechanism of stroke, aggressive management of papillary fibroelastoma was pursued. She was started on therapeutic anticoagulation with apixaban and evaluated by cardiothoracic surgery for surgical removal, which took place in August 2024. Discussion Cardiac fibroelastomas are an underrecognized cause of stroke and carry a high risk of morbidity and mortality if untreated, even when the size is small. This case illustrates the importance of early and aggressive intervention of papillary fibroelastomas when associated with otherwise cryptogenic embolic events. The gold‐standard treatment for management of embolic events in the setting of cardiac fibroelastomas is surgical excision, which can leave the valve intact for &gt;95% of patients and carries a low risk of recurrent stroke. In this case, the patient was started on antiplatelet agents however recurrent strokes occurred while adherent to these therapies. In patients unable to undergo surgical excision, initiation of anticoagulation may be considered, but is of uncertain benefit.

Abstract 345: Occult Antiphospholipid Syndrome Presenting as Subdural Hematoma: A Rare Manifestation of Arterial Hypercoagulability

Objective To describe a case of antiphospholipid syndrome (APS) which presented with subdural hemorrhage, a rarely described manifestation of a commonly hypercoagulable disorder. Background APS is a common arterial and venous hypercoagulable state—though rare in the general population with an incidence of 5 per 100,000 individuals. It most commonly presents with systemic ischemic insults, commonly to the brain in the form of ischemic stroke. This case highlights a known rare manifestation of APS: intracranial hemorrhage. Design/Methods: N/A Results Patient is a 49 year old female with history of end‐stage renal disease who initially presented with altered mentation and hypertension. Her GCS was 7 upon arrival prompting intubation. CT head at that time revealed acute left parietal subdural hematoma. There was no clear history of trauma per the patient's family, and the patient was unable to provide any additional history of their own at that time. The etiology of her hemorrhage, in the acute setting, was not clearly discerned. She was managed in the ICU for several days, however she remained somnolent and unable to participate in examination despite removal of sedating agents. A repeat CT scan of the head was done at that time which revealed multifocal hypodensities consistent with late acute‐early subacute ischemic stroke. Subsequent CT angiography of the head and neck was negative for large vessel occlusive disease, extracranial atherosclerotic disease, vasospasm or other clear cerebrovascular constriction. Other embolic stroke workup including transthoracic and transesophageal echocardiogram was negative. At this point, a broader workup for embolic stroke of unclear source was launched. These studies included hypercoagulablity labs were sent and ultimately returned positive with elevated anticardiolipin and beta‐2 microglobulin consistent with an antiphospholipid antibody syndrome, prompting the initiation of anticoagulation. The patient has since improved clinically and is no longer mechanically ventilated, though does still require significant assistance with activities of daily living. Conclusions While rare, patients with otherwise unexplained hemorrhage should be investigated for possible immune‐mediated mechanisms for stroke—both ischemic and hemorrhagic.