Use Of Long-term Anticoagulation Research Articles

Nationwide Incidence and Trends in Central Retinal Arterial Occlusion Management: A 5000-Patient Analysis.

Central retinal artery occlusion (CRAO) is a rare and visually debilitating vascular condition characterized by sudden and severe vision loss. CRAO is a compelling target for intravenous alteplase (tPA) and endovascular mechanical thrombectomy (MT) due to pathophysiological similarities with acute ischemic stroke; however, the utility of these interventions in CRAO remains dubious due to limited sample sizes and potential risks. To assess usage and outcomes of tPA and MT in CRAO, we queried the National Inpatient Sample database using International Classification of Disease, Ninth and Tenth edition for patients with CRAO and acute ischemic stroke between 2010 and 2019. Our cohort of 5009 CRAO patients were younger with higher rates of obesity, hypertension, long-term anticoagulant use, and tobacco use compared to acute ischemic stroke patients. CRAO patients had lower rates of tPA administration (3.41% vs 6.21%) and endovascular MT (0.38% vs 1.31%) but fewer complications, including deep vein thrombosis, pneumonia, urinary tract infection, acute kidney injury, and acute myocardial infarction (all P < 0.01). CRAO patients had lower rates of poor functional outcome (31.74% vs 58.1%) and in-hospital mortality (1.2% vs 5.64%), but higher rates of profound blindness (9.24% vs 0.58%). A multivariate regression showed no relationship between tPA and MT and profound blindness, although the limited sample size of patients receiving interventions may have contributed to this apparent insignificance. Further investigation of larger patient cohorts and alternative treatment modalities could provide valuable insights for revascularization therapies in CRAO to optimize visual restoration and clinical outcomes.

Oral Anticoagulation and Mortality in Cases with Intracranial Bleeding: Analysis of Nationwide Prescription and Hospitalization Data.

To demonstrate the safety of direct oral anticoagulants in relation to intracranial bleeding (ICB), we compared the number of patients taking anticoagulants in all cases of hospitalization and cases of hospitalization for ICB over time in Germany. We analyzed the intrahospital mortality of ICB cases in relation to long-term use of anticoagulants (LUAs).We performed a retrospective registry analysis of nationwide German hospitalizations including all hospital admissions and admission for ICB in patients aged ≥60 years in the period from 2006 to 2020 and separated for LUAs. In 2006, the age-standardized rate of hospitalized male patients with LUAs was 7.3% and that of female patients was 5.6%. In 2020, the rates increased to 22.0 and 17.7% for male and female patients, respectively. Among patients hospitalized for ICB in 2006, 7.0 and 5.6% were male and female patients with LUAs, respectively. In 2020, the rate increased to 13.7% for males and 10.8% for females.In 2006, age-standardized mortality rates of male and female patients with ICB without LUAs were 24.1 and 23.9%, respectively. In 2020, the rate slightly decreased to 22.7% in males, but it remained almost unchanged in females at 23.8%. In the cases with LUA, the mortality rate decreased from 30.1 to 24.3% in males and from 28.4 to 24.2% in females in the same period. LUA seems to be safe because there is a slower increase of the rate of LUAs in ICB cases than in generally hospitalized cases in the period from 2006 to 2020. In addition, mortality in ICB cases with LUA tends to decrease compared to cases without LUA.

Outcomes of Unicompartmental Knee Arthroplasty in Patients Receiving Long-Term Anticoagulation Therapy: A Propensity-Matched Cohort Study

BackgroundAlthough total knee arthroplasty has been considered the gold-standard treatment for severe osteoarthritis of the knee, unicompartmental knee arthroplasty (UKA) has become an increasingly favorable alternative for single-compartment osteoarthritis of the knee. Few studies have examined potential high-risk populations undergoing this procedure. The purpose of this study was to investigate the outcomes of UKA in patients receiving long-term anticoagulation therapy. MethodsIn this study, a large administrative database was queried to identify patients undergoing UKA between 2009 and 2019, who were then divided into a cohort receiving long-term anticoagulation and a control cohort. Propensity scores were utilized to match these patients. Multivariable logistic regression was utilized to compare 90-day and 2-year complication rates between cohorts. ResultsPatients who were on long-term anticoagulation had significantly increased odds of extended length of stay, surgical site infection, wound complication, transfusion, deep vein thrombosis, pulmonary embolism, and readmission at 90-day follow-up. The long-term anticoagulation cohort also experienced significantly higher odds of periprosthetic joint infection and mechanical complications at 2-year follow-up; however, odds of conversion to total knee arthroplasty were not increased. ConclusionsThis study demonstrated that long-term anticoagulation use was associated with poorer medical and surgical outcomes at both 90 days and 2 years postoperatively in patients undergoing UKA, even after rigorous adjustment for confounders.

Abstract 19197: Cardiopulmonary Outcomes and Disparities in Long-Term Anticoagulant Use in Secondary Pulmonary Hypertension Patients: A Nationwide Analysis

Introduction: The use of anti-coagulation in pulmonary hypertension patients has shown to improve mortality. Our aim was to characterize patient demographics, analyze disparities and investigate the effect of long-term anti-coagulant (AC) use on outcomes in secondary pulmonary hypertension (PAH) patients. Methods: This was a retrospective cohort study using the 2019 Nationwide Inpatient Sample database to identify admissions in adults with diagnoses of secondary PAH and long-term AC use. Multivariate linear and logistic regression models were adjusted for demographic variables and comorbid conditions. Primary outcome was all-cause mortality, and secondary outcomes were outcomes of long-term AC use in secondary PAH patients and length of stay (LOS). Results: Out of 1,141,870 secondary PAH patients, 287,940 had long-term AC use. The AC-PAH cohort when compared to the Non-AC-PAH cohort had lower in-hospital mortality (3.35% vs 5.18%, p&lt;0.001) and shorter LOS (6.04 days vs 7.03 days, p&lt;0.001). The AC-PAH cohort had older patients (mean age 74.46 vs 69.55 years, p&lt;0.001), more White patients (73.10% vs 64.76%, p&lt;0.001) and fewer Black patients (15.62% vs 20.10%, p&lt;0.001). The AC-PAH cohort when compared to the Non-AC-PAH cohort had lower odds of pulmonary embolism (PE)(OR 0.92, 95% CI 0.86-0.98, P&lt;0.05), acute respiratory failure (RF)(OR 0.73, 95% CI 0.71-0.75, p&lt;0.001), ventilator dependence (OR 0.46, 95% CI 0.38-0.55, p&lt;0.001), systemic HTN (OR 0.91, 95% CI 0.83-0.99, p&lt;0.05), cardiac arrest (OR 0.65, 95% CI 0.59-0.72, p&lt;0.001), ischemic cardiomyopathy (OR 0.94, 95% CI 0.90-0.98, p&lt;0.005), STEMI (OR 0.31, 95% CI 0.22-0.42, p&lt;0.001), NSTEMI (OR 0.52, 95% CI 0.49-0.55, p&lt;0.001) and acute ischemic stroke (OR 0.71, 95% CI 0.66-0.77, p&lt;0.001). The AC-PAH cohort had higher odds of chronic RF (OR 1.07, 95% CI 1.02-1.12, P&lt;0.005) and atrial fibrillation (A.Fib)(OR 2.79, 95% CI 2.72-2.86, p&lt;0.001). Conclusion In secondary PAH patients, the long-term use of AC was associated with lower in-hospital mortality, shorter LOS and lower odds of having PE, acute RF, ventilator dependence, systemic HTN, ischemic cardiomyopathy, STEMI, NSTEMI and acute ischemic stroke. More extensive research is required in this area to investigate outcomes further.

Abstract 12823: As Anticoagulation Use Increases, Embolic Events Downtrend in Atrial Fibrillation Hospitalizations

Background: Direct oral anticoagulants and Left atrial appendage closure (LAAC) were approved for use in 2010 and 2015, respectively. Data on temporal changes in stroke prevention strategies and rates of embolic complications in atrial fibrillation (AF) in the 2010s decade are limited. Aims: Describe trends in long-term anticoagulation (AC), LAAC use, and in-hospital AF associated ischemic stroke (IS), transient ischemic attacks (TIA), and systemic embolic events (SEE) between 2010 and 2019. Methods: The national inpatient database was used to identify patients with AF from 2010 to 2019. Data were divided into 2 eras: 2010-2014 and 2015-2019. Results: A total of 40,787,136 inpatients with AF were identified: prevalence increased from 18,594,372 in 2010 to 2014 (46%; mean [SD] age 75.5 [12.0] years; 50.3% male) to 22,192,764 in 2015 to 2019 (54%; mean [SD] age 75.1 [11.8] years; 52.5% male). There was a marked increase in long-term AC use (27.2% to 40.2%; P=0.001) and rates of percutaneous LAAC procedures (0.01% to 0.6%; P &lt;0.001) from 2015 to 2019. IS rates among patients with AF increased from 2010 to 2014 (3.5% to 3.8%; P=0.04), with no significant temporal change from 2015 to 2019 (P=0.84). TIA rates declined from 2010 to 2014 (1.2% to 1.0%; P=0.017) and continued a downtrend from 2015 to 2019 (0.9% to 0.7%; P=0.002). There was no temporal change in SEE or the composite outcome of all embolic events from 2010 to 2014, followed by a decline from 2015 to 2019 in SEE (0.5% to 0.4%; P 0.012) and all embolic events (5.1% to 4.8%; P 0.026) ( Figure 1 ). Mean rates of major bleeding events increased from 5.7% in 2010-2014 to 9.1% in 2015-2019 (P &lt;0.001). Conclusion: In an inpatient AF population, the composite outcome of all embolic events and specifically SEE downtrend from 2015 to 2019, likely due to increased AC use. Further data assessing the risk-benefit ratio of available therapies for stroke prevention in inpatients with AF - AC and LAAC - are needed to optimize personalized strategies.

Outcomes among patients with pancreatic malignancy on long-term anticoagulation hospitalized for acute pulmonary embolism: A nationwide analysis.

e16266 Background: Pancreatic cancer is known to have an increased risk of thromboembolic events. Acute pulmonary embolism further complicates the clinical picture and confers a poor prognosis in this population. Data regarding prophylactic anticoagulation in patients with pancreatic malignancy is lacking, although there is evidence that prophylaxis does reduce incidence of venous thromboembolism in pancreatic malignancy. Whether this benefit equates to improved clinical outcomes needs further clarification. Methods: We utilized the 2018-2020 National Inpatient Sample (NIS) Database in conducting a retrospective cohort study. We identified patients who have pancreatic malignancy and acute pulmonary embolism using appropriate ICD-10 CM codes. We stratified patients based on the presence or absence of long-term anticoagulation. A survey multivariable logistic and linear regression analysis was used to calculate adjusted odds ratios (ORs) for the primary and secondary outcomes. A p value of &lt;0.05 was considered statistically significant. The aim of this study is to investigate the outcomes among patients with pancreatic malignancy hospitalized for acute pulmonary embolism looking primarily at the in-hospital mortality, hospital length of stay (LOS) as well as total hospital charges. Results: We identified a total of 160,000 hospitalized patients with acute pulmonary embolism, of which 0.6% (1,120/160,000) had malignant neoplasm of the pancreas and 20.09% (225/1120) are on long-term anticoagulation. The overall in-hospital mortality among those with pancreatic malignancy hospitalized for acute PE was 5.91% (66/1,120). Among those who are on long-term anticoagulation, the overall in-hospital mortality rate was lower at 4.44% (10/225), however, it was not significantly different from those who are not on anticoagulation 6.29% (14/225) (p value=0.64). Utilizing a stepwise survey multivariable logistic regression model that adjusted for patient and hospital level confounders, the use of long-term anticoagulation among hospitalized acute PE patients with history of pancreatic malignancy did not significantly decrease risk for in-hospital mortality (adjusted OR 0.37; 95% confidence interval [CI], 0.09-1.57; p=0.18), hospital LOS (adjusted OR 0.80; 95% confidence interval [CI], 0.63-10.26; p=0.86) or total hospital charges (p=0.32). Conclusions: Our analysis showed that among patients with pancreatic malignancy hospitalized for acute pulmonary embolism, the use of prior long-term anticoagulation did not significantly decrease the risk for in-hospital mortality, hospital LOS as well as total hospital charges. Prospective studies with control of possible confounders are warranted to further clarify the use of prophylactic anticoagulation in pancreatic malignancy and its impact on outcomes.

Impact of oral anticoagulation on inhospital mortality of patients with hip fracture – Analysis of nationwide hospitalization data

ObjectivesOral anticoagulation (OAC) may have an impact on mortality in cases hospitalized for hip fracture (HF). We studied nationwide time trends of OAC prescriptions and compared time trends of inhospital mortality of HF cases with and without OAC in Germany DesignRetrospective cohort study SettingNationwide German hospitalization, Diagnosis-Related Groups Statistic Patients/ParticipantsAll hospital admissions for HF 60 years and older in the years 2006 through 2020. InterventionAdditional diagnosis with a personal history of long-term use of anticoagulants (ICD code Z92.1). Main Outcome MeasurementsInhospital mortality ResultsCases hospitalized for HF 60 years and older increased by 29.5%. In 2006, 5.6% had a documented history of long-term use of OACs. This proportion rose to 20.1% in 2020. Age-standardized hospitalization mortality in HF cases without long-term use of OACs in males decreased steadily from 8.6% (95% confidence intervals 8.2 - 8.9) in 2006 to 6.6% (6.3 – 6.9) in 2020 and in females from 5.2% (5.0 - 5.3) to 3.9% (3.7 – 4.0). Mortality of HF cases with long-term use of OACs remained unchanged: males 7.0% (5.7 – 8.2) in 2006 and 7.3% (6.7 - 7.8) in 2020, females 4.8% (4.1 - 5.4) and 5.0% (4.7 - 5.3). ConclusionInhospital mortality of HF cases with and without long-term OAC show different trends. In HF cases without OAC, mortality decreased from 2006 to 2020. In cases with OAC such a decrease could not be observed.

Factors related to postoperative vitreous hemorrhage after small-gauge vitrectomy in proliferative diabetic retinopathy patients

BackgroundThe role of anticoagulation or antiplatelet on post-vitrectomy vitreous hemorrhage (POVH) in patients with proliferative diabetic retinopathy (PDR) is rarely investigated in the small-gauge vitrectomy era. We investigate the relationship between the long-term use of those medications and POVH in a group of PDR patients.MethodsA retrospective cohort study was carried out in a group of PDR patients who underwent small-gauge vitrectomy in our center. The baseline data on diabetes, diabetic complications, long-term use of anticoagulants and antiplatelet agents, ocular findings, and vitrectomy details were collected. The occurrence of POVH was recorded during at least three-month follow-up. Factors related to POVH were analyzed using logistic analysis.ResultsDuring a median follow-up of 16 weeks, 5% (11/220) of patients had POVH, and 75 had received antiplatelet or anticoagulation agents before the operation. Factors related to persistent POVH were the use of antiplatelet or anticoagulation agents (5.98, 1.75–20.45, p = 0.004), the presence of myocardial revascularization (130.65, 3.53-4834.50, p = 0.008), the presence of coronary artery disease (CAD) treated with medicine (56.52, 1.99–1604.06, p = 0.018), and younger age (0.86, 0.77–0.96, p = 0.012). For those receiving preoperative antiplatelet or anticoagulation agents, the probability of developing POVH was higher in the patients whose previous therapy was adjusted compared to those with continued therapy (p = 0.02 by Log-rank test).ConclusionsWe identified long-term use of anticoagulation or antiplatelet medication, the presence of CAD, and younger age as three independent factors related to POVH. In PDR patients on long-term antiplatelet or anticoagulation medications, particular attention should be given to controlling intraoperative bleeding, and follow-up for POVH should be scheduled.

In-Hospital Outcomes of Acute Ischemic Stroke in Patients With Hypertrophic Cardiomyopathy

To investigate the in-hospital outcomes of acute ischemic stroke in patients with hypertrophic cardiomyopathy (HCM). Using weighted discharge data from the National Inpatient Sample, we identified 5804 nonelective hospitalizations for ischemic stroke in adult patients with HCM between 2011 and 2017. For comparison, 58,179 hospitalizations for ischemic stroke in adult patients without HCM were selected as controls using the simple random sampling method. Compared with the patients without HCM, those with HCM had a higher prevalence of hyperlipidemia (62.4% vs 57.5%, respectively, P<.001) and chronic heart failure (25.4% vs 13.6%, respectively, P<.001) but a lower prevalence of diabetes (28.2% vs 34.9%, respectively, P<.001) and hypertension (42.9% vs 53.4%, respectively, P<.001). Atrial fibrillation was documented in 45.1% (n=2617) of the patients with HCM. However, only 28.0% (n=733) of these patients had long-term use of anticoagulants. The in-hospital death rate among the patients with HCM was 6.3% (n=368), which was significantly higher than that in the patients without HCM (4.1%, P<.001). Having HCM (odds ratio [OR], 1.35; P<.001), atrial fibrillation (OR, 2.08; P<.001), and chronic heart failure (OR, 1.65; P<.001) were significant predictors of in-hospital death. In patients with HCM who were discharged alive, 50.0% were transferred to skilled nursing facilities compared with 45.3% of those without HCM (P<.001). The prognosis of acute ischemic stroke is worse in patients with HCM than in those without HCM. These findings emphasize the importance of aggressive treatment of predisposing factors for stroke in patients with HCM, especially atrial fibrillation.

Comparison of endovenous laser ablation and conservative treatment in acute thrombophlebitis of the varicose great saphenous vein: rationale, design and first results of clinical trial

Thrombophlebitis of the superficial lower limb veins is one of the most common complications of chronic vein disease. Nowadays a long-term (at least 45 days) subcutaneous injection of fondaparinux sodium or heparin in combination with elastic compression of the limb is recommended for treatment of superficial vein thrombosis with a moderate risk of thrombus propagation to deep venous system. However, long-term use of anticoagulants is not always possible and sometimes contraindicated. Endovenous laser ablation (EVLA) around thrombus-free junction of great or small saphenous veins without subsequent long-term use of anticoagulants seems to be a promising intervention for treatment of acute thrombophlebitis of varicose superficial veins.The prospective single-center randomized open-label clinical trial was dedicated for comparison the efficacy and safety of three following treatments options for patients with acute thrombosis of the varicose great saphenous vein and location of thrombi in the trunk and/ or its large inflows: EVLA close to saphenous vein junction without anticoagulation, EVLA and 7 days of anticoagulation and noninvasive treatment with anticoagulation for 45 days (subcutaneous injections of the fondaparinux 2,5 mg). Class 2 compression stockings are used in all patients. Adverse outcomes are recorded at 7, 45 and 90 days after randomization. These include the progression of superficial vein thrombosis, recurrent superficial vein thrombosis, thrombosis involvement of the superficial segment of the perforating vein up to the fascia, deep vein thrombosis according to compression ultrasound, and pulmonary embolism with symptoms. Bleedings according to the World Society of Thrombosis and Hemostasis and the Academic Research Consortium classification as well other complications are also recorded. The first 30 patients included in the study have a low incidence of venous thrombosis risk factors and localization of the thrombus relatively far from the saphenofemoral junction. EVLA resulted in persistent cessation of venous blood flow at the intervention site. New episodes of venous thrombosis were noted only in the group of medical treatment — deep vein thrombosis of the contralateral tibia 5 days after stopping of 45-day treatment with fondaparinux and thrombus in the recanalized inflow of the great saphenous vein without involving its trunk at the 21st day after stopping of 45-day injection of fondaparinux. There were no complications in the area of intervention and bleedings.

Safety of discontinuation of anticoagulants after venous thromboembolism: whether D-dimer level should be taken into account?

Due to the continued risk of recurrence after a first episode of proximal deep vein thrombosis (DVT) of the lower extremities and/ or pulmonary embolism (PE) occurring without major transient risk factors, long-term use of anticoagulants is indicated in many cases. One attractive way to individualize the duration of treatment in these cases appears to be the assessment of blood D-dimer concentration. However, according to the prospective studies PROLONG, PROLONG II and REVERSE II, even persistent normalization of blood D-dimer concentration does not guarantee the absence of relapse. The available evidence also does not allow a differentiated approach to the assessment of the role of D-dimer for cases where proximal DVT and/or PE occurs in patients without identifiable risk factors or with minor risk factors. An attempt to clarify some of these uncertainties was made in the prospective APIDULCIS study, which included 732 patients who first had proximal DVT and/or PE, with symptoms occurring in the absence of obvious provoking factors (75.6% of cases) or associated with minor (weak) and transient risk factors (24.4%). The prerequisites included a normal blood D-dimer concentration. Patients were discontinued anticoagulants and blood D-dimer concentration measurements were repeated after 15, 30, and 60 days. If it remained low, the anticoagulant was not resumed (39.1% of cases), and when it first increased, apixaban was administered in a dose of 2.5 mg twice daily. The APIDULCIS study confirmed that anticoagulants cannot be discontinued after 1 year of use after the first unprovoked episode of proximal DVT and/or PE, even with persistent normal blood D-dimer concentration; it was shown that recurrence rate after the first episode of proximal DVT and/or PE, provoked by a minor transient risk factor, is high enough even after at least 1 year of anticoagulant treatment and at stable normal blood D-dimer concentration after their cancellation; comfirmed the effectiveness and safety of a reduced dose of apixaban (2.5 mg 2 times a day) during prolonged treatment of the first episode of proximal DVT and/or PE.

Evaluating Adverse Outcomes in Anticoagulated Patients Undergoing Skin Grafting for Diabetic Foot Ulcers

INTRODUCTION: Split thickness skin grafting (STSG) is a common method for wound closure in patients with diabetic foot ulcers (DFUs). Many diabetic patients have co-morbidities necessitating long-term anticoagulant therapy. These medications may cause surgeons to avoid STSG, but our experience does not warrant such concerns. No published studies examine the risks of skin grafting in the setting of chronic anticoagulation. We posit that anticoagulant therapy has no effect on STSG failure or other adverse outcomes. METHODS: We queried the TriNetX Network, which provides access to electronic medical records for over 75 million patients from 57 healthcare organizations throughout the U.S., for patients with a history of DFUs treated with STSG. We divided those found into two groups: long-term anticoagulant use prior to grafting and no long-term anticoagulant use. Patients were propensity score matched by age and comorbidities. Outcomes following STSG were evaluated at 1 month and 5 years. RESULTS: After matching, we found 429 patients for the matched cohorts. Within 1 month, the anticoagulated group showed no significant increase in graft failure (p = 0.825) or regrafting (p = 0.1243). For long-term outcomes, we found no significant increase in graft failure (p = 0.2797) or regrafting (p = 0.3524) (Figure 1). However, the anticoagulated group had a significant increase in endovascular procedures (p = 0.0096) and amputation (p = 0.0117), and a trend toward death (p = 0.066). CONCLUSION: Anticoagulation therapy does not lead to increased complications after STSG for wound closure, though remain at risk for other complications. All those with diabetic foot ulcers should receive standard of care treatment including STSG when appropriate.

DELAYED LEAD PERFORATION OF THE RIGHT ATRIUM IN THE PRESENCE OF PERSISTENT LEFT SUPERIOR VENA CAVA: A RARE COINCIDENCE

DELAYED LEAD PERFORATION OF THE RIGHT ATRIUM IN THE PRESENCE OF PERSISTENT LEFT SUPERIOR VENA CAVA: A RARE COINCIDENCE

Simultaneous endovascular "edge-to-edge" clipping of the mitral valve leaflets and closure of the left atrial appendage in a high surgical risk patient

Mitral regurgitation is one of the most common valvular heart diseases, with the gold standard of its treatment being an open surgical intervention. However, it is not always performed in patients with a high surgical risk. Atrial fibrillation is a frequent companion of mitral valve regurgitation. It significantly increases the risk of ischemic strokes and systemic thromboembolism and required the administration of anticoagulants. Long-term use of anticoagulants entails an increased risk of hemorrhagic complications. Surgical endovascular closure of the left atrial appendage allows for reduction of the risks both of embolic and hemorrhagic complications.&#x0D; This paper presents a clinical case of the first in Russia successful simultaneous endovascular remodeling of the mitral valve by edge-to-edge leaflet clipping and closure of the left atrial appendage with an Amplatzer Amulet occluder. This was an 85-year old patient with advanced mitral regurgitation, who was not considered a candidate for an open surgery due to his high surgical risk. The severity of the patients condition was related to atrial fibrillation, rectal cancer and severe anemia. The patient underwent simultaneous sequential clipping of the mitral valve leaflets and closure of the left atrial appendage. Control trans-esophageal echocardiography showed a significant decrease in the mitral regurgitation grade. There were no complications during the hospital stay and in the early postoperative period.&#x0D; The lack of convincing data and research makes it impossible to delineate clear indications and contraindications for the combination of two procedures within one surgical session. However, simultaneous endovascular clipping of the mitral valve leaflets and an occluder implantation into the left atrial appendage may become the method of choice in the treatment of patients with severe mitral valve regurgitation, prevention of embolic and hemorrhagic complications in high risk comorbid patients.

The effect of anticoagulants on clinical outcomes of mortality, stroke, myocardial infarction, pulmonary embolism, and major bleeding for patients with heart failure in sinus rhythm.

One to two percent of the population in developed countries are affected by chronic heart failure and this increases to greater than 10% in those over 70 years old. Heart failure (HF) predisposes patients to thromboembolic events. Anticoagulants are often used to prevent thromboembolic events in specific patient populations, such as those with atrial fibrillation. Currently, no guidance exists on the long-term use of anticoagulants for patients with HF in sinus rhythm. This article critically appraises a systematic review which assesses whether the long-term use of oral anticoagulants reduces total mortality and stroke in patients with HF in sinus rhythm.

The impact on renal function after long-term use of anticoagulants in atrial fibrillation patients

Abstract Funding Acknowledgements Type of funding sources: Private hospital(s). Main funding source(s): This study was supported by the research program of the Chang Gung Memorial Hospital. Objective Long-term oral anticoagulant should be considered or recommended in patients with atrial fibrillation (AF) and CHA2DS2VASc score ≥1 for stroke prevention. Warfarin and different direct oral anticoagulants (DOACs) are metabolized differently by the kidney. The impact on renal function after long-term use of anticoagulants in the patients with AF remains unclear. This study aimed to compare DOACs and warfarin’s impact on the decline in renal function from a large cohort with AF. Methods This study included patients with nonvalvular AF from 2000 to 2018, mainly through the medical history (ICD code) of the Chang Gung Research Database. Baseline estimated glomerular filtration rate (eGFR), follow-up eGFR and the change in eGFR between 2-year eGFR and baseline eGFR were compared between different DOACs and warfarin after propensity score matching. The primary study endpoint was acute kidney injury (AKI). Results 3657 patients were enrolled in this study and the mean observation time was 3.3 ± 0.9 years. During the observation period, there was a significantly higher incidence of AKI during follow-up in the warfarin group than in the different DOAC groups before and after propensity score matching (before: warfarin vs. DOAC: 9.2% vs. 5.2%, p&amp;lt;0.001; after: warfarin vs. DOAC: 8.9% vs. 4.4%, p&amp;lt;0.001). There was no difference in the incidence of AKI between dabigatran group and anti-factor Xa inhibitor group after propensity score matching. The incidence of AKI was similar among rivaroxaban, apixaban and edoxaban groups after propensity score matching. The change in eGFR between 2-year eGFR and baseline eGFR did not differ between the warfarin and DOAC groups after propensity score matching (warfarin vs. DOAC: -1.27 ± 20.32 vs. -1.94 ± 17.24 mL/min/1.73 m2, p=0.461). Conclusions During the mean observation time of 3.3 ± 0.9 years, warfarin was associated with a higher incidence of AKI compared with DOACs. The decline in renal function did not differ among warfarin and different DOAC groups.

Long-term anticoagulation is associated with type II endoleaks and failure of sac regression after endovascular aneurysm repair

ObjectiveWithin the context of endovascular aneurysm repair (EVAR), the role of anticoagulation therapy on endoleak development and subsequent reintervention is unclear with conflicting data in the literature. The hypothesis of this study is that long-term anticoagulation is associated with persistent type II endoleaks and failure of sac regression in patients undergoing endoluminal repair of intact infrarenal aortic aneurysm. MethodsRetrospective cohort abstracted from the Vascular Quality Initiative index hospitalization and long-term follow-up datasets for EVAR (2003-2017) were included in the analysis. Patients not taking aspirin preoperatively and postoperatively were excluded. Patients taking anticoagulation and aspirin concomitantly (treatment) after the index procedure were compared against patients taking aspirin alone (control). Anticoagulation included warfarin and novel oral anticoagulants, including factor Xa inhibitors and direct thrombin inhibitors. One-to-one greedy matching using propensity scores was implemented to match patients. The primary end points were failure of aneurysm sac regression, sac expansion, risk of endoleak, and reintervention rate for endoleak at follow-up. Sac regression was defined as a decrease of at least 5 mm and sac expansion was defined as an increase of at least 5 mm. ResultsThere were 9004 patients who received ASA alone and 332 patients who received ASA and anticoagulation. Propensity scores were used to create 301 matching pairs to account for differences in baseline characteristics and comorbidities, including but not limited to age, sex, smoking, coronary artery disease, heart failure, and chronic kidney disease between the treatment and control groups. After adjusting for covariables anticoagulation use was independently associated with a significantly decreased abdominal aortic aneurysm sac regression (41.59% vs 58.41%; P = .001), but no statistically significant difference in sac expansion with long-term anticoagulation use (9.7% vs 4.9%; P = .056). There was increased risk of type II endoleaks (11.96% vs 6.31%; P = .023; relative risk, 1.89; 95% confidence interval, 1.11-3.23; P = .016), but no significant differences in type I, III, or indeterminate endoleaks. There was no statistical difference in 2-year reintervention rates (4.32% vs 2.66%; hazard ratio, 1.43; 95% confidence interval, 0.55-3.77; P = .461). There were no differences in any primary outcome between warfarin and novel oral anticoagulants. ConclusionsThese data demonstrate that long-term aspirin plus anticoagulation use is associated with a lack of aortic sac reduction and persistent type II endoleak, but not an increased risk for subsequent reintervention. Because prior studies have demonstrated that sac regression is a correlate of survival, these findings associating regression failure suggest a potential therapeutic failure for patients undergoing EVAR who also require long-term anticoagulation therapy. Although not a contraindication, long-term anticoagulation should be considered when counseling patients with a surgical indication aortic aneurysm.

Similarity-based prediction of ejection fraction in heart failure patients

Biomedical research is increasingly employing real world evidence (RWE) to foster discoveries of novel clinical phenotypes and to better characterize long term effect of medical treatments. However, due to limitations inherent in the collection process, RWE often lacks key features of patients, particularly when these features cannot be directly encoded using data standards such as ICD-10. Here, we propose a novel data-driven statistical machine learning approach, named Feature Imputation via Local Likelihood (FILL), designed to infer missing features by exploiting feature similarity between patients. We test our method using a particularly challenging problem: differentiating heart failure patients with reduced versus preserved ejection fraction (HFrEF and HFpEF respectively). The complexity of the task stems from three aspects: the two share many common characteristics and treatments, only part of the relevant diagnoses may have been recorded, and the information on ejection fraction is often missing from RWE datasets. Despite these difficulties, our method is shown to be capable of inferring heart failure patients with HFpEF with a precision above 80% when considering multiple scenarios across two RWE datasets containing 11,950 and 10,051 heart failure patients. This is an improvement when compared to classical approaches such as logistic regression and random forest which were only able to achieve a precision < 73%. Finally, this approach allows us to analyse which features are commonly associated with HFpEF patients. For example, we found that specific diagnostic codes for atrial fibrillation and personal history of long-term use of anticoagulants are often key in identifying HFpEF patients.

The impact on renal function after long-term use of anticoagulants in atrial fibrillation patients

ObjectiveLong-term oral anticoagulant should be considered or recommended in patients with atrial fibrillation (AF) and CHA2DS2VASc score ≥ 1 for stroke prevention. Warfarin and different direct oral anticoagulants (DOACs) are metabolized differently by the kidney. The impact on renal function after long-term use of anticoagulants in the patients with AF remains unclear. This study aimed to compare DOACs and warfarin’s impact on the decline in renal function from a large cohort with AF.MethodsThis study included patients with nonvalvular AF from 2000 to 2018, mainly through the medical history (ICD code) of the Chang Gung Research Database. Baseline estimated glomerular filtration rate (eGFR), follow-up eGFR and the change in eGFR between 2-year eGFR and baseline eGFR were compared between different DOACs and warfarin after propensity score matching. The primary study endpoint was acute kidney injury (AKI).Results3657 patients were enrolled in this study and the mean observation time was 3.3 ± 0.9 years. During the observation period, there was a significantly higher incidence of AKI during follow-up in the warfarin group than in the different DOAC groups before and after propensity score matching (before: warfarin vs. DOAC: 9.2% vs. 5.2%, p < 0.001; after: warfarin vs. DOAC: 8.9% vs. 4.4%, p < 0.001). There was no difference in the incidence of AKI between dabigatran group and anti-factor Xa inhibitor group after propensity score matching. The incidence of AKI was similar among rivaroxaban, apixaban and edoxaban groups after propensity score matching. The change in eGFR between 2-year eGFR and baseline eGFR did not differ between the warfarin and DOAC groups after propensity score matching (warfarin vs. DOAC: − 1.27 ± 20.32 vs. -1.94 ± 17.24 mL/min/1.73 m2, p = 0.461).ConclusionsDuring the mean observation time of 3.3 ± 0.9 years, warfarin was associated with a higher incidence of AKI compared with DOACs. The decline in renal function did not differ among warfarin and different DOAC groups.

Abstract 12504: The Gender-Based Outcome in the Patients Undergoing Percutaneous Left Atrial Appendage Occlusion With the Watchman Device: A Longitudinal Nationwide Inpatient Sample Analysis

Introduction: Compared to men, women have an increased risk of having a stroke, cardiovascular disease, and death. It requires continuous anticoagulation use based on CHA 2 DS 2 -VASc scores for stroke prevention. The Watchman device is indicated for patients with non-valvular AF at high risk of stroke who have contraindications to long-term anticoagulation use. We sought to determine the periprocedural outcome difference based on gender in the patients undergoing watchman device implantation. Methods: National Inpatient Sample databases from 2016 to 2018 were utilized using Stata 16.0. NIS databases are the ICD-10-CM code-based largest publicly available all-payer inpatient database. Patients with atrial fibrillation who underwent the watchman procedure were identified; later divided and compared based on gender. Multivariate logistic regression, linear regression, and student t-t-tests were used for analysis. Data were further analyzed after greedy propensity matching for accuracy. Results: Out of 33,825 patients who had the procedure, 14,105 (41.8%) were female, and 19,690 (58.2%) were male. The mean age for women and men were 76.5±7.5 and 75.6±8.1 respectively. Co-morbidities such as DM, CAD, CKD, PVD, and history of CABG were more in men, whereas anemia and pulmonary hypertension were more in women. Mortalities in women were 30 whereas it was 26 in men. There was no difference in mortality on multivariate logistic regression analysis. Complications such as pericardial drain and major bleeding requiring blood transfusion were higher in women. There was no difference in pericardial complications, ischemic stroke, hemorrhagic stroke, and AKI. The overall mean LOS and cost per hospitalization were higher in women. Conclusions: Patients undergoing watchman procedure showed no difference in periprocedural mortality between men and women; however, women had high events of pericardial drainage and major bleeding requiring blood transfusion.