Management Of Anticoagulant Therapy Research Articles

Anticoagulant Therapy in Pregnant Women with Mechanical Heart Valves: Italian Federation of Centers for Diagnosis and Surveillance of the Antithrombotic Therapies (FCSA) Position Paper.

The management of anticoagulant therapy in pregnant women with mechanical heart valves (MHVs) is difficult and often challenging even for clinicians experienced in the field. These pregnancies, indeed, are burdened with higher rates of complications for both the mother and the fetus, compared to those in women without MHVs. The maternal need for an optimal anticoagulation as provided by vitamin K antagonists is counterbalanced by their teratogen effect on the embryo and fetus. On the other hand, several concerns have been raised about the efficacy of heparins in pregnant women with MHVs, considering the high risk of thrombotic complications in these patients. Therefore, numerous clinical issues about the management of pregnant women with MHVs remain unanswered, such as the selection of the best anticoagulant agent, the optimal anticoagulation levels to be achieved and maintained, and the evaluation of long-term effects for both the mother and the fetus. Based on a comprehensive review of the current literature, the Italian Federation of the Centers for the Diagnosis and the Surveillance of the Antithrombotic Therapies (FCSA) proposes experience-based suggestions and expert opinions. Particularly, this consensus document aims at providing practical guidance for clinicians dealing with pregnant women with MHVs, to optimize maternal and fetal outcomes while guaranteeing adequate anticoagulation. Finally, FCSA highlights the need for the creation of multidisciplinary teams experienced in the management of pregnant women with MHVs during pregnancy, delivery, and postpartum, in order to better deal with such complex clinical issues and provide a comprehensive counseling to these patients.

#1617 Effect of pre-renal transplant anticoagulation and antiplatelet therapy on post-transplant outcomes: a retrospective single-center study

Abstract Background and Aims The management of anticoagulation and antiplatelet therapy in stage V chronic kidney disease (CKD) patients undergoing renal transplantation is controversial. While some centers utilize reversal agents or procoagulants before surgery, other experiences suggest that renal transplantation can be safely performed without discontinuation of such treatments. The aim of this study is to assess the incidence of hemorrhagic and thrombotic complications within the first 72 hours post-transplant in anticoagulated or antiplatelet-treated patients compared to those without these treatments (control group). Method Retrospective cohort study of patients undergoing renal transplantation at our center between June 2018 and February 2022, with a 6-month post-transplant follow-up. Epidemiological, clinical, and analytical data were collected. Results 147 patients, predominantly male (60.3%). 8.1% were anticoagulated, and 16.3% were on antiplatelet therapy. Antiplatelet-treated patients were older (63 years) with a higher prevalence of cardiovascular disease history (54.2%). Anticoagulated patients showed a higher frequency of diabetes (50%) and atrial fibrillation (16.7%). The time on dialysis was also longer in anticoagulated or antiplatelet-treated patients (39.5 and 39 vs 33 months). 80.9% were first-time kidney transplant recipients from brain-dead donors, although the donor's age was lower in the control group. Ischemia time was similar in all three groups with no statistically significant differences. However, the length of hospital stay was longer for those receiving anticoagulation or antiplatelet therapy compared to the control group. 58.3% of anticoagulated patients received warfarin (pre-surgery INR of 1.5). In 50% of cases, reversal was performed using coagulation factors, vitamin K, fresh frozen plasma, or combinations of these therapies. 83.3% of antiplatelet-treated patients received aspirin, mainly for secondary prevention (54.2%), and only 8.3% received reversal therapy through plasma administration. The incidence of hemorrhagic and thrombotic complications was low (<5%) and did not significantly differ between anticoagulated or antiplatelet-treated patients and those without these treatments, although transfusion rates were higher in the anticoagulation group (75%) compared to 51.4% in the control group and 62.5% in antiplatelet-treated patients. Conclusion There are no significant differences regarding hemorrhagic and thrombotic complications between anticoagulated or antiplatelet-treated patients and those without these treatments, while the percentage of blood transfusions and hospital stay was higher in anticoagulated or antiplatelet-treated patients.

Differences in quality of anticoagulation care delivery according to ethnoracial group in the United States: A scoping review

Anticoagulation therapy is standard for conditions like atrial fibrillation, venous thromboembolism, and valvular heart disease, yet it is unclear if there are ethnoracial disparities in its quality and delivery in the United States. For this scoping review, electronic databases were searched for publications between January 1, 2011 – March 30, 2022. Eligible studies included all study designs, any setting within the United States, patients prescribed anticoagulation for any indication, outcomes reported for ≥ 2 distinct ethnoracial groups. The following four research questions were explored: Do ethnoracial differences exist in 1) access to guideline-based anticoagulation therapy, 2) quality of anticoagulation therapy management, 3) clinical outcomes related to anticoagulation care, 4) humanistic/educational outcomes related to anticoagulation therapy. A total of 5374 studies were screened, 570 studies received full-text review, and 96 studies were analyzed. The largest mapped focus was patients’ access to guideline-based anticoagulation therapy (88/96 articles, 91.7%). Seventy-eight articles made statistical outcomes comparisons among ethnoracial groups. Across all four research questions, 79 articles demonstrated favorable outcomes for White patients compared to non-White patients, 38 articles showed no difference between White and non-White groups, and 8 favored non-White groups (the total exceeds the 78 articles with statistical outcomes as many articles reported multiple outcomes). Disparities disadvantaging non-White patients were most pronounced in access to guideline-based anticoagulation therapy (43/66 articles analyzed) and quality of anticoagulation management (19/21 articles analyzed). Although treatment guidelines do not differentiate anticoagulant therapy by ethnoracial group, this scoping review found consistently favorable outcomes for White patients over non-White patients in the domains of access to anticoagulation therapy for guideline-based indications and quality of anticoagulation therapy management. No differences among groups were noted in clinical outcomes, and very few studies assessed humanistic or educational outcomes.Graphical Scoping Review: Differences in quality of United States anticoagulation care delivery by ethnoracial group. AF = atrial fibrillation; AMS = anticoagulation management service; DOACs = direct oral anticoagulants; INR = international normalized ratio; PSM = patient self-management; PST = patient self-testing

Thromboembolic prevention in athletes: management of anticoagulation in sports players affected by atrial fibrillation.

Atrial fibrillation (AF) is a common cardiac arrhythmia that poses a significant risk of stroke and thromboembolic events. Anticoagulation therapy is essential for preventing stroke in patients with AF. An increasing number of people of all ages, including cardiac patients, approach physical activity as both a leisure-time exercise and a competitive sport. Therefore, patients at risk of AF are increasingly allowed to practice sports activities. Management of oral anticoagulant therapy (OAT) in these patients is extremely challenging because of the need to balance the risks and benefits of medications, considering both hemorrhagic (in case of trauma) and ischemic complications when the drugs are avoided. Official recommendations are limited for these patients and forbid sports that increase the risk of trauma and consequent bleeding in most cases. These recommendations are strongly influenced by the "traditional" management of OAT, which mainly involves coumarin derivatives. Non-vitamin K antagonist direct oral anticoagulants (DOACs), with their more favorable pharmacokinetic-pharmacodynamic profile than that of coumarin derivatives, may represent an opportunity to modify the approach to sports activity in patients with AF and indications for OAT. This study aimed to review the use of anticoagulants in athletes with AF, highlight their efficacy and safety, and provide practical considerations regarding their management.

Perioperative Management of Anticoagulation and Antithrombotic Therapy

The latest updates to the NCCN Guidelines for perioperative management of anticoagulation and antithrombotic therapies reflect significant changes in the use of bridging anticoagulation. For patients with low- to intermediate-risk atrial fibrillation, the standard of care has shifted toward reduced reliance on bridging anticoagulation. The rationale for this shift is based on the BRIDGE trial, which revealed a 3-fold greater risk of major bleeding without significant reduction in thrombotic outcomes in patients receiving bridging therapy. In patients with mechanical heart valves, findings from the PERIOP2 study led to similar conclusions. Both of these studies have contributed to a paradigm shift in perioperative anticoagulation management, pivoting toward personalized therapy based on patient-specific bleeding and thrombotic risks. For emergent or elective surgeries, the NCCN Guidelines provide a framework for more individualized decision-making, emphasizing the need for ongoing cooperation among physicians, surgeons, and patients.

External validation of PE-SARD bleeding score for early major bleeding in patients with acute pulmonary embolism: Insight from the COMMAND VTE Registry-2

Abstract Background/Introduction The current guidelines and existing bleeding risk scores focus on assessing the risk of anticoagulant-related bleeding in patients with pulmonary embolism (PE) who are candidates for extended anticoagulation therapy. However, there is no consensus on the risk of bleeding in the acute phase. The Syncope, Anemia, Renal Dysfunction (PE-SARD) bleeding score has been developed to predict early major bleeding in acute PE patients. However, the score has not yet been externally validated. Purpose The present study aimed to externally validate the PE-SARD bleeding score, using a large-scale multicenter observational database of patients with venous thromboembolism (VTE). Methods The COMMAND VTE Registry-2 is a multicenter registry enrolling 5197 consecutive acute symptomatic VTE patients among 31 centers in Japan between January 2015 and August 2020. The present study population was consisted of 2722 patients with PE who received anticoagulation therapy during the acute phase and had a calculated PE-SARD bleeding score. The eligible patients were classified into three groups: high-risk group with a PE-SARD score >2.5 points, intermediate-risk group with a score of 1–2.5 points, and low-risk group with a score of 0 point. The discriminatory and calibration ability of the PE-SARD score for 30-day major bleeding were assessed by calculating the area under the receiver operating characteristic curve and creating a calibration plot, respectively. Results The high-risk group accounted for 537 patients (20%), intermediate-risk group for 1381 (51%), and low-risk group for 804 (30%). The proportion of thrombolysis use did not significantly differ across the groups. Among the patients who received direct oral anticoagulants (DOACs), the proportion of high-dose DOAC initiation was highest (54%) in the low-risk group and lowest in the high-risk group (29%). During the first 30 days of anticoagulation therapy, major bleeding occurred in 118 patients. The cumulative 30-day incidence of major bleeding substantially increased in the higher risk categories by the PE-SARD bleeding score (high-risk group: 8.2% [95% CI, 6.2%–10.9%], intermediate-risk group: 4.5% [95% CI, 3.5%–5.8%], and low-risk group: 1.8% [95% CI, 1.0%–3.0%], long-rank P<0.001). The discriminating power of the score was modest with a C-statistic of 0.65 (95%CI 0.61–0.70). Based on the calibration plot, the PE-SARD bleeding score was well calibrated. A sensitivity analysis excluding 275 outpatients showed similar results. Conclusions The risks of 30-day major bleeding in patients with PE substantially increased in the higher risk categories by using the PE-SARD bleeding score. The score is potentially helpful for management of anticoagulation therapy in the acute phase.The Kaplan-Meier curves

Abstract 12981: Digital Health for the Management of Oral Anticoagulation Therapy: A Systematic Review and Meta-Analysis

Background: Direct oral anticoagulants (DOACs) have progressively replaced vitamin K antagonists (VKAs). However, in certain conditions, especially antiphospholipid syndrome, mechanical heart valves and rheumatic mitral stenosis, VKAs remain the only drugs with established safety and efficacy. In low-income contexts, they are frequently the preferred option due to the high costs of DOACs. Its management is often challenging, and different digital health strategies have been implemented to support it. Aims: To systematically review the evidence on the impact of digital health strategies to support anticoagulation management compared to usual care on thromboembolic and bleeding events. Methods: Randomized controlled trials were searched in 5 databases from inception to September 2021. Two independent reviewers performed study selection, data extraction, and quality assessment using the Cochrane risk of bias tool (RoB2). Total thromboembolic events, major bleeding, mortality, and time in therapeutic range were assessed. Results were pooled using random effect models. Results: In total, 25 randomized controlled trials were included (25,746 patients) and classified as moderate to high risk of bias. Telemedicine resulted in a trend of reduced risk of thromboembolic events (13 studies, relative risk [RR] 0.75, 95% CI 0.53-1.07; I2=42%), comparable rates of major bleeding (11 studies, RR 0.94, 95% CI 0.82-1.07; I2=0%) and mortality (12 studies, RR 0.96, 95% CI 0.78-1.20; I2=11%), and an improved time in therapeutic range (16 studies, mean difference 3.38, 95% CI 1.12-5.65; I2=90%). In the subgroup of multitasking intervention, telemedicine resulted in an important reduction of thromboembolic events (RR 0.20, 95% CI 0.08-0.48). Conclusions: Digital health strategies resulted in similar rates of major bleeding and mortality, a trend for fewer thromboembolic events and better anticoagulation quality compared to standard care. Given the potential benefits of digital health-based care, such as greater access to remote populations, these findings may encourage further implementation of these strategies for anticoagulation management, particularly as part of multifaceted interventions for integrated care of chronic diseases.

Abstract 13662: Novel Morphological Classification of Left Atrial Appendage Using 3-Dimensional Printer -Rock, Paper and Scissors-

Background: Left atrial appendage (LAA) of Asians is generally larger and more complicated than that of non-Asians. Whereas the four classifications from previous reports are widely used in the world, different physicians have different point of views in the real-world practice. Purpose: To identify the relationship between morphological features of LAA and cardioembolic stroke in Japanese patients. Methods: All left atrial appendage closure (LAAC) cases in our institution performed between February 2020 and April 2023 were retrospectively analyzed. The three-dimensional printing of LAA was generated from cardiovascular computed tomography imaging data. The shapes of the LAA were classified into 3 morphological types: (1) The LAA with bi lobe was defined as “Scissors” type; (2) The one with complicated peripheral branches was “Paper” type; (3) The simple one was “Rock” type. We examined the relationship between the risk of cardioembolic stroke and the morphological features of the LAA. Results: The cohort consisted of 93 consecutive patients (age, 75±1 years; male gender, 72%; the size of WATCHMAN device, 29±0 mm). There were 41 (44%) patients who had a history of cardioembolic stroke (27% vs. 41% vs. 58%; Rock vs. Scissors vs. Paper types, p-value = 0.0466). In the multivariate analysis, the Paper type is the potential risk factor of cardioembolic stroke (p-value < 0.01) (Table1.2). Conclusions: The morphological features of LAA by three-dimensional printing was significantly related to cardioembolic stroke in this population. Physicians should pay attention to anticoagulant therapy management and proactively consider LAAC in LAA with complicated peripheral branches.

Precision medicine in hemostasis: a review of prothrombin complex concentrates and the role of viscoelastic tests in tailoring therapy

This review explores the role of precision medicine in the management of bleeding disorders and anticoagulation therapy, with a focus on the use of visco-elastic tests such as Thromboelastography (TEG) and Rotational Thromboelastometry (ROTEM). These tests provide real-time, dynamic insight into a patient's coagulation status, guiding the choice between three-factor prothrombin complex concentrate (PCC3) and four-factor PCC (PCC4), as well as the use of activated four-factor PCC (FEIBA). The specific ROTEM tests, INTEM and EXTEM, further enhance our understanding of the intrinsic and extrinsic coagulation pathways. Moreover, the use of tranexamic acid (TXA) and fibrinogen, guided by these visco-elastic tests, has shown promise in trauma patients. TXA has been associated with survival benefit when administered immediately or within 3 hours of injury. Fibrinogen, a key factor in clot formation, can be monitored and supplemented as needed to optimize hemostasis. In conclusion, the practice of precision medicine, with the aid of TEG and ROTEM, offers the potential to enhance the safety and efficacy of PCC therapy, TXA administration, and fibrinogen supplementation. These tools are invaluable in tailoring therapy to the specific needs of each patient, potentially optimizing patient outcomes and minimizing the risk of adverse events.

A novel shared decision-making (SDM) tool for anticoagulation management in atrial fibrillation: protocol for a prospective, cluster randomized controlled trial

BackgroundAtrial fibrillation (AF) is a common arrhythmia that requires anticoagulation therapy to prevent stroke. However, there is still a significant under-/over-treatment in stroke prevention for patients with AF. The adherence and the risk of bleeding associated with oral anticoagulation therapy (OACs) are major concerns. Shared decision-making (SDM) is an approach that involves patients and healthcare providers in making decisions about treatment options. This study aims to assess the effectiveness of a novel SDM tool for anticoagulation management in AF.MethodsThe study will be a prospective, cluster randomized controlled trial involving 440 patients with AF in 8 community health service centers (clusters) in Shanghai, China. The SDM group will receive anticoagulation management through the novel SDM tool, while the control group will receive standard care. The follow-up period will be at least 2 years. The primary outcome will be any bleeding event, while secondary outcomes include the accordance of stroke prophylaxis for AF according to the current guidelines, time in therapeutic range (TTR), the occurrences of major bleeding and thrombosis events, and patient knowledge, adherence, and satisfaction.DiscussionThis study will provide evidence of the effectiveness of shared decision-making in improving the appropriateness of OAC use in Chinese AF patients. The findings may inform the development of guidelines and policies for the management of AF and anticoagulation therapy in China and other countries.Trial registrationChiCTR ChiCTR2200062123. Registered on 23 July 2022.

Development and validation of the Chinese oral anticoagulants knowledge tool (C-OAKT): A pilot study

ObjectiveTo develop and validate an oral anticoagulant knowledge tool for Chinese-speaking patients treated with warfarin or direct oral anticoagulants (DOACs) in Hong Kong. MethodThis pilot validation study consisted of the following three phases: (1) the development of a knowledge tool and content validity assessment; (2) a pilot study of 200 participants, consisting of 100 patients taking warfarin or DOACs, 50 pharmacists, and 50 members of the general public; and (3) known-group validity and reliability assessments. ResultsA 19-item “Chinese Oral Anticoagulants Knowledge Tool (C-OAKT)” was developed with a scale content validity index of 0.95. The mean score for known-group validity was significantly higher in the pharmacist group than the patient groups, and the patient groups scored significantly higher than the general public (mean ± standard deviation [SD] = 90.00 ± 7.11 vs. 51.55 ± 17.49 vs. 19.0 ± 15.42, respectively; p < 0.001). The mean score was higher for patients who attended a pharmacist-managed anticoagulant therapy management clinic (PAC) than for non-PAC patients (mean ± SD = 56.80 ± 13.60 vs. 46.30 ± 9.43; p = 0.004). An analysis of internal consistency showed a Cronbach's alpha value of 0.86. ConclusionThe results of the pilot validation study suggested that the C-OAKT is a valid and reliable instrument for assessing patients' knowledge of oral anticoagulants in ambulatory care settings. InnovationsThis is the first validated Chinese version of an anticoagulant knowledge assessment tool. This tool will be utilized in public hospitals in Hong Kong, and will facilitate future research exploring the relationship between anticoagulant knowledge and patient-related outcomes.

439 A review of the management of Anti-coagulation and anti-platelet medication in surgical patients in a University Hospital

Abstract Management of surgical patients on anti-coagulation and anti-platelet medication can be challenging. Balance between discontinuation, with thrombotic risk, and continuation or early re-initiation with risk of bleeding should be considered. In emergency setting patients are managed depending on clinical situation. Aim To review the management of anticoagulant or antiplatelet therapy in acute and elective surgical patients. Methods Method: Electronic data was retrospectively reviewed for both elective and emergency admissions to surgical ward during two weeks period. Data including age, sex, admission diagnosis, indication and nature of anti-thrombotic or antiplatelet medication, and thromboembolic or bleeding complications were collected. Results 30 patients (19 male, 11 female) with a mean age of 74 (54-90) were reviewed. 22 patients were emergency admission and 8 were elective. All elective cases had their medication withheld. Three patients developed complications including 1 rectal bleeding, 1 post liver biopsy bleed and 1 internal jugular vein thrombosis. 17 emergency patients had their medication withheld. 5 patients underwent surgery and 7 patients had endoscopic invasive procedures (ERCP). One patient developed bowel ischemia from arterial thrombosis following emergency open cholecystectomy. Among the 5 patients who continued the medication one patient had ERCP and others did not receive any intervention. Conclusion Patients on anti-coagulation and anti-platelet medication undergoing invasive procedure can develop thrombo-embolic or bleeding complication.

Thromboprophylaxis in pediatric patients with earthquake-related crush syndrome: a single centre experience.

Injuries increase the riskof venous thromboembolism (VTE). However, the literature on the management of anticoagulant therapy in pediatric patients with crush injury is limited. In this study, we aimed to share our experience about anticoagulant thromboprophylaxis in pediatric patients with earthquake-related crush syndrome. This study included patients who were evaluated for VTE risk after the Turkey-Syria earthquake in 2023. Since there is no specific pediatric guideline for the prevention of VTE in trauma patients, risk assessment for VTE and decision for thromboprophylaxis was made by adapting the guideline for the prevention of perioperative VTE in adolescent patients. Forty-nine patients [25 males and 24 females] with earthquake-related crush syndrome had participated in the study. The median age of the patients was 13.5 (8.8-15.5) years. Seven patients (14.6%) who had no risk factors for thrombosis were considered to be at low risk and did not receive thromboprophylaxis. Thirteen patients (27.1%) with one risk factor for thrombosis were considered to be at moderate risk and 28 patients (58.3%) with two or more risk factors for thrombosis were considered to be at high risk. Moderate-risk patients (n = 8) and high-risk patients aged < 13years (n = 11) received prophylactic enoxaparin if they could not be mobilized early, while all high-risk patients aged ≥ 13years (n = 13) received prophylactic enoxaparin. With the decision-making algorithm for thyromboprophylaxis we used, we observed a VTE rate of 2.1% in pediatric patients with earthquake-related crush syndrome.

Developing and Validating a Self-Care Self-Efficacy Scale for Oral Anticoagulation Therapy in Patients With Nonvalvular Atrial Fibrillation: Protocol for a Mixed Methods Study.

Oral anticoagulation therapy (OAC) is the cornerstone treatment for preventing venous thromboembolism and stroke in patients with nonvalvular atrial fibrillation (NVAF). Despite its significance, challenges in adherence and persistence to OAC regimens have been reported, leading to severe health complications. Central to addressing these challenges is the concept of self-efficacy (SE) in medication management. Currently, there is a noticeable gap in available tools specifically designed to measure SE in OAC self-care management, while such tools are crucial for enhancing patient adherence and overall treatment outcomes. This study aims to develop and validate a novel scale aimed to measure self-care self-efficacy (SCSE) in patients with NVAF under OAC, which is the patients' Self-Care Self-Efficacy Index in Oral Anticoagulation Therapy Management (SCSE-OAC), for English- and Italian-speaking populations. We also seek to assess patients' SE in managing their OAC treatment effectively and to explore the relationship between SE levels and sociodemographic and clinical variables. Using a multiphase, mixed methods observational study design, we first conceptualize the SCSE-OAC through literature reviews, patient focus groups, and expert consensus. The scale's content validity will be evaluated through patient and expert reviews, while its construct validity is assessed using exploratory and confirmatory factor analyses, ensuring cross-cultural applicability. Criterion validity will be examined through correlations with clinical outcomes. Reliability will be tested via internal consistency and test-retest reliability measures. The study will involve adult outpatients with NVAF on OAC treatment for a minimum of 3 months, using both e-surveys and paper forms for data collection. It is anticipated that the SCSE-OAC will emerge as a reliable and valid tool for measuring SE in OAC self-care management. It will enable identifying patients at risk of poor adherence due to low SE, facilitating targeted educational interventions. The scale's validation in both English and Italian-speaking populations will underscore its applicability in diverse clinical settings, contributing significantly to personalized patient-centered care in anticoagulation management. The development and validation of the SCSE-OAC represent a significant advancement in the field of anticoagulation therapy. Validating the index in English- and Italian-speaking populations will enable personalized patient-centered educational interventions, ultimately improving OAC treatment outcomes. The SCSE-OAC's focus on SCSE introduces a novel approach to identifying and addressing individual patient needs, promoting adherence, and ultimately improving health outcomes. Future endeavors will seek to extend the validation of the SCSE-OAC across diverse cultural and linguistic landscapes, broadening its applicability in global clinical and research settings. This scale-up effort is crucial for establishing a universal standard for measuring SCSE in OAC management, empowering clinicians and researchers worldwide to tailor effective and culturally sensitive interventions. ClinicalTrials.gov NCT05820854; https://tinyurl.com/2mmypey7. PRR1-10.2196/51489.

Telemedicine-Based Management of Oral Anticoagulation Therapy: Systematic Review and Meta-analysis.

Oral anticoagulation is the cornerstone treatment of several diseases. Its management is often challenging, and different telemedicine strategies have been implemented to support it. The aim of the study is to systematically review the evidence on the impact of telemedicine-based oral anticoagulation management compared to usual care on thromboembolic and bleeding events. Randomized controlled trials were searched in 5 databases from inception to September 2021. Two independent reviewers performed study selection and data extraction. Total thromboembolic events, major bleeding, mortality, and time in therapeutic range were assessed. Results were pooled using random effect models. In total, 25 randomized controlled trials were included (n=25,746 patients) and classified as moderate to high risk of bias by the Cochrane tool. Telemedicine resulted in lower rates of thromboembolic events, though not statistically significant (n=13 studies, relative risk [RR] 0.75, 95% CI 0.53-1.07; I2=42%), comparable rates of major bleeding (n=11 studies, RR 0.94, 95% CI 0.82-1.07; I2=0%) and mortality (n=12 studies, RR 0.96, 95% CI 0.78-1.20; I2=11%), and an improved time in therapeutic range (n=16 studies, mean difference 3.38, 95% CI 1.12-5.65; I2=90%). In the subgroup of the multitasking intervention, telemedicine resulted in an important reduction of thromboembolic events (RR 0.20, 95% CI 0.08-0.48). Telemedicine-based oral anticoagulation management resulted in similar rates of major bleeding and mortality, a trend for fewer thromboembolic events, and better anticoagulation quality compared to standard care. Given the potential benefits of telemedicine-based care, such as greater access to remote populations or people with ambulatory restrictions, these findings may encourage further implementation of eHealth strategies for anticoagulation management, particularly as part of multifaceted interventions for integrated care of chronic diseases. Meanwhile, researchers should develop higher-quality evidence focusing on hard clinical outcomes, cost-effectiveness, and quality of life. PROSPERO International Prospective Register of Systematic Reviews CRD42020159208; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=159208.

Influence of perioperative antiplatelet and anticoagulant medication management on bleeding events in dermatosurgery-A prospective observational study.

Perioperative management of antiplatelet and anticoagulant (AP/AC) therapy is a matter of balancing the risks of bleeding and thromboembolic events. Reliable data for dermatosurgery are still lacking, especially for direct oral anticoagulants (DOAC). The aim was to prospectively evaluate the influence of AP/AC-medication on bleeding risk in dermatosurgery with focus on exact intervals between DOAC intake and procedure performed on post-operative bleeding. Patients with or without AP/AC-therapy were included in the study without randomization. Exact times of DOAC-intake, procedure performed and post-operative bleeding were documented. Data collection was prospectively and standardized done by one person. We evaluated 1852 procedures in 675 patients. Post-operative bleeding occurred after 15.93% (n = 295) of all procedures, but only a few of them were severe (1.57%, n = 29). Compared to patients without AP/AC-medication, severe post-operative bleeding occurred significantly more often under dual antiplatelet therapy (11.76%, n = 2; p = 0.0166) and bridging of either vitamin K antagonist (9.09%, n = 2; p = 0.0270) or DOAC (15.38%, n = 2; p = 0.0099). There was no significant difference in the frequency of severe bleeding regarding to the preoperative DOAC-free period. Although AP/AC-therapy is associated with a significant higher rate of post-operative bleeding, no life-threatening bleeding was recorded. Long preoperative pausing or bridging of DOAC does not lead to significantly less severe bleeding events.

Potential for a Virtual Care Model in the Perioperative Management of Anticoagulant Therapy: A 5-Year Retrospective Clinic Review

Abstract Background With a trend toward greater virtual care in selected clinical settings, perioperative anticoagulant management appears well suited for this care delivery model. We explored the potential for virtual care among patients who are receiving anticoagulant therapy and require perioperative management around the time of an elective surgery/procedure. Methods We undertook a retrospective review of patients who were receiving anticoagulant therapy, either a direct oral anticoagulant (DOAC) or warfarin, assessed in a perioperative anticoagulation-bridging clinic over a 5-year period from 2016 to 2020. Using prespecified criteria, we determined the proportion of patients who likely would be suitable for virtual care (receiving a DOAC or warfarin and having a minimal- or low-/moderate-bleed-risk surgery/procedure), those who likely would be suitable for in-person care (receiving warfarin and requiring heparin bridging for a mechanical heart valve), and patients who would be suitable for either care delivery model (receiving a DOAC or warfarin, but not with a mechanical heart valve, and requiring a high-bleed-risk surgery/procedure). Results During the 5-year study period, there were 4,609 patients assessed for perioperative anticoagulant management in whom the most widely used anticoagulants were warfarin (37%), apixaban (30%), and rivaroxaban (24%). Within each year assessed, 4 to 20% of all patients were undergoing a minimal-bleed-risk procedure, 76 to 82% were undergoing a low-/moderate-bleed-risk surgery/procedure, and 10 to 39% were undergoing a high-bleed-risk surgery/procedure. The proportion of patients considered suitable for virtual, in-person, or either virtual or in-person management was 79.6, 7.1, and 13.3%, respectively. Conclusion In patients who were assessed in a perioperative anticoagulation clinic, there was a high proportion of patients in whom a virtual care model might be suitable.

Management of oral anticoagulant therapy after intracranial hemorrhage in patients with atrial fibrillation.

Intracranial hemorrhage (ICH) is considered a potentially severe complication of oral anticoagulants (OACs) and antiplatelet therapy (APT). Patients with atrial fibrillation (AF) who survived ICH present both an increased ischemic and bleeding risk. Due to its lethality, initiating or reinitiating OACs in ICH survivors with AF is challenging. Since ICH recurrence may be life-threatening, patients who experience an ICH are often not treated with OACs, and thus remain at a higher risk of thromboembolic events. It is worthy of mention that subjects with a recent ICH and AF have been scarcely enrolled in randomized controlled trials (RCTs) on ischemic stroke risk management in AF. Nevertheless, in observational studies, stroke incidence and mortality of patients with AF who survived ICH had been shown to be significantly reduced among those treated with OACs. However, the risk of hemorrhagic events, including recurrent ICH, was not necessarily increased, especially in patients with post-traumatic ICH. The optimal timing of anticoagulation initiation or restarting after an ICH in AF patients is also largely debated. Finally, the left atrial appendage occlusion option should be evaluated in AF patients with a very high risk of recurrent ICH. Overall, an interdisciplinary unit consisting of cardiologists, neurologists, neuroradiologists, neurosurgeons, patients, and their families should be involved in management decisions. According to available evidence, this review outlines the most appropriate anticoagulation strategies after an ICH that should be adopted to treat this neglected subset of patients.

In vitro evaluation of anticoagulant therapy management when urgent percutaneous coronary intervention is required in rivaroxaban-treated patients.

We investigated in vitro the management of intraprocedural anticoagulation in patients requiring immediate percutaneous coronary intervention (PCI) while using regular direct oral anticoagulants (DOACs). Twenty-five patients taking 20 mg of rivaroxaban once daily comprised the study group, while five healthy volunteers included the control group. In the study group, a beginning (24 h after the last rivaroxaban dose) examination was performed. Then, the effects of basal and four different anticoagulant doses (50 IU/kg unfractionated heparin (UFH), 100 IU/kg UFH, 0.5 mg/kg enoxaparin, and 1 mg/kg enoxaparin) on coagulation parameters were investigated at the 4th and 12th h following rivaroxaban intake. The effects of four different anticoagulant doses were evaluated in the control group. The anticoagulant activity was assessed mainly by anti-factor Xa (anti-Xa) levels. Beginning anti-Xa levels were significantly higher in the study group than in the control group (0.69 ± 0.77 IU/mL vs. 0.20 ± 0.14 IU/mL; p < 0.05). The study group's 4th and 12th-h anti-Xa levels were significantly higher than the beginning level (1.96 ± 1.35 IU/mL vs. 0.69 ± 0.77 IU/mL; p < 0.001 and 0.94 ± 1.21 IU/mL vs. 0.69 ± 0.77 IU/mL; p < 0.05, respectively). Anti-Xa levels increased significantly in the study group with the addition of UFH and enoxaparin doses at the 4th and 12th h than the beginning (p < 0.001 at all doses). The safest anti-Xa level (from 0.94 ± 1.21 to 2.00 ± 1.02 IU/mL) was achieved 12 h after rivaroxaban with 0.5 mg/kg enoxaparin. Anticoagulant activity was sufficient for urgent PCI at the 4th h after rivaroxaban treatment, and additional anticoagulant administration may not be required at this time. Twelve hours after taking rivaroxaban, administering 0.5 mg/kg of enoxaparin may provide adequate and safe anticoagulant activity for immediate PCI. This experimental study result should confirm with clinical trials (NCT05541757).

Bridging the Gap in Cancer-Related Stroke Management: Update on Therapeutic and Preventive Approaches.

The underlying aetiopathophysiology of cancer-related strokes and thromboembolisms differs from that of noncancer-related strokes, which makes treating cancer-related strokes and thromboembolisms a distinct clinical challenge. This necessitates the development of novel, individualised diagnostic and treatment strategies. However, limited guidelines are available for the management of cancer-related strokes and the prevention of acute strokes or other thromboembolic events in this patient population. In this article, we present an updated overview of the therapeutic and preventive strategies for strokes in cancer settings. These strategies include acute reperfusion therapy, anticoagulant therapy, antiplatelet therapy, and lifestyle management options. We also outline comprehensive pathways and highlight gaps in the evidence-based clinical management of cancer-related strokes or thromboembolisms. Additionally, future recommendations for the management of strokes in cancer patients are provided.