Outpatient Anticoagulation Research Articles

A More Selective vs a Standard Risk-Stratified, Heparin-Based, Obstetric Thromboprophylaxis Protocol

In 2016, our institution adopted a pregnancy-related venous thromboembolism (VTE) prophylaxis protocol based on American College of Obstetricians and Gynecologists guidelines that recommended postpartum heparin-based chemoprophylaxis (enoxaparin) based on a risk-stratified algorithm. In response to increased wound hematomas without significant reduction in VTE using this protocol, a more selective risk-stratified approach was adopted in 2021. To evaluate outcomes of the more selective risk-stratified approach to heparin-based obstetric thromboprophylaxis (enoxaparin) protocol. Retrospective observational study of 17 489 patients who delivered at a single tertiary care center in the southeast US between January 1, 2016, and December 31, 2018 (original protocol), and between December 1, 2021, and May 31, 2023 (more selective protocol). Patients receiving outpatient anticoagulation for active VTE or high VTE risk during pregnancy were excluded. Standard risk-stratified and more selective postpartum VTE chemoprophylaxis protocols. The primary outcome was clinical diagnosis of wound hematoma up to 6 weeks pos tpartum. The secondary outcome was new diagnosis of VTE up to 6 weeks post partum. We compared baseline characteristics and outcomes between groups and estimated adjusted odds ratios with 95% CIs of primary and secondary outcomes using the original protocol group as reference. Of 17 489 patients included in the analysis, 12 430 (71%) were in the original protocol group and 5029 (29%) were in the more selective group. Rates of chemoprophylaxis decreased from 16% (original protocol) to 8% (more selective protocol). Patients in the more selective group were more likely to be older, be married, and have obesity or other comorbidities (hypertension, diabetes, cardiac disease). Compared with the original protocol, the more selective protocol was associated with a decrease in any wound hematoma (0.7% vs 0.3%; adjusted odds ratio [aOR], 0.38; 95% CI, 0.21-0.67), specifically due to a lower rate of superficial wound hematomas (0.6% vs 0.3%; aOR, 0.43; 95% CI, 0.24-0.75). There was no significant increase in VTE or individual types of VTE (0.1% vs 0.1%; aOR, 0.40; 95% CI, 0.12-1.36). A more selective risk-stratified approach to an enoxaparin thromboprophylaxis protocol for VTE was associated with decreased rates of wound hematomas without increased rates of postpartum VTE.

Estimation of the outpatient anticoagulation cost for pulmonary embolism in Greece

Estimation of the outpatient anticoagulation cost for pulmonary embolism in Greece

Venous thromboembolism in patients with pancreatic adenocarcinoma: Disease burden and initiation of ambulatory thromboprophylaxis

Background/ObjectivesAmbulatory thromboprophylaxis (AT) in patients with pancreatic adenocarcinoma (PAC) reduces venous thromboembolism (VTE) risk and is recommended for patients receiving systemic chemotherapy. We evaluated VTE rates, severity, timing, and risk factors in PAC patients as well as AT rates and initiation times. MethodsPatients diagnosed with PAC were included. Data collected included patient demographics, medical history, PAC diagnosis, development of VTE, AT, and bleeding episodes. VTE was defined as a DVT or a PE. Patients were classified as receiving AT for VTE prevention if they received a prescription for outpatient anticoagulation. ResultsThe cohort included 243 PAC patients. VTE occurred in 24 %. Overall, 52 % developing VTE were hospitalized and 5 % died as a result of the VTE. Of those who developed VTE 50 % were diagnosed within the first 2 months of PAC diagnosis. Univariate predictors of elevated VTE risk included an elevated Onkotev score, metastasis at diagnosis, male gender and not receiving AT. Multivariate predictors of elevated VTE risk included male gender (P = 0.014) and not receiving AT (P = 0.001). Overall, 30 % of patients received AT. The median time from diagnosis to initiation of AT was 43 days. Major bleeding occurred in 5.8 %. Patients receiving AT were not at a significantly increased risk of major bleeding (p = 0.5). Patients with intestinal tumor invasion were at significantly increased risk of major bleeding (P = 0.021). ConclusionVTE risk is significant and morbid in PAC patients. AT rates are low, and initiation is often delayed. Therapeutic endoscopists diagnosing PAC may be helpful in AT initiation.

Changes in Time in Therapeutic Range Within a Warfarin Anticoagulation Clinic Following Introduction of Direct Oral Anticoagulants

Background: As direct oral anticoagulants (DOACs) have become widely recommended as first-line anticoagulation therapy, patients who remain on warfarin are likely those unable to afford, adhere to, or utilize DOAC therapy due to the presence of a contraindication. It is currently unknown how availability of DOACs have affected populations being managed at warfarin (VKA) anticoagulation clinics. Methods: This was a retrospective chart review assessing warfarin-treated patients at an outpatient anticoagulation clinic. The primary endpoint was the 6-month time in therapeutic range (TTR) before and after DOACs were recommended as first-line therapy by clinical guidelines. Study periods were January to June 2015, before DOACs were recommended over VKA, and January to June 2022, when DOACs were often recommended over VKA. TTR, demographic changes, and the presence of contraindications to DOAC therapy in the clinic population between the two time periods were assessed. Results: No difference in 6-month TTR was observed between study periods (59% in 2015 vs 63% in 2022; P = .45). Patient demographics did not significantly vary, which may be due to the clinic retaining 45% of patients between both time periods. Contraindications to DOAC therapy were identified in 39% of the 2015 group and 49% of the 2022 group (P = .18). The most common contraindication was indication for anticoagulation. Conclusion: Availability of DOACs did not seem to significantly affect the population or management of warfarin-treated patients at an outpatient anticoagulation clinic, however, contraindications and potential challenges to use of DOAC therapy are present in many patients.

Postpartum Outcomes in Patients Receiving Venous Thromboembolism Prophylaxis during Antepartum Admission.

We evaluated if venous thromboembolism (VTE) prophylaxis in the inpatient antepartum period was associated with wound hematomas, VTE occurrence, and other adverse outcomes. This study is a secondary analysis of a retrospective cohort of patients who delivered at University of Alabama at Birmingham (UAB). Patients receiving outpatient anticoagulation (AC) were excluded. We grouped patients into those who received inpatient antepartum prophylactic AC and those who did not. The primary outcome was wound hematomas from delivery to 6 weeks postpartum (PP). Secondary outcomes included VTE occurrence and select adverse outcomes, including other wound complications, unplanned procedures, mode of anesthesia, and intensive care unit (ICU) admission. Analyses were performed with no AC group as the reference. A sensitivity analysis excluding those who received inpatient PP AC was performed. Of 1,035 included patients, only 169 patients received inpatient prophylactic AC. They were older, had higher body mass indices, and more comorbidities. Patients receiving inpatient antepartum AC had higher wound hematomas (adjusted odds ratio [aOR] 23.81; 95% confidence interval [CI] 7.04-80.47). They had similar risk for developing VTE as the control group (aOR 2.68; 95% CI 0.19-37.49) but were more likely to have wound complications (aOR 2.36; 95% CI 1.24-4.47), maternal deaths (p < 0.05), and require PP ICU admission (aOR 13.38; 95% CI 4.79-37.35). When excluding those receiving any PP AC, there was no difference in bleeding complications between the two groups and VTE rates remained unchanged. Rates of maternal deaths and PP ICU admissions remained higher in those who received inpatient antepartum AC prophylaxis. In this small cohort study, increased wound hematomas were found in those who received inpatient antepartum AC prophylaxis with no difference in VTE occurrence. While adverse events were increased in the inpatient AC group, this was mostly associated with PP AC prophylaxis. Larger studies should be conducted to describe the true benefits and risks of antepartum AC prophylaxis and determine efficacy of this widely used practice. · Peripartum chemoprophylaxis is associated with increased wound hematomas.. · VTE is rare, despite its association with significant peripartum morbidity/mortality.. · Large studies are needed to guide practices that optimize the risk/benefit ratio of chemoprophylaxis..

Thoracoscopic thymectomy for myasthenia gravis and non-invasive thymoma after COVID-19 pneumonia

Modern guidelines have identified thoracoscopic thymectomy as a preferable option for myasthenia gravis and non-invasive thymoma. In the era of the new coronavirus infection, it is relevant to develop protocols for anesthetic and perioperative support of patients undergoing thymectomy for myasthenia gravis after COVID-associated pneumonia (CAP). We present the results of thoracoscopic thymectomies in patients after CAP. Multidisciplinary team should determine therapeutic support, the need for plasmapheresis and thymectomy. Plasmapheresis and glucocorticosteroids are effective in addition to anticholinesterase therapy at the stages of perioperative support for correction of neurological status in patients with myasthenia combined with chronic obstructive pulmonary disease and pulmonary hypertension. Outpatient direct anticoagulants are advisable considering the need for prolonged postoperative prevention of thrombotic events.

Abstract 14420: Role of Thromboprophylaxis in Outpatients With COVID-19: A Meta-Analysis of Randomized Controlled Trials

Introduction: COVID-19 has been known to cause a hypercoagulable state, leading to venous and arterial thromboembolism. While thromboprophylaxis with anticoagulation (AC) agents is beneficial in hospitalized patients, their role is unclear in outpatients with COVID-19. We conducted a meta-analysis to assess the potential role of AC in outpatients with COVID-19. Methods: Multiple online databases were searched for randomized clinical trials (RCTs) comparing prophylactic AC to placebo in patients presenting in the outpatient setting with COVID-19. The primary outcomes of interest were hospitalization, death, venous thromboembolism (VTE) and bleeding at the longest available follow up. A random-effects model was used to estimate pooled risk ratios (RR) and 95% confidence intervals (CI). Results: Four RCTs with a total of 1,464 patients (AC group n=726, placebo group n=738) were included. The mean age was 55 years, 48% of patients were men and the mean duration of follow up was 65 days. Both groups had similar risk of hospitalization (RR 0.93, 95% CI 0.56-1.53, p = 0.76) (Figure 1), death (RR 1.09, 95% CI 0.07-17.14, p = 0.95), VTE (RR 0.35, 95% CI 0.08-1.49, p = 0.16) (Figure 2), and bleeding (RR 1.99, 95% CI 0.73-5.40, p = 0.18). Conclusions: Thromboprophylaxis with AC in outpatients with COVID-19 is not associated with reduction in the risk of hospitalization, death or VTE when compared with placebo.

Compliance status and influencing factors of anticoagulation therapy in outpatient undergoing major orthopedic surgery.

This study was designed to investigate influencing factors of out-of-hospital anticoagulation therapy compliance among patients undergoing major orthopaedic surgeries. A cross-sectional, descriptive study was conducted from July 2022 to February 2023 among outpatients who underwent major orthopedic surgery in our hospital. Patients (n = 200) were surveyed using the General Information Questionnaire, the General Self-Efficacy Scale, the Specificity of Medication-Taking Beliefs Scale, and the Morisky Medication Adherence Scale. Factors that influenced patient compliance were also determined using univariate and multivariate regression analyses. One hundred eighty-three valid questionnaires were returned, the compliance with outpatient anticoagulation therapy among patients undergoing major orthopaedic surgeries was good in 56.3% (103/183) of all cases and poor in 43.7% (80/183). Multivariate logistic regression analysis showed that medication duration, adverse effects, self-efficacy and medication beliefs influenced adherence to out-of-hospital anticoagulation therapy in patients undergoing major orthopedic surgery (P < 0.05). Poor compliance with out-of-hospital anticoagulation therapy in patients undergoing major orthopedic surgery is mainly associated with a long course of medication, adverse reactions, low self-efficacy and low medication beliefs. Healthcare staff should strengthen post-discharge anticoagulation management based on relevant influencing factors to enhance patient compliance.

Acute Kidney Injury in Coronavirus Disease and Association with Thrombosis

Introduction: Coronavirus disease (COVID-19) is a global pandemic which continues to cause systemic inflammation, leading to multi-system organ damage including acute kidney injury (AKI) and thrombotic complications. We hypothesize that D-dimer level predicts an increased risk of AKI and thrombotic complications in COVID-19. Methods: This was a retrospective cohort study performed at a single-center academic center. Patients hospitalized with COVID-19 between January 1, 2020, and January 1, 2021, were included in the analysis. Demographics and associated medical records were reviewed from the electronic medical record. Statistical analysis was done to determine the incidence of AKI and thrombosis and if D-dimer was predictive of an adverse event. Results: The study included 389 patients with the diagnosis of COVID-19 who were hospitalized. AKI was evident in 143 patients with 59 experiencing a thrombotic event. Factors associated with AKI included age, chronic kidney disease, proteinuria, use of outpatient angiotensin-blocking medications, and D-dimer greater than 1.75 (p < 0.05). Factors associated with thrombosis included use of outpatient anticoagulants, elevated WBC, interleukin-6 (IL-6), and D-dimer greater than 1.75 (p < 0.05). When D-dimer was dichotomized at the median value for the entire dataset (value greater than 1.75), there was good discrimination for AKI and very good discrimination for thrombosis. Conclusions: Complications of acute renal failure and thrombosis are common in patients presenting with COVID-19. D-dimer was found to be predictive of both. Future studies to validate the association of these two events in patients presenting with COVID-19 are warranted as early treatment with antithrombotic agents may have a role in preventing adverse sequelae and outcomes.

Use of Rivaroxaban in Children with Congenital Heart Disease: A Single-Center Case Series.

Rivaroxaban is a direct oral anticoagulant approved for therapeutic and prophylactic anticoagulation in both adults and children. Studies on rivaroxaban use in pediatric patients with congenital heart disease (CHD) are limited. Currently, warfarin (oral) and enoxaparin (injection) are the primary options for pediatric outpatient anticoagulation. Rivaroxaban may be a less burdensome alternative, but its use has not been well described in the pediatric CHD population. We describe our single-center experience. From May 2020-July 2022, we identified all pediatric CHD patients started on rivaroxaban. Dosing was based on recommendations reported in the EINSTEIN-Jr (Male et al. in Lancet Haematol 7:e18-e27, 2020) and UNIVERSE study (McCrindle et al. in J Am Heart Assoc 10:e021765, 2021) protocols. Qualitative outcomes on safety and efficacy are reported. There were 27 patients studied with an age range of 4months-15years at time of medication initiation. Single ventricle heart disease was present in 70% (19/27) of patients. Of the 27 patients initiated on rivaroxaban, 15 (56%) were started for VTE prophylaxis and 12 (44%) were started for VTE treatment. No patients started on rivaroxaban for prophylaxis developed a VTE. There was resolution or lack of propagation in 10 of the 12 patients started for treatment. There were two clinically relevant bleeding episodes. Our single-center case series describes the experience with rivaroxaban for VTE prophylaxis and treatment in pediatric congenital heart disease. Larger studies are required to further investigate safety, efficacy, and use indications.

Systemic thrombolytic and ultrasound-assisted catheter-directed thrombolysis for treatment of acute pulmonary embolism: a 7-year, multicenter experience.

Treatment of acute pulmonary embolism (PE) varies based upon risk stratification and ranges from outpatient oral anticoagulation to emergency surgical embolectomy. Patients with high-risk PE can be considered for systemic thrombolytic (ST) based upon guideline recommendations, but intermediate-risk PE does not currently have strong evidence to guide primary reperfusion strategies via thrombolytic administration. Ultrasound-assisted catheter-directed thrombolysis (USAT) is an alternative reperfusion option to ST but is not currently recommended as first line in any key guidelines due to limited available evidence. This retrospective, multicenter, observational study compares 210 patients treated with USAT (n = 105) or ST (n = 105) for acute high- or intermediate-risk PE in three hospitals. Baseline characteristics were significant in that severity of illness was higher in those that received ST, which limited comparisons of outcomes. The primary outcome of major bleeding in patients receiving USAT was 15.2% and 22.9% in those that received ST. Efficacy of reperfusion strategy was observed to be 86.7% of patients in USAT group and 65.7% in ST group. Reperfusion strategies had no difference in in-hospital death, intensive care length of stay, or hospital length of stay. Predefined subgroup analysis found that high-risk PE had higher mortality (14.7%) than intermediate-risk PE (0%) regardless of reperfusion strategy. Upon multivariate analysis, high-risk PE was the only independent risk factor for major bleeding while USAT therapy and intermediate-risk PE were independent predictors of efficacy. Due to the difference in baseline severity of illness, direct comparisons in primary outcomes to each group was not performed. We have described real world usage of both USAT and ST and which patients were likely to receive each therapy at these institutions.

High rate of recurrent venous thromboembolism in children and adolescents with unprovoked venous thromboembolism

BackgroundUnprovoked venous thromboembolism (VTE) is rare in pediatrics. Current recommendations for anticoagulation duration after unprovoked VTE differ for pediatric and adult populations. ObjectivesThis single-center, retrospective cohort study aimed to determine the incidence rate of recurrent VTE in children and adolescents with unprovoked VTE, evaluate the potential risk factors for recurrence, and describe the anticoagulation regimens and bleeding in this population. MethodsChildren with an index, unprovoked VTE at the age of 1 to <21 years between 2003 and 2021 were included. The time to recurrent VTE and anticoagulation duration were summarized using Kaplan-Meier estimators. Clinical covariates were assessed for association with recurrence using stratified Kaplan-Meier curves and univariate Cox proportional hazards regression. ResultsEighty-five children met the inclusion criteria, and there were 26 recurrent events in 250 person-years of follow-up (incidence rate = 104 [95% CI, 71-153] per 1000 person-years). An age of ≥12 years at index VTE (hazard ratio [HR], 7.56; 95% CI, 1.60-35.83) and inherited thrombophilia (HR, 2.28; 95% CI, 1.05-4.95) were significantly associated with recurrent VTE. Female sex had a nonstatistically significant decreased hazard of recurrence (HR, 0.56; 95% CI, 0.25-1.27). Duration of anticoagulation was variable, with a median duration of 274 days (IQR, 101-2357) for outpatient therapeutic anticoagulation. Twelve of the 26 (46%) recurrent events occurred while anticoagulation was prescribed. ConclusionThe incidence rate of recurrent VTE in pediatric patients with a prior unprovoked VTE is high, particularly for adolescents and those with inherited thrombophilia. Therefore, future research should focus on the efficacy of prolonged anticoagulation for this population.

Venous thromboembolism and adverse outcomes in highest thromboembolism risk patients compared with those at lower risk

A risk-based institutional protocol for inpatient heparin-based venous thromboembolism prophylaxis in a general obstetrical population previously demonstrated a greater than 2-fold increase in wound hematomas with no change in the frequency of thromboembolism. We sought to compare the rates of thromboembolism and bleeding outcomes in patients at the highest risk for thromboembolism (eg, those with a history of thromboembolism or thrombophilia who require anticoagulation prophylaxis or therapy throughout pregnancy) than low-risk patients. We performed a retrospective cohort study of all deliveries >20 weeks at a single center from 2013-2018. Patients were categorized as high-risk (received outpatient heparin-based prophylaxis or treatment) or low-risk (no outpatient anticoagulation). The primary outcome was newly diagnosed postpartum thromboembolism; the main secondary outcome was wound/perineal hematoma. The outcomes were compared between the high- and low-risk cohorts. Adjusted odds ratios (with 95% confidence intervals) were calculated with the low-risk group as reference. Of 24,303 total deliveries, 395 (1.7%) were high-risk and 23,905 (98.3%) were low-risk. Among the low-risk patients, 8.6% received anticoagulation prophylaxis in accordance with our risk-based inpatient thromboembolism prophylaxis protocol. High-risk patients were more likely to be older and have a higher body mass index, earlier delivery gestational age, medical comorbidities, and pregnancy complications, eg, preeclampsia. Despite outpatient antepartum anticoagulation, high-risk patients had an 11-fold increased risk of thromboembolism (adjusted odds ratio, 11.1 [4.7-26.2]) than low-risk patients. High-risk patients also had significantly more wound/perineal hematomas (adjusted odds ratio, 4.8 [2.7-8.4]), overall wound complications (adjusted odds ratio, 3.0 [2.0-4.4]), blood transfusions, intensive care unit admissions, maternal deaths, and longer maternal lengths of stay. Patients at the highest risk of obstetrical thromboembolism had an 11-fold increased risk of thromboembolism with a more moderate increase (∼5-fold) in postpartum wound and bleeding complications than low-risk patients. This more favorable risk or benefit profile supports current anticoagulation recommendations in high-risk patients.

Clinical Outcome of Different Post-operative Prophylactic Strategies on Symptomatic Venous Thromboembolism after Total Knee Arthroplasty

IntroductionThe objective of this study was to evaluate the use of different post-operative prophylactic strategies on the rates of symptomatic venous thromboembolic events (VTE) incidence after primary total knee arthroplasty (TKA).MethodsA retrospective study of patients who underwent primary TKA procedure was performed from January 2015 through July 2020. Outcomes examined prophylaxis medication used during inpatient and outpatient care, amount of medication, length of medication, complications occurring within 90 days post-operatively, including symptomatic VTE (deep venous thrombosis (DVT), and pulmonary embolism (PE)), gastrointestinal (GI) bleeding requiring medical attention, change in management protocols after post-operative complications, and mortality.ResultsIn total, 5,663 cases were included (mean age 66 ± 10 years, mean BMI 34.1 ± 7.1kg/m2). The overall post-operative complication rate was 0.9% (DVT: 0.5%, PE: 0.3%, VTE: 0.04%, and GI bleeding: 0.09%). Enoxaparin use as inpatient anticoagulation medication was reduced significantly (67% vs. 13%, p < 0.001), and apixaban was increased significantly (6% vs. 49%, p < 0.001). Average hospital stays were reduced significantly among the years (3 ± 2 days vs. 2 ± 1 days, p < 0.001), and complication rates were not significantly different between the five years (~1%, p < 0.001). Most post-operative complications occurred on either aspirin 325 mg (36%) or apixaban (26%). However, the relative risk ratio results indicating that utilization of warfarin, rivaroxaban, and aspirin 81 mg as outpatient anticoagulation medication were more likely to increase the risk of symptomatic VTE incidence compared to other anticoagulants. The average time of complication detected was 21 ± 21 days (range: 1 – 87 days). More than 54% of complication events occurred after the patient had completed their medication (enoxaparin, rivaroxaban, and apixaban).ConclusionsThe observed incidence of symptomatic VTE in this study was similar to previous studies regardless of the type of post-operative inpatient or outpatient prophylaxis prescribed. The ultimate choice of prophylaxis should remain with the treating physician and their knowledge of a particular patient’s medical history.

A call to action for anticoagulation stewardship

A call to action for anticoagulation stewardship

Impact of pharmacist intervention to deprescribe inappropriate aspirin therapy in an outpatient anticoagulation clinic at a community hospital

Study objectiveThis study describes a pharmacist-led process to identify and discontinue inappropriate aspirin in patients receiving concomitant anticoagulant therapy and to evaluate the effectiveness of the intervention. SettingThe study took place in an outpatient anticoagulation clinic within a small community hospital. ParticipantsPatients ≥40 years old on indefinite anticoagulation therapy for atrial fibrillation and/or venous thromboembolism were included. DesignThis is a quality improvement initiative. InterventionsUtilizing the electronic medical record and patient interview, use and indication for daily aspirin therapy was confirmed. Prospectively collected patient demographics and past medical history were used to determine appropriateness of aspirin therapy. For patients identified as receiving inappropriate aspirin therapy, a fax was sent to the referring provider recommending aspirin discontinuation. Main outcome measuresTo assess the effectiveness of the intervention, outcomes were retrospectively measured. The primary outcome was the percentage of “accepted” recommendations. Secondary outcomes included the prevalence, dosing, and indications for aspirin therapy. ResultsEighty (33 %) of 242 patients were on aspirin. Fifty-two patients with atrial fibrillation and/or venous thromboembolism were assessed and aspirin was deemed inappropriate in 22 patients. The provider agreed with deprescribing aspirin therapy in 45 %. The most common dose and indication of aspirin therapy was 81 mg (98 %) and primary prevention (40 %) respectively. ConclusionsIn our small practice, pharmacist-led interventions were an effective means to recommend aspirin discontinuation in our identified patients. Further studies are needed to optimize a pharmacist's role and address the long-term effects of deprescription.

Adverse Events in HVAD vs. HM3 Patients under Outpatient Bridging with Low-Molecular Weight Heparin for Subtherapeutic Anticoagulation

<h3>Purpose</h3> The standard of care in patients with durable left-ventricular assist devices combines antiplatelet with anticoagulation therapy. Current guidelines recommend use of intravenous (IV) unfractionated heparin as bridge to therapeutic INR-values in the postoperative period. However, management of subtherapeutic INR in the ambulatory setting is not yet clearly defined by guidelines. The protocol at our center proposes the use of unfractionated heparin perioperatively and low-molecular weight heparin in outpatients. Therefore, we aimed to analyse outcomes in patients with continuous-flow LVAD (CF-LVAD). <h3>Methods</h3> In this single-center retrospective trial all patients after CF-LVAD implantation at our center were included between 1/2015 and 12/2020 (n=110 patients; HVAD n=80, HM3 n=30). Patients were followed up from initial discharge after LVAD implantation until death, heart transplantation or end of the observation period (9/2021). Bridging for subtherapeutic INR (≤ 0.4 below target INR) were provided with enoxaparin in a therapeutic dose adapted to weight and renal function. Only patients with an INR > 0.4 below target INR were admitted to hospital for bridging with IV unfractionated heparin. Bleeding events leading to hospital admission, cerebrovascular events and pump thromboses were evaluated and provided in percent of study population and/or events per patient year (eppy). <h3>Results</h3> Follow-up covers a total of 214.2 patient years. Overall mortality was 18.2 %. Bleeding events occurred in 42.7 %, of which GI bleeding constituted the largest group with 21.8 % (HVAD: 0.25 eppy; HM3: 0.05 eppy). Stroke/TIA/PRIND occurred in 5.5 % of the patients (HVAD: 0.07 eppy; HM3: 0.01 eppy; in total: 0.03 eppy). Intracerebral hemorrhage (overall 0.04 eppy) occurred 6.3 times more often in HVAD patients. Pump thrombosis occurred in 8.2 % of all CF-LVAD patients and was limited to HVAD (0.13 eppy). <h3>Conclusion</h3> Current studies tend to promote the use of low molecular weight heparins, especially enoxaparin for outpatient anticoagulation bridging in case of subtherapeutic INRs. However, in most cases old generation CF-LVADs were studied. Our study includes a relevant number of HM3 devices. Overall, the adverse event rates presented herein suggest feasibility of low-molecular weight heparin bridging in patients with HM3 devices.

Are outpatient anticoagulation management services the wave of the future (again)?

Are outpatient anticoagulation management services the wave of the future (again)?

Population-based study of long-term anticoagulation for treatment and secondary prophylaxis of venous thromboembolism in men with prostate cancer in Sweden

BackgroundEpidemiological data on anticoagulation for venous thromboembolism (VTE) in prostate cancer are sparse. We aimed to investigate associations between anticoagulation duration and risks of VTE recurrence after treatment cessation and major on-treatment bleeding in men with prostate cancer in Sweden.MethodsUsing nationwide prostate cancer registry and prescribing data, we followed 1413 men with VTE and an outpatient anticoagulant prescription following prostate cancer diagnosis. Men were followed to identify cases of recurrent VTE, and hospitalized major bleeding. We calculated adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) to quantify the association between anticoagulation duration (reference ≤ 3 months) and recurrent VTE using Cox regression. We estimated 1-year cumulative incidences of major bleedings from anticoagulation initiation.ResultsThe outpatient anticoagulation prescribed was parenteral (64%), direct oral anticoagulant (31%), and vitamin K antagonist (20%). Median duration of anticoagulation was 7 months. Adjusted HRs (95% CI) for off-treatment recurrent pulmonary embolism (PE) were 0.32 (0.09–1.15) for > 3–6 months’ duration, 0.21 (0.06–0.69) for > 6–9 months and 0.16 (0.05–0.55) for > 9 months; corresponding HRs for deep vein thrombosis (DVT) were 0.67 (0.27–1.66), 0.80 (0.31–2.07), and 1.19 (0.47–3.02). One-year cumulative incidences of intracranial, gastrointestinal and urogenital bleeding were 0.9%, 1.7%, 3.0% during treatment, and 1.2%, 0.9%, 1.6% after treatment cessation.ConclusionThe greatest possible benefit in reducing recurrent VTE risk occurred with > 9 months anticoagulation for PE and > 3–6 months for DVT, but larger studies are needed to confirm this. Risks of major bleeding were low overall.

63 Topical Use of Tranexamic Acid in the Emergency Department

The usage of topical TXA has been shown in certain cases of epistaxis to reduced time to stop bleeding, rates of rebleeding, time spent in the emergency department and increased patient satisfaction. Local administration of topical TXA has since been described in various settings in emergency medicine journals. This study seeks to evaluate the use of tranexamic acid as a medication for the management of epistaxis and other superficial hemorrhages in the emergency department (ED) of local community hospitals. Retrospective review of adult ED patients from two community hospitals presenting with epistaxis or other superficial hemorrhage, treated with topical tranexamic acid (TXA) and discharged home between 2016 and 2019. Excluded from the study are traumatic nose injuries, major trauma patients, post-operative patients, and patients with incomplete data. Abstracted data included demographics, chief complaints, discharge diagnosis, history of anticoagulant use, outcome of TXA use, and 72 hours return to the ED with recurrent hemorrhage. Data analysis was performed on the index cases only. Demographics and outcomes are reported as descriptive statistics. Significance is set at 0.05 for comparison between anti-coagulation groups. There were 341 cases meeting inclusion criteria. Ten cases were excluded with four nasal trauma, three post-operative cases, and three with missing data. Nineteen case were patients returning within 72 hours, leaving 312 index cases. There were 192 cases of epistaxis and 120 cases of cutaneous (81) or mucosal (39) wounds. Overall, 48.4% of the patients were on outpatient anti-coagulants with 7.7% on two medications. The 72-hour return rate was 5.8% with 6.8% in the epistaxis group and 4.2% in the superficial wound group. Outpatient anti- coagulation did not affect 72 hours returns in epistaxis (6.5% versus 7.1%; p=0.856) but was significant in superficial wounds (11.6% return in anti-coagulant group versus 0%; p=0.002). In this four-year study of topical tranexamic acid use in two community emergency departments, 48.4% of the patients were on outpatient anti-coagulants. The 72-hour return rate for epistaxis was 6.8% and not affected by anti-coagulant use while the return rate for superficial wounds was 4.2% and impacted by anti-coagulant use. Epistaxis and superficial wound treated in the emergency department with topical tranexamic acid have a small return rate for hemorrhage control, despite outpatient anti-coagulant use.View Large Image Figure ViewerDownload Hi-res image Download (PPT)