Previous Thromboembolic Events Research Articles

The rate of postoperative hematoma following risk-adapted cessation of oral anticoagulation in patients undergoing endoscopic endonasal surgery for pituitary adenomas.

This study describes the management of patients on oral anticoagulation (OAC) undergoing endoscopic endonasal transsphenoidal surgery (EETS) and analyzes the risk of postoperative hematoma and epistaxis following treatment of pituitary adenoma (PA). Patients with OAC prior to EETS for PA were analyzed in a single center retrospective case series of consecutive patients with PA, who were treated between December 2008 and July 2022. Patient data (age, sex, clinical, endocrinology, tumor histology) were entered into a SPSS® database. The rate of postoperative hemorrhage (intracranial and epistaxis) and other perioperative complications were assessed. Of 305 patients, 20 patients were on OAC prior to EETS for PA. Indications included non-valvular atrial fibrillation (AF) in 10 patients and previous venous thromboembolic event (VTE) in 8 patients, in 2 patients had overlapping indications. Twelve patients on direct oral anticoagulants (DOAC) paused medication 1-3 days (43.6 ± 23.6h) before surgery, while phenprocoumon was paused 234 ± 123.55h (min 6, max 22 days) before surgery. Baseline characteristics such as age, sex, tumor growth direction, tumor volume, and largest diameter showed no significant differences. No significant increase in postoperative hemorrhage was observed in patients with OAC compared to those without. One patient on apixaban paused 48h before surgery experienced postoperative epistaxis. Among patients without OAC, one experienced intracranial hemorrhage and seven experienced epistaxis. Patients with OAC prior to EETS for PA have no increased risk for postoperative hematoma when OAC is paused based on individual risk assessment and recent general recommendations.

Current Strategies for Atrial Fibrillation Prevention and Management: Taming the Commonest Cardiac Arrhythmia.

Atrial fibrillation (AF) is the commonest cardiac arrhythmia, constituting a major cause of morbidity and mortality, with an age-dependent incidence and prevalence ranging from 1-2% in the general population to ~10% in persons aged >60 years. The global prevalence of AF is rapidly increasing, mostly due to the aging population. If not properly and timely managed, this arrhythmia adversely affects left ventricular function, increases the risk of stroke five-fold, impairs quality of life, and shortens longevity. There is a genetic, hence non-modifiable, predisposition to the arrhythmia, while several life-style and cardiometabolic inciting factors, such as hypertension, heart failure, coronary disease, metabolic syndrome, alcohol use, and thyroid disorders, can be addressed, attesting to the importance of a holistic approach to its management. Thromboembolism is a serious consequence of AF, which could lead to a disabling stroke or have a lethal outcome. The risk of a thromboembolic complication can be estimated as based on a scoring system that takes into consideration the patient's age, previous thromboembolic events, and clinical comorbidities. In addition, rapid AF could affect cardiac performance, leading to an elusive type of arrhythmia-induced cardiomyopathy and heart failure with grave consequences if undetected and untreated. Furthermore, AF may cause silent brain infarcts and/or its hemodynamic perturbations can account for a type of dementia that needs to be taken into account, emphasizing the need for AF screening and prevention strategies. All these issues are herein detailed, the causes of the arrhythmia are tabulated, and an algorithm illustrates our current approach to its management.

Characteristics and Manifestations of Patients with Cerebral Venous Sinus Thrombosis and Factors Associated with Unfavorable Functional Outcomes

Background: Cerebral venous sinus thrombosis (CVST) is a rare cerebrovascular disease that typically affects young females. Objectives: To describe the clinical, laboratory, and neuroimaging characteristics of CVST and evaluate the differences in characteristics of patients with unfavorable versus favorable outcomes. Methods: This retrospective study (2007 - 2018) reviewed all consecutive patients with CVST, assessing their demographic, clinical, laboratory, neuroimaging characteristics, and clinical outcomes. The modified Rankin Scale (mRS) was used to assess the functional outcomes of patients after a three-month follow-up. Factors affecting patients’ outcomes (favorable [mRS ≤ 2] vs. unfavorable [mRS > 2]) were examined using the Independent t-test and chi-squared test. Results: A total of 141 patients (mean age: 38.15 ± 13.71; female-to-male ratio of 2.28) with CVST were included. Most of the admissions (42.6%) were in the summer. Most patients had a subacute disease onset (66.0%), with headaches being the most frequent manifestation (66.0%). Regular oral contraceptive pill use and fasting were the most frequent clinical risk factors (52.0% and 22.7%, respectively). Different types of inherited thrombophilia (deficiency in protein C, protein S, or antithrombin III) were recorded in nearly 13 to 16% of patients. The lateral transverse sinus (61.7%) and the superior sagittal sinus (45.4%) were the most frequently involved. The mortality rates at discharge and after three months were 4.3% and 8.0%, respectively. In the follow-up assessment, 81.3% of patients showed a favorable outcome [mRS ≤ 2], while 18.7% had an unfavorable outcome. Patients with unfavorable outcomes were significantly older compared to those with favorable outcomes (52 ± 5.81 vs. 35.95 ± 1.42, P = 0.017). Significant associations were observed between admission season (P = 0.020), chief complaint (P = 0.028), course of the disease (P = 0.021), previous thromboembolic events (P = 0.001), and antiphospholipid IgG (P = 0.032). Conclusions: The most prevalent risk factors among patients with CVST were being female, a history of using oral contraceptives, and fasting. Older patients with reduced consciousness, an acute disease course, a history of thromboembolic events, and positive antiphospholipid IgG are more likely to have an unfavorable outcome.

Sudden cardiac death after early-onset myocardial infarction: a multicentre longitudinal cohort study with a 20-year follow-up.

Sudden cardiac death (SCD) is a serious consequence of a myocardial infarction (MI), but identifying patients at risk of developing SCD remains a major clinical challenge, especially in the case of juvenile MI. The aim of this study is to identify predictors of SCD after early-onset MI using long-term follow-up data relating to a large nationwide patient cohort. The Italian Genetic Study on Early-onset MI enrolled 2000 patients experiencing a first MI before the age of 45 years, who were followed up for a median of 19.9 years. Fine-Gray proportional hazard models were used to assess the associations between their clinical, demographic, and index event data and the occurrence of SCD. Sudden cardiac death occurred in 195 patients, who were more frequently males, were hypertensive and/or diabetic, had a history of previous thrombo-embolic events with a greater atherosclerotic burden, and had a lower left ventricular ejection fraction (LVEF) after the index event. A multivariable analysis showed that the independent predictors of SCD were diabetes, hypertension, previous thrombo-embolic events, a higher SYNTAX score, and a lower LVEF. There was no clear evidence of the clustering of SCD events during the follow-up. Sudden cardiac death was the first post-MI clinical event in 101 patients; the remaining 94 experienced SCD after a non-fatal MI or hospitalization for coronary revascularization. Sudden cardiac death frequently occurs during the 20 years after early-onset MI. The nature of the identified predictors and the absence of clustering suggest that the pathophysiological basis of SCD may be related to progressive coronary atherosclerosis.

Epidemiology of maxillofacial trauma in elderly patients receiving oral anticoagulant or antithrombotic medication; a Swiss retrospective study

BackgroundThe percentage of elderly trauma patients under anticoagulation and antiplatelet agents has been rising lately. As newer agents are introduced, each comes with its own advantages and precautions. Our study covered elderly patients admitted to the ED with maxillofacial trauma while on anticoagulation (AC) or antiplatelet therapy (APT). We aimed to investigate the demographic characteristics, causes, and types of maxillofacial trauma, along with concomitant injuries, duration of hospitalisation, haemorrhagic complications, and the overall costs of care in the emergency department (ED).MethodsData were gathered from the ED of Bern University Hospital. In this retrospective analysis, patients over 65 of age were included, who presented at our ED with maxillofacial trauma between 2013 and 2019 while undergoing treatment with therapeutic AC/APT.ResultsThe study involved 188 patients with a median age of 81 years (IQR: 81 [74; 87]), of whom 55.3% (n=104) were male. More than half (54.8%, n=103) were aged 80 years or older. Cardiovascular diseases were present in 69.7% (n=131) of the patients, with the most common indications for AC/APT use being previous thromboembolic events (41.5%, n=78) and atrial fibrillation (25.5%, n=48). The predominant cause of facial injury was falls, accounting for 83.5% (n=157) of cases, followed by bicycle accidents (6.9%, n=13) and road-traffic accidents (5.3%, n=10). The most common primary injuries were fractures of the orbital floor and/or medial/lateral wall (60.1%, n=113), zygomatic bone (30.3%, n=57), followed by isolated orbital floor fractures (23.4%, n=44) and nasal bone fractures (19.1%, n=36). Fractures of the mandible occurred in 14.9% (n=28). Facial hematomas occurred in 68.6% of patients (129 cases), primarily in the midface area. Relevant facial bleeding complications were intracerebral haemorrhage being the most frequent (28.2%, n=53), followed by epistaxis (12.2%, n=23) and retrobulbar/intraorbital hematoma (9%, n=17). Sixteen patients (8.5%) experienced heavy bleeding that required emergency treatment. The in-hospital mortality rate was 2.1% (4 cases).ConclusionsThis study indicates that falls are the leading cause of maxillofacial trauma in the elderly, with the most common diagnoses being orbital, zygomatic, and nasal fractures. Haemorrhagic complications primarily involve facial hematomas, especially in the middle third of the face, with intracerebral haemorrhage being the second most frequent. Surgical intervention for bleeding was required in 8.5% of cases. Given the aging population, it is essential to improve prevention strategies and update safety protocols, particularly for patients on anticoagulant/antiplatelet therapy (AC/APT). This can ensure rapid diagnostic imaging and prompt treatment in emergencies.

Left atrial appendage clipping during hybrid atrial fibrillation ablation: a very long-term, single-center experience

Abstract Background/introduction Epicardial left atrial appendage (LAA) clipping is an effective strategy for stroke prophylaxis in high thromboembolic (TE) and bleeding risk patients with atrial fibrillation (AF). In addition to LAA exclusion from systemic circulation, clipping promotes concomitant appendage isolation, which might have positive impacts on arrhythmia control. Purpose The aim of this study was to report safety, success rate, and the long-term clinical outcomes of LAA clipping in a large cohort of AF patients undergoing concomitant hybrid ablation. Methods Consecutive patients undergoing hybrid AF ablation between 2013 and 2023 were enrolled. Hybrid ablation was performed in a one-step procedure consisting of thoracoscopic epicardial radiofrequency (RF) ablation followed by endocardial mapping and ablation, if needed. Ablation lesion set included pulmonary vein (PV) and posterior wall (PW) isolation, as well as RF applications to the LAA/posterolateral ridge. LAA clipping was performed via Atriclip exclusion system (Atricure, Inc., The Nederlands) after epicardial ablation. Additional endocardial lesions were performed in case of incomplete epicardial ablation or at physician’s discretion. Results A total of 130 patients were included (mean age: 65±9.4; 72.3% males); among them, 19.2% and 55.4% had persistent or long-standing persistent AF, respectively. Mean CHA2DS2-VASC and HAS-BLED were 3.1±1.1 and 2.3+-0.5. Five patients (3.8 %) had absolute contraindication to long-term oral anticoagulation, 3 (2.3%) had previous life-threatening bleeding events, 17 (13.1%) had a previous TE event. The final clip size was 35mm in 90.7% cases. Acute success was achieved in 97.7%; failure was due to LAA size (n=1), proximity to phrenic nerve (n=1), or bypass graft (n=1). One patient had incomplete occlusion due to a large secondary lobe, which required a second clip. No periprocedural complications related to clipping were documented. At a mean follow-up of 51±35 months, one (0.8%) patient had a stroke and 3 (2.3%) a transient ischemic attack (4 events per 552 patient/years; 0.7%). One patient had a microreentrant tachycardia mapped from the area near the LAA clipping. Conclusion In a large cohort undergoing hybrid AF ablation, epicardial LAA clipping was safe and highly successful. Acute failure was rare and due to LAA morphology or proximity to phrenic nerve and bypass graft. Thromboembolic event rate was very low.

Omitting transesophageal echocardiography before catheter ablation of atrial fibrillation

BackgroundData about necessity of performing transesophageal echocardiography (TOE) prior to every catheter ablation (CA) of atrial fibrillation (AF) is scarce. We aimed to evaluate the safety of an individualized risk-based approach to TOE with respect to thromboembolic cerebrovascular events (CVE) in patients undergoing CA for AF or left atrial tachycardia (AT).MethodsWe performed a retrospective clinical study based on our institutional registry database. Patients undergoing CA for AF or left-sided AT following initial AF ablation at two participating centers were enrolled. Prior to the procedure, patients were scheduled for TOE only if they had a history of thromboembolic stroke, left atrial appendage (LAA) thrombus, or inappropriate anticoagulation regimen in the previous 3 to 4 weeks. The incidence of periprocedural cerebrovascular thromboembolic events was assessed.ResultsWe analyzed 1155 patients (median age 70 years, 54.8% male, 48.1% had persistent AF/AT). In 261 patients, a TOE was performed; in 2 patients (0.7%), an LAA thrombus was detected, which led to cancellation of the catheter ablation; in 894 patients, the TOE was omitted. Of the 1153 (0.35%) patients who underwent ablation, 4 (0.35%) experienced a CVE (one TIA and three strokes). The rate of CVE in our study does not exceed that reported in most multicenter trials. The low event rates limited statistical analysis of possible risk factors for CVE. In all 4 patients with CVE, post-CVE imaging showed the absence of LAA thrombus.ConclusionsAn individualized selective approach to TOE before catheter ablation of AF or left AT showed a very low risk of overt intraprocedural thromboembolic events for the population in our study. A further randomized controlled study is needed to determine whether TOE prior to catheter ablation without ICE could be omitted in patients with uninterrupted OAC without previous thromboembolic events or a history of left atrial thrombus.

Odds and associated factors for thrombosis development among Lebanese COVID-19 patients: a case-control retrospective study.

Thromboembolism is reported to be up to 27% in COVID-19 patients due to SARS-CoV-2 infection. Dysregulated systemic inflammation and various patient traits play a vital role in thrombosis progression. To assess odds and associated factors for thrombosis development among Lebanese COVID-19 patients. This was a case-control retrospective study conducted in January-May 2021. Patients infected with COVID-19 and developed thrombosis were classified as cases and patients who were thrombosis-free identified as control. A questionnaire assessed socio-demographics, clinical parameters, and WHO COVID-19 disease severity. Among 267 patients, 26 (9.7%) developed thrombosis and the majority of thrombosis 34.6% was myocardial infarction, and the least (3.8%) was for catheter-related thrombosis. Results showed that the risk of thrombosis development is higher in patients with previous thromboembolic event (OR = 9.160) and previous intake of anti-hypertensive medications at home (OR = 3.116). However, females (OR = 0.330; CI: 0.118-0.925), intake of anticoagulants during hospital admission (OR = 0.126; CI: 0.053-0.300) and non-severe COVID-19 were at lower thrombosis risk (OR = 0.273). Patients who developed thromboembolic events had longer hospital stay (OR = 0.077). Patients with COVID-19 and thromboembolism were at higher risk of mortality as compared to patients with COVID-19 but without thromboembolism. The use of anticoagulants significantly reduced the risk for thromboembolism.

Adverse Events and Clinical Correlates in Asian Patients with Atrial Fibrillation and Diabetes Mellitus: A Report from Asia Pacific Heart Rhythm Society Atrial Fibrillation Registry.

Aims. To evaluate the adverse events (and its clinical correlates) in a large prospective cohort of Asian patients with atrial fibrillation (AF) and diabetes mellitus (DM). Material and Methods. We recruited patients with atrial fibrillation (AF) from the Asia-Pacific Heart Rhythm Society (APHRS) AF Registry and included those for whom the diabetic mellitus (DM) status was known. We used Cox-regression analysis to assess the 1-year risk of all-cause death, thromboembolic events, acute coronary syndrome, heart failure and major bleeding. Results. Of 4058 patients (mean age 68.5 ± 11.8 years; 34.4% females) considered for this analysis, 999 (24.6%) had DM (age 71 ± 11 years, 36.4% females). Patients with DM had higher mean CHA2DS2-VASc (2.3 ± 1.6 vs. 4.0 ± 1.5, p < 0.001) and HAS-BLED (1.3 ± 1.0 vs. 1.7 ± 1.1, p < 0.001) risk scores and were less treated with rhythm control strategies compared to patients without DM (18.7% vs. 22.0%). After 1-year of follow-up, patients with DM had higher incidence of all-cause death (4.9% vs. 2.3%, p < 0.001), cardiovascular death (1.3% vs. 0.4%, p = 0.003), and major bleeding (1.8% vs. 0.9%, p = 0.002) compared to those without DM. On Cox regression analysis, adjusted for age, sex, heart failure, coronary and peripheral artery diseases and previous thromboembolic event, DM was independently associated with a higher risk of all-cause death (HR 1.48, 95% CI 1.00-2.19), cardiovascular death (HR 2.33, 95% CI 1.01-5.40), and major bleeding (HR 1.91, 95% 1.01-3.60). On interaction analysis, the impact of DM in determining the risk of all-cause death was greater in young than in older patients (p int = 0.010). Conclusions. Given the high rates of adverse outcomes in these Asian AF patients with DM, efforts to optimize the management approach of these high-risk patients in a holistic or integrated care approach are needed.

E080 Catheter-related venous thrombosis in patients with systemic sclerosis: a case series

Abstract Background/Aims Systemic sclerosis (SSc) is characterised by endothelial dysfunction and vasculopathy, which may lead to venous thrombosis. Here, we report four cases of extensive venous thrombosis of the upper limbs and right atrium associated with implantable venous access devices (port-a-cath) in patients with a diagnosis of SSc, who presented to our specialist centre between 2018 and 2022. Methods We retrospectively reviewed four patients with SSc and port-a-cath-associated thrombosis who presented to the Department of Rheumatology, Royal Free Hospital NHS Trust between 2018 and 2022. All patients are diagnosed with systemic sclerosis according to the 2013 ACR/EULAR classification criteria. Results Three patients were diagnosed with a port-a-cath-associated thrombosis in 2022, and one in 2018. Two patients had limited cutaneous SSc with positive anti-centromere antibodies, and 2 had diffuse subset with anti-U3RNP antibodies. All patients had a right-sided port-a-cath that had been in-situ for at least 3 years. Two patients were diagnosed with right atrium thrombus (measuring 2.2 and 3 cm respectively), one patient with an internal jugular vein and right subclavian thrombosis, and one with a left subclavian thrombosis. None had a history of previous thromboembolic event. A full thrombophilia screen was negative in 2 patients, and is pending in the others. Of note, 2 patients had COVID-19 infection within the 3 months prior the thrombotic event. 1 patient had tocilizumab administered through the line, 1 rituximab and IVIG, the other 2 had prostanoids only. Conclusion We described four recent cases of port-a-cath-associated thrombosis of the upper limbs and right atrium in SSc patients with no previous history of thrombosis. This highlights the increased risk of thrombosis related to long term indwelling catheters in SSc and demonstrates the potential interplay between covid microvasculopathy and the associated thrombotic risks reported with both ACA and antiU3RNP antibodies in SSc. We note that from previous reports the relative lower risk of adverse outcomes in SSc patient receiving parenteral nutrition. Further research into frequency of port-a-cath-related thrombosis in SSc patients is warranted, especially with use of prostanoids, and adequate screening and non-invasive follow up might be needed to avoid life-threatening thromboembolic complications. Disclosure C. Giacomassi: None. T. Eldaw: None. S. Vigneswaran: None. A. Debres: None. C. Denton: None. V. Ong: None.

Thrombophilia and Retina

Retinal vascular occlusions are one of the most common retinal diseases that cause vision loss. Thrombophilia is the tendency of the formation of thrombosis secondary to genetic or acquired factors. The most frequent thrombophilic disorders reported in retinal arterial and venous occlusions are Factor V Leiden mutation and Antiphospholipid Syndrome, whereas the least reported thrombophilic conditions are Anti-thrombin III, Protein S, and Protein C deficiencies. In addition, Hyperhomocysteinemia and Methylenetetrahydrofolate Reductase polymorphism are frequently seen. When retinal vascular occlusions are seen in elderly patients without any systemic diseases, in young patients, in patients with previous thromboembolic events or family thrombosis history, thrombophilia screening tests should be performed in detail.

Post COVID Thrombotic Sequelae: Once Bitten, Twice Shy!

Introduction Long Covid has been recognized as a distinct entity with thrombotic sequelae [1]. Persistent systemic vascular inflammation caused by thrombosis drives the complications associated with long COVID. The risks of arterial and venous thrombosis after COVID-19 extend well beyond the hospitalization period. Early prophylactic anticoagulation has been shown to reduce the incidence of post-covid thrombotic sequelae [2]. Some evidence suggests the use of a higher than prophylactic dose for primary venous thromboembolism prophylaxis, especially in patients with a history of venous thromboembolism (VTE) [1]. We present a case of long Covid who developed recurrent thrombosis despite being on a therapeutic dose of anticoagulation. Case Presentation A 55-year-old male was brought to our Emergency Department with complaints of diffuse abdominal pain and black-coloured stools for three days. Contrast-enhanced CT abdomen (CECT) showed distal superior mesenteric artery (SMA) thrombosis and splenic infarct (Figure 1). He was treated for mild Covid-19 infection three months back. History also revealed he was hospitalized two months ago with a diagnosis of non-ST segment elevated myocardial infarction (NSTEMI) and acute ischemic stroke (Figure 2), which was managed with antiplatelets, statins and anticoagulants. He was discharged on oral anticoagulants (Tab Rivaroxaban 15 mg twice daily) for three months and was on regular follow-up. There was no history of smoking or hypertension. Protein C, Protien S, homocysteine levels were normal. After the diagnosis of SMA thrombosis, his anti-coagulation was increased to Tab Rivaroxaban 20 mg twice daily. No further thrombotic episodes have been noted as of date. Discussion This case suggests that unexplained repeat thrombotic events at multiple sites may have been a consequence of Covid-19 infection. Covid-19 patients experience both arterial and venous thromboembolism [3]. Most commonly, the former presents as myocardial infarction and ischemic stroke, whereas the latter as deep venous thrombosis and pulmonary embolism. Mechanisms include changes in lung structure secondary to chronic hypoxia, persistent immune dysfunction, and endothelial damage [1]. Risks of thrombotic events after mild Covid-19 are less clear, with the need and intensity of prophylactic anti-coagulation in this subset of patients being a matter of future research [4]. Shabaka et al. have shown that patients with a history of Covid-19 infection and previous thromboembolic events were at higher risk of developing a repeat thrombotic event [5]. Physicians need to be vigilant about the thrombotic events in patients with long Covid, even in patients receiving therapeutic anti-coagulation. Such patients require more frequent monitoring for signs of thrombotic events, risk factor management, and adherence to preventive therapies [3].

Factors Affecting Residual Stump Length Following Endovenous Laser Ablation.

Current instruction for endovenous laser ablation (EVLA) recommends that the laser fibre tip should be at least 2cm caudal to the saphenofemoral or saphenopopliteal junction. This is to reduce risk of deep vein thrombosis (DVT) whilst ensuring that the Great Saphenous Vein (GSV)/Short saphenous vein (SSV) occlusion (residual stump) is close to the SFJ/SPJ to reduce recurrence rates. Our aim was to primarily assess the effects of pre-operative junction distance of the laser fibre on stump length but also look at other factors affecting this. This was a retrospective analysis of an electronic collected database performing EVLA of the GSV and SSV under local anaesthesia. Patients with previous venous thromboembolic events and incomplete data were excluded. Patients were reviewed at 6weeks with venous Duplex scan to assess for the residual stump distance and DVT. Multivariable logistic regression was used to account for confounders. Between 2012 and 2018, 2341 patients underwent EVLA and complete data were available on 825 (35.2%) patients. All patients were scanned 6weeks after procedure. Sixty-nine patients (8.4%) had flush occlusion, 3 patients (.4%) had extension into femoral or popliteal vein but not considered to be a DVT and 1 patient had a DVT. High BMI and increasing length of the pre-operative junction was associated with lower incidence of flush occlusion; higher rates of flush occlusions were noted in patients undergoing short saphenous vein (SSV) EVLT (OR 4.11, 95% CI 2.34-7.20; P < .001). Consideration should be given to increase the intra-procedure laser tip junction to more than 2cm particularly in patients undergoing SSV treatment to ensure that residual stump is sufficiently distal to SPJ and SFJ reducing risks of thrombus into the femoral or popliteal veins. Lower BMI may be associated with higher risk of this though the reasons for this are unclear.

612 EVOLUTION OF ATRIAL FIBRILLATION PATTERNS AND IMPACT ON ALL-CAUSE MORTALITY IN A CONTEMPORARY COHORT OF EUROPEAN PATIENTS WITH ATRIAL FIBRILLATION

Abstract Background Paroxysmal atrial fibrillation (AF) often shows a natural evolution towards more sustained forms of the arrhythmia. Real-world data on clinical factors associated with AF progression and its impact on long-term outcomes are limited. Aim of the study To investigate the factors associated with progression of AF and its impact on all-cause mortality in a contemporary cohort of European AF patients. Methods We analyzed patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Patients with paroxysmal AF at baseline or first detected AF who underwent successful cardioversion were included. Patients with known rhythm status at 1-year were then stratified into two groups: (i) No AF progression and (ii) AF progression, (as defined by transition to persistent or permanent AF). All-cause mortality at 2-year of follow-up was the primary outcome of the analysis. Results A total of 2688 patients were included (median age 67 years, interquartile range [IQR] 60-75, females 44.7%, CHA2DS2VASc score median 3 [1-4], HASBLED median 1 [1-2]). After 1-year of follow-up 2094 (77.9%) patients showed no AF progression while 594 (22.1%) developed AF progression. On multivariable logistic regression analysis, no physical activity (odds ratio [OR] 1.35, 95% confidence interval [CI] 1.02-1.78), valvular heart disease (OR 1.63, 95%CI 1.23-2.15), left atrium diameter (OR 1.03, 95% CI 1.01-1.05) and left ventricular ejection fraction (OR 0.98, 95% CI 0.97-1.00) were independently associated with AF progression at 1-year. At the end of 2-year of follow-up, death occurred in 80/2621 (3.1%) patients. Kaplan-Meier analysis showed a lower cumulative survival from all-cause mortality in patients with AF progression compared to non-progression AF patients (Log Rank p=0.01, Figure). On multivariable Cox regression analysis, adjusted for age, sex, heart failure, coronary artery disease, hypertension, diabetes mellitus, previous thromboembolic events, peripheral artery disease, chronic kidney disease and use of oral anticoagulants, patients with AF progression had an independently higher risk for all-cause mortality (adjusted hazard ratio [aHR] 1.77, 95%CI 1.09-2.89). Conclusions In a contemporary cohort of European AF patients, a substantial number of patients evolved to persistent/permanent AF within 1 year. Clinical factors related to atrial structural remodeling were independently associated with arrhythmia evolution. AF progression was associated with an increased risk of all-cause mortality.

Factors associated with progression of atrial fibrillation and impact on all-cause mortality: an ancillary analysis from the ESC-EHRA EURObservational Research Programme in Atrial Fibrillation General

Abstract Background Paroxysmal atrial fibrillation (AF) often shows a natural progression towards more sustained forms of the arrhythmia. Real-world data on clinical factors associated to AF progression and its impact on long-term outcome are limited. Purpose To investigate the factors associated with progression of AF and its impact on all-cause mortality in a contemporary cohort of European AF patients Methods We analyzed patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Patients with paroxysmal AF at baseline or first detected AF who underwent successful cardioversion were included. Patients with known rhythm status at 1-year were then stratified into two groups: (i) No AF progression and (ii) AF progression (as defined by transition to persistent or permanent AF). All-cause mortality at 2-year of follow-up was the primary outcome of the analysis. Results A total of 2688 patients were included (median age 67 years, interquartile range [IQR] 60–75, females 44.7%, CHA2DS2VASc score median 3 [1–4], HASBLED median 1 [1–2]). After 1-year of follow-up 2094 (77.9%) patients showed no AF progression while 594 (22.1%) developed AF progression. On multivariable logistic regression analysis, no physical activity (odds ratio [OR] 1.35, 95% confidence interval [CI] 1.02–1.78), valvular heart disease (OR 1.63, 95% CI 1.23–2.15), left atrium diameter (OR 1.03, 95% CI 1.01–1.05) and left ventricular ejection fraction (OR 0.98, 95% CI 0.97–1.00) were independently associated with AF progression at 1-year. At the end of 2-year of follow-up, death occurred in 80/2621 (3.1%) patients. Kaplan-Meier analysis showed a lower cumulative survival from all-cause mortality in patients with AF progression compared to non-progression AF patients (Log Rank p=0.01, Figure 1). On multivariable Cox regression analysis, adjusted for age, sex, heart failure, coronary artery disease, hypertensions, diabetes mellitus, previous thromboembolic events, peripheral artery disease, chronic kidney disease and use of oral anticoagulants, patients with AF progression had an independently higher risk for all-cause mortality (adjusted hazard ratio [aHR] 1.77, 95% CI 1.09–2.89). Conclusions In a contemporary cohort of European AF patients, a substantial number of patients progressed to sustained AF within 1 year. Clinical factors related to atrial structural remodeling were independently associated with arrhythmia progression. AF progression was associated with an increased risk of all-cause mortality. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): Since the start of EORP, the following companies have supported the programme: Abbott Vascular Int. (2011–2021), Amgen Cardiovascular (2009–2018), AstraZeneca (2014–2021), Bayer (2009–2018), Boehringer Ingelheim (2009–2019), Boston Scientific (2009–2012), The Bristol Myers Squibb and Pfizer Alliance (2011–2016), The Alliance Daiichi Sankyo Europe GmbH and Eli Lilly and Company (2011–2017), Edwards (2016–2019), Gedeon Richter Plc. (2014–2017), Menarini Int. Op. (2009–2012), MSD-Merck &amp; Co. (2011–2014), Novartis Pharma AG (2014–2020), ResMed (2014–2016), Sanofi (2009–2011), SERVIER (2010–2021), and Vifor (2019–2022).

Baseline characteristics of patients with atrial fibrillation and cancer enrolled in the BLITZ-AF Cancer registry

Abstract Background Evidences on atrial fibrillation (AF) in patients with cancer are limited, specifically with respect to antithrombotic therapy. Methods BLITZ-AF Cancer is a prospective, non-interventional study of the epidemiology and management of AF in patients with cancer. Patients were included from 112 cardiology units in Italy, Belgium, Netherlands, Spain, Portugal, and Ireland, based on the following criteria: age ≥18 years; documented cancer other than basal-cell or squamous-cell carcinoma of the skin diagnosed within 3 years; electrocardiographically confirmed AF within 1 year; no concomitant interventional study. Follow-up is ongoing. Results From June 26th, 2019 to Sep. 30th, 2021, 1,514 subjects were enrolled. The most frequent cancer locations were lung (14.9%), colorectal (14.1%), breast (13.9%), prostate (8.8%), and non-Hodgkin lymphoma (8.1%); 463 (30.6%) of participants had metastases. AF was first-detected in 323 (21.3%), paroxysmal in 460 (30.4%), persistent in 192 (12.7%), long-standing persistent in 33 (2.2%), and permanent in 506 (33.4%); 590 (39.0%) patients had symptoms attributable to AF. Baseline characteristics are presented in Table 1. Males were more than women and almost half of the subjects was &amp;gt;75 years-old. Cardiovascular risk factors were common and approximately 31% had heart failure or coronary artery disease. Previous thromboembolic and haemorrhagic events had occurred in 14% and 10% of subjects, respectively. The median CHA2DS2VASc score was 3. As shown in Figure 1, the prescription of oral anticoagulants, especially direct-acting ones (DOACs), rose after the cardiology assessment, while the percentage of participants without any antithrombotic therapy declined. Among 1,427 patients with non-valvular AF (i.e., no mitral stenosis or prosthetic mechanical valve), 997 (69.9%) were prescribed on DOACs at discharge/after consultation. At multivariable logistic regression analysis, variables associated with DOAC use were female sex (OR 1.58, 95% CI 1.22–2.05), age (OR 2.00, 95% CI 1.39–2.88 and OR 2.63, 95% CI 1.84–3.76, respectively, for 65–74 years and ≥75 years vs &amp;lt;65 years), hypertension (OR 1.43, 95% CI 1.10–1.87), long-standing persistent or permanent AF (OR 1.36, 95% CI 1.05–1.78). Haemoglobin &amp;lt;12 g/dL (OR 0.57, 95% CI 0.45–0.73), and planned cancer treatment (OR 0.72, 95% CI 0.57–0.92) were independently associated with a lower prescription of DOACs. Conclusions BLITZ-AF Cancer provides extensive information on a large, contemporary cohort of individuals with AF and cancer. This baseline snapshot indicates that cardiologists pursue the implementation of DOACs in these patients, although residual use of other antithrombotic therapies or lack of any thrombo-prophylaxis remains substantial. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): This study was supported by an unrestricted grant from Daiichi Sankyo.

Acil Bölümünde Nadir Bir Tanı: Renal Enfarktüs

Objective: Renal infarction (RI), which is caused by sudden cessation of renal blood flow, is a rare disease. In this study, we planned to investigate the demographic and clinical characteristics and outcomes of patients diagnosed with renal infarction in the emergency department.&#x0D; Material and Methods: Patients over the age of 18 who presented to the emergency department with abdominal/flank pain, nausea, and vomiting between 2010 and 2021 and were diagnosed with acute renal infarction in contrast-enhanced abdominal computed tomography were included in the study. The data of the patients were reviewed retrospectively. Demographic and clinical characteristics, as well as laboratory results of the patients, were recorded. &#x0D; Results: A total of 38 patients were included in the study. The mean age of the patients was 61.8±18 years and 63.2% (n=24) were male. The most common complaints of the patients were abdominal pain (84.2%), flank pain (68.4%), and nausea-vomiting (50%). More rarely, patients complained about chest pain, dyspnea, and fever. Acute renal failure developed in 4 patients (10.5%). While only three (7.9%) of the patients had no known disease, the others had comorbidities such as hypertension (31.6%), ischemic heart disease (31.6%), previous thromboembolic events (31.6%), diabetes (26.3%), cancer (23.7%), heart failure (21.1%), and atrial fibrillation (18.4%). The most common cause of RI was cardioembolic events (44.7%), followed by hypercoagulability (28.9%), renal artery damage (15.8%), and idiopathic causes (10.5%).&#x0D; Conclusion: Acute RI is a disease that is rarely detected in the emergency department. Because there is a lack of specific clinical findings, it is often overlooked or diagnosed late. Delay in diagnosis can significantly cause morbidity and mortality. The diagnosis of acute RI should be considered especially in patients with a high risk of thromboembolism and who present to the emergency department with complaints of unexplained abdominal or flank pain.

PB1832: ARTERIAL THROMBOSIS AND ACUTE MYELOID LEUKEMIA – IS THERE A CONNECTION?

Background: Arterial thrombotic events (ATE) are important cause of noncancer-related deaths among patients with cancer. It is estimated that the prevalence of ATE among those patients is between 2-5%. However, data regarding acute myeloid leukemia (AML) related ATE are scarce and far less available than those related to venous thrombotic events. Aims: To determine the incidence of ATE in nonM3-AML patients and to underline the potential risk factors for ATE development. Methods: The single center, retrospective, cohort study was carried out in University Clinical Center of Serbia. Adult patients, who were diagnosed with nonM3-AML between January 2009. and December 2021. were included. In all patients the occurrence of ATE (e.g. a heart attack, a stroke, critical limb ischemia) was assessed during the active treatment and the three months following the last chemotherapy session. Diagnosis of ATE was established using clinical, laboratory and radiological methods. Patients who experienced venous thromboembolism during the treatment period were excluded. Demographic data, presence of obesity, smoking status, history of thrombosis, baseline laboratory findings (complete blood count, fibrinogen, D-dimer, PT, aPTT, LDH), leukemia-related parameters (cytogenetics (including ELN risk stratification), flow cytometry), Khorana score, ECOG PS, HCT CI score, concurrent COVID-19 were collected from patients’ health records. The methods of descriptive (mean ± standard deviation, median (range), frequency (%)) and analytic statistics (Student’s t-test, chi-squared test) were used. Results: A total of 545 patients (293 males (53.8%)) were included in the study. Median age of the study population was 58 (range: 18-81) years. ATE was noted in 18/545 (3.3%) subjects with following distribution: ischemic stroke 12/18 (66.7%), myocardial infarction 5/18 (27.8%), and acute lower extremity arterial thrombosis 1/18 (5.5%). ATE was diagnosed most commonly during the induction (8 (44.4%) patients), reinduction (3 (16.7%) patients) and consolidation (4 (22.2%) patients) cycles. However, cases of ATE were noted at diagnosis (1 (5.6%) patient), after transplantation (1 (5.6%) patient) or at relapse (1 (5.6%) patient) as well. ATE were significantly more frequent among patients with previous history of thromboembolic events (p = 0.016). Moreover, ATE were more common in patients with adverse cytogenetic abnormalities (p < 0.001). Other examined parameters did not significantly differ between those with and without ATE. Summary/Conclusion: The incidence of arterial thrombosis in our group was 3.3% which is in accordance with the previously published studies. Since the great number of already known risk factors for the arterial thrombosis are modifiable (e.g. smoking, diet, physical activity, excessive drinking…) it is important to actively work on the reduction on those risk factors, especially if the patient has the history of previous thromboembolic event and/or suffer from high risk AML. Prophylactic therapy with antiplatelet agents is aggravated due to the lack of firmer evidences and the presence of thrombocytopenia. Therefore further studies regarding this issue are needed.

Symptomatic thromboembolic events after knee arthroscopy

IntroductionKnee arthroscopy is considered a safe procedure with low rate of complications. The aim of the study was to calculate the incidence of symptomatic thromboembolic events: deep vein thrombosis and pulmonary embolism, associated with knee arthroscopy and evaluate possible related risk factors. Materials and MethodsRetrospective cohort study. Patients who underwent knee arthroscopy between January 2011 and December 2015 at a University Hospital were included. Follow-up was performed during the first 30 postoperative days. Demographic characteristics, symptomatic thromboembolic events, type of arthroscopic procedure and possible risk factors were recorded. Results1,097 arthroscopic knee surgeries were performed in the 5 years of the study. 100% had 10-day postoperative follow-up and 90.5% of patients completed the 30-day follow-up. The mean follow-up time was 15.1 months. The rate of symptomatic thromboembolic events during follow-up was 1.4% (n= 14). There were two risk factors statistically associated with the outcome of the study: previous thromboembolic events (p= 0.013) and the current use of anticoagulants (p= 0.001). The mean age of the group with thromboembolic events was significantly higher (58 years) than that of the control group (46 years) (p=0.009). DiscussionThe incidence of symptomatic thromboembolic events associated with knee arthroscopy was low. The routine use of thromboembolic prophylaxis is not recommended in patients undergoing this surgery. We recommend using it in patients with risk factors such as history of previous thromboembolic events and actual use of anticoagulants. Likewise, its use in patients over 50 years should be considered. Level of evidenceIII, Retrospective Cohort Study.

Patients’ perspective on a pill-in-the-pocket oral anticoagulation as an alternative stroke prevention strategy in atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Oral anticoagulation (OAC) decisions are binary: if atrial fibrillation (AF) is detected and additional risk factors are presented, lifelong continuous OAC is recommended regardless of AF burden or temporal patterns. AF-related stroke risk appears to be lower in patients with paroxysmal AF and, therefore, indefinite OAC may have limited benefit whilst exposing patients to a significant bleeding risk. ‘Pill-in-the-pocket’ OAC during and shortly after AF challenges this dichotomous approach to OAC and is being explored in several pilot studies as an alternative AF-related stroke prevention strategy. Purpose This patient questionnaire sought to examine patients’ perspective of ‘pill-in-the pocket’ OAC strategy. Methods An 8-question interactive survey was developed in collaboration with AF Association (UK based charity) and included a short description of implantable cardiac monitors main features, implant procedure and associated risks. The survey was available online on the AF Association website from 30/09/2020 to 2/11/2020. Results Overall, 321 participants with an underlying diagnosis of AF replied to the online survey over the course of four and half weeks. The majority (82%) were taking direct oral anticoagulants. Just over two thirds of patients had concerns regarding bleeding side-effects from taking OAC and, approximately, a quarter had experienced a bleeding event (1.5% major bleeding and 24.2% minor bleeding). When asked if it was shown to be safe to monitor their heart rhythm continuously and take anticoagulants only during an episode of AF and for a small number of days afterwards (i.e. ‘pill-in-the-pocket’), 53.7% of participants would use guided by an implantable cardiac monitored. Slightly lower number of patients (48%) would take pill-in-the-pocket oral anticoagulation guided by a wearable device. In the comments the main reasons not to pursue ‘pill-in-the-pocket’ were permanent AF, previous thromboembolic events and concerns regarding reliability of monitoring technologies. In contrast, those who were receptive to this alternative approach had previous bleeding episodes, had very infrequent AF episodes and wanted to reduce their medication burden. Conclusion Approximately half of patients with choose a ‘pill-in-the-pocket’ OAC guided by daily rhythm monitoring with an ICM if proven to be safe and effective at reducing thromboembolism.