Use Of Prophylactic Anticoagulation Research Articles

Venous Thromboembolism Prophylaxis in Obstetric Patients.

Venous thromboembolism (VTE), including both pulmonary embolism (PE) and deep vein thrombosis (DVT), is the leading cause of maternal death in developed countries. Pregnancy is associated with an increased risk of VTE due to physiologic changes during the obstetric period that promote a hypercoagulable state. Appropriate use of prophylactic anticoagulants can decrease the event rate of thrombus formation in at-risk patients. In the United States, there is not a validated risk-assessment tool for VTE in obstetric patients or a clear consensus on initiation and optimal dosing strategy for the prophylactic use of anticoagulants. This article reviews the mechanism of coagulation disturbance that leads to an increased risk of VTE in obstetric patients, as well as the available literature surrounding pharmacologic prophylaxis.

Thrombosis in Acute Promyelocytic Leukemia: The Current Understanding.

Despite enormous improvement in the management of patients with acute promyelocytic leukemia (APL), the distinctive coagulopathy observed at presentation in affected patients is often life-threatening. While hemorrhagic manifestations are well known and described in this setting, APL-related thromboses are underappreciated. Data regarding this complication are scarce showing variable incidence. Furthermore, risk factors for thrombosis are inconsistent and unreliable; so, differentiation of increased risk of hemorrhage from an increased thrombotic risk is quite difficult in the absence of adequate predictive scores. Besides, prophylactic use of anticoagulants and recombinant thrombomodulin are a matter of ongoing debate. Also, due to the common feature of thrombocytopenia and other hemorrhagic risks, patients with APL are excluded from trials analyzing anticoagulant prophylaxis in cancers; so, data from prospective trials are lacking. A detailed analysis of thrombotic risks in APL with the development of a reliable risk stratification model is needed to further improve the care of APL patients.

Effectiveness and safety of prophylactic anticoagulation among hospitalized patients with inflammatory bowel disease

AbstractHospitalized patients with inflammatory bowel disease (IBD) are at increased risk of venous thromboembolism (VTE). We aimed to evaluate the effectiveness and safety of prophylactic anticoagulation compared with no anticoagulation in hospitalized patients with IBD. We conducted a retrospective cohort study using a hospital-based database. We included patients with IBD who had a length of hospital stay ≥2 days between 1 January 2016 and 31 December 2019. We excluded patients who had other indications for anticoagulation, users of direct oral anticoagulants, warfarin, therapeutic-intensity heparin, and patients admitted for surgery. We defined exposure to prophylactic anticoagulation using charge codes. The primary effectiveness outcome was VTE. The primary safety outcome was bleeding. We used propensity score matching to reduce potential differences between users and nonusers of anticoagulants and Cox proportional-hazards regression to estimate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs). The analysis included 56 194 matched patients with IBD (users of anticoagulants, n = 28 097; nonusers, n = 28 097). In the matched sample, prophylactic use of anticoagulants (vs no use) was associated with a lower rate of VTE (HR, 0.62; 95% CI, 0.41-0.94) and with no difference in the rate of bleeding (HR, 1.05; 95% CI, 0.87-1.26). In this study of hospitalized patients with IBD, prophylactic use of heparin was associated with a lower rate of VTE without increasing bleeding risk compared with no anticoagulation. Our results suggest potential benefits of prophylactic anticoagulation to reduce the burden of VTE in hospitalized patients with IBD.

Adoption of a National Prophylactic Anticoagulation Guideline for Hospitalized Pregnant Women With COVID-19: Retrospective Cohort Study.

Both COVID-19 and pregnancy are associated with hypercoagulability. Due to the increased risk for thrombosis, the United States National Institute of Health's recommendation for prophylactic anticoagulant use for pregnant patients has expanded from patients hospitalized for severe COVID-19 manifestation to all patients hospitalized for the manifestation of COVID-19 (no guideline: before December 26, 2020; first update: December 27, 2022; second update: February 24, 2022-present). However, no study has evaluated this recommendation. The objective of this study was to characterize prophylactic anticoagulant use among hospitalized pregnant people with COVID-19 from March 20, 2020, to October 19, 2022. This was a retrospective cohort study in large US health care systems across 7 states. The cohort of interest was pregnant patients who were hospitalized with COVID-19, without previous coagulopathy or contraindication to anticoagulants (n=2767). The treatment group consisted of patients prescribed prophylactic dose anticoagulation between 2 days before and 14 days after COVID-19 treatment onset (n=191). The control group was patients with no anticoagulant exposure between 14 days before and 60 days after COVID-19 treatment onset (n=2534). We ascertained the use of prophylactic anticoagulants with attention to the updates in guidelines and emerging SARS-CoV-2 variants. We propensity score matched the treatment and control group 1:1 on the most important features contributing to the prophylactic anticoagulant administration status classification. Outcome measures included coagulopathy, bleeding, COVID-19-related complications, and maternal-fetal health outcomes. Additionally, the inpatient anticoagulant administration rate was validated in a nationwide population from Truveta, a collective of 700 hospitals across the United States. The overall administration rate of prophylactic anticoagulants was 7% (191/2725). It was lowest after the second guideline update (no guideline: 27/262, 10%; first update: 145/1663, 8.72%; second update: 19/811, 2.3%; P<.001) and during the omicron-dominant period (Wild type: 45/549, 8.2%; Alpha: 18/129, 14%; Delta: 81/507, 16%; and Omicron: 47/1551, 3%; P<.001). Models developed on retrospective data showed that the variable most associated with the administration of inpatient prophylactic anticoagulant was comorbidities prior to SARS-CoV-2 infection. The patients who were administered prophylactic anticoagulant were also more likely to receive supplementary oxygen (57/191, 30% vs 9/188, 5%; P<.001). There was no statistical difference in a new diagnosis of coagulopathy, bleeding, or maternal-fetal health outcomes between those who received treatment and the matched control group. Most hospitalized pregnant patients with COVID-19 did not receive prophylactic anticoagulants across health care systems as recommended by guidelines. Guideline-recommended treatment was administered more frequently to patients with greater COVID-19 illness severity. Given the low rate of administration and differences between treated and untreated cohorts, efficacy could not be assessed.

Predicting Stroke in Heart Failure and Preserved Ejection Fraction Without Atrial Fibrillation.

The rate of stroke in patients with heart failure (HF) and preserved ejection fraction but without atrial fibrillation (AF), is uncertain as is whether it is possible to reliably predict the risk of stroke in these patients. We validated a previously developed simple risk model for stroke among patients enrolled in the I-Preserve trial (Irbesartan in Heart Failure With Preserved Systolic Function) and PARAGON-HF trial (Efficacy and Safety of LCZ696 Compared to Valsartan, on Morbidity and Mortality in Heart Failure Patients With Preserved Ejection Fraction). The risk model consisted of 3 variables: history of previous stroke, insulin-treated diabetes, and plasma N-terminal pro-B-type natriuretic peptide level. Of the 8924 patients included in the pooled trial dataset, 5126 patients did not have AF at baseline. Among patients without AF, 190 (3.7%) experienced a stroke over a median follow-up of 3.6 years (rate 10.5 per 1000 patient-years). The risk for stroke increased with increasing risk score: second tertile hazard ratio, 1.78 (95% CI, 1.17-2.71); third tertile hazard ratio, 3.03 (95% CI, 2.06-4.47), with the first tertile as reference. For patients in the third tertile, the occurrence rate of stroke was 17.7 per 1000 patient-years, similar to that in patients with AF not receiving anticoagulation (20.7 per 1000 patient-years), and those with AF who were receiving anticoagulation (14.5 per 1000 patient-years). Model discrimination was good with a C index of 0.81 (0.68-0.91) and a simple score could be created from the model. A simple risk model can detect a subset of HF and preserved ejection fraction patients without AF who have a higher risk for stroke. The balance of risk-to-benefit in these individuals may justify the use of prophylactic anticoagulation, but this hypothesis needs to be prospectively evaluated. URL: https://www. gov; Unique identifiers: NCT00095238 and NCT01920711.

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

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

Unfractionated Heparins, Low-Molecular-Weight Heparins, and Indirect Factor Xa Inhibitors in Plastic and Reconstructive Surgery: An Evidence-Based Review.

Venous thromboembolism can present with devastating complications and sequalae, particularly in the surgical patient. Current data supports prophylactic anticoagulant use in the high-risk inpatient, defined as those with a 2005 Caprini Risk Assessment Model score of ≥7. The most utilized chemoprophylaxis agents include unfractionated heparin, low-molecular-weight heparins, and indirect factor Xa inhibitors. The authors review their mechanisms of action, metabolism, reversal agents, indications, contraindications, advantages, and disadvantages in plastic and reconstructive surgery.

Anticoagulation and interventional pain treatment has anything changed?

Interventional pain management bears a significant risk of hemorrhagic complications. This risk increases in patientswith coagulation disorders and those taking anticoagulant therapy. The population of the latter is growing, and manynew drugs and new treatment regimens have become widespread in recent years. The latest guidelines on the periproceduraluse of anticoagulant therapy also apply to regional anaesthesia techniques for the treatment of chronicand acute pain. However, despite the existence of guidelines and recommendations, decision-making difficultiescan still be encountered in the practice of interventional pain management. The presentation includes a summaryof existing recommendations for the prophylactic use of anticoagulants and antiaggregants in clinical practice inthe periprocedural period. Also included is a discussion of selected concerns regarding their use in the practice ofinterventional pain management.

Anaesthetic Management of Caesarean Section in Asymptomatic COVID-19 Positive Parturients with Abnormal Laboratory Findings: A Series of 15 Cases

During the Coronavirus Disease 2019 (COVID-19) pandemic, Caesarean Sections (CS) were prioritised over other elective surgeries, leading to the identification and management of asymptomatic COVID-19 positive parturients. The present case series aimed to explore the possibility of laboratory abnormalities and adverse events that can occur in asymptomatic COVID-19 positive cases in the post-pandemic era when routine screening is no longer in place. Out of 141 asymptomatic COVID-19 positive CS patients, 15 cases were selected based on specific criteria. Demographic characteristics and clinical indicators were analysed, including age, gravidity, indications for CS, laboratory values {such as D-dimer, C Reactive Protein (CRP), and platelet count}, blood transfusion requirements, and obstetric outcomes. Indications for CS were predominantly previous CS and failure to progress. Laboratory abnormalities included elevated D-dimer, CRP, leukocyte count, and thrombocytopenia in some cases. Haemodynamic stability was maintained in all patients. The use of prophylactic anticoagulation was noted, potentially offering protection against thrombosis. Asymptomatic COVID-19 positive parturients can exhibit significant laboratory abnormalities. Thromboprophylaxis may play a role in mitigating thrombotic risks. The significance of the present case series lies in the fact that the laboratory abnormalities could only be detected since all positive patients were investigated as per hospital protocol, which will be missed in the post-COVID-19 era where routine investigations are not performed on asymptomatic patients. Therefore, healthcare workers should be aware of this possibility

Effectiveness and safety of extended thromboprophylaxis in post-discharge patients with COVID-19: A systematic review and meta-analysis

BackgroundThe effect of extended thromboprophylaxis in improving the prognosis of adult patients with coronavirus disease 2019 (COVID-19) after discharge remains debatable. This meta-analysis was aimed to determine the advantages and disadvantages of extended thromboprophylaxis in these patients. MethodsDifferent databases such as PubMed, Embase, Web of Science, and Cochrane Library were systematically searched for studies that evaluated the effects of extended thromboprophylaxis in post-discharge patients with COVID-19 until 13 June 2022. The primary efficacy outcome was defined by the composite outcome of thromboembolism and all-cause mortality, and the safety outcome was defined by bleeding events. The odds ratios (ORs) and 95 % confidence intervals (CIs) of efficacy and safety outcomes were calculated using fixed- or random-effects model. Interaction analysis was performed to assess and compare observational studies and randomised controlled trials (RCTs). A sensitivity analysis was performed after excluding studies of poor quality. ResultsEight studies involving 10,148 patients were included. The results confirmed that extended thromboprophylaxis, primarily prophylactic use of anticoagulants for <35 days, was significantly associated with reduced composite outcome in high-risk post-discharge patients with COVID-19 (OR: 0.52; 95 % CI: 0.41–0.67, P = 0.000). Interaction analysis revealed that the effect estimates were consistent between the RCT and observational studies (Pinteraction = 0.310). Furthermore, extended thromboprophylaxis did not increase the risk of major bleeding events (OR: 1.64; 95 % CI: 0.95–2.82, P = 0.075). ConclusionIn post-discharge patients with COVID-19 at high risk of thromboembolism, extended thromboprophylaxis, primarily prophylactic use of anticoagulants for <35 days, can significantly reduce the risk of thrombosis and all-cause mortality without increasing the risk of major bleeding events. RegistrationPROSPERO CRD42022339399.

Venous Thromboembolism Prophylaxis in High-Risk Pediatric Oncology Patients

Introduction Pediatric oncology patients are at increased risk for hospital-acquired venous thromboembolism (HA-VTE), which is associated with increased morbidity in this population. Up to 20% of pediatric oncology patients with central venous catheters (CVC) experience HA-VTE. However, much debate exists over the use of pharmacologic thromboprophylaxis to prevent HA-VTE in the pediatric oncology population, primarily due to lack of evidence regarding safety and efficacy. Pediatric oncology patients have many well-established risk factors for VTE including adolescence, obesity, CVC presence, and receipt of asparaginase chemotherapy. Given the uncertainty regarding prevention strategies in this population, research is needed regarding the use of prophylactic anticoagulation in pediatric oncology patients. Objective: To evaluate the use of prophylactic anticoagulation in pediatric oncology patients at risk for HA-VTE. Methods A retrospective, single center chart review of pediatric oncology patients who received clinical care at a tertiary care children's hospital was performed. Over 1600 patients were captured from a departmental database of all new oncologic diagnoses identified between January 1, 2014 and December 31, 2014. Patients were excluded if they received care at another institution or did not have an additional risk factor for HA-VTE outside of cancer diagnosis. Defined risk factors were age >12 years, body mass index (BMI) >30, CVC placement, receipt of asparaginase, and history of thrombosis. 514 patients met inclusion criteria. Patient age, BMI, history of thrombophilia, type of CVC, cancer type, steroid administration and asparaginase administration were analyzed as potential risk factors for VTE. Logistic regression was used to model odds of thrombus as a function of risk factors. A classification and regression tree (CART) model was also fitted to identify predictors of thrombus. Results Of 514 patients identified as high-risk for VTE, only 19 (3.7%) received prophylaxis. Most patients received enoxaparin for prophylaxis. Almost 15% (75/514) developed VTE during the study period. Of those who developed a VTE, 9% (7/75) were on prophylaxis at the time of VTE. 100% of the patients that developed VTE had a CVC in place. Obese patients were most likely to develop VTE with an odds ratio of 2.2 (95% CI 1-4.3, p 0.032). 28% (18/65) of obese patients developed VTE, yet only 6% (4/65) of obese patients received prophylaxis. Of these obese patients, 50% (2/4) developed VTE despite prophylaxis. Patients age >12 years were more likely to have VTE than those age <12 years (OR 1.1; 95% CI 1-1.1, p 0.023). Patients with Hickman catheters also had twice the odds of developing VTE (OR 2.1; 95% CI 1-4.1, p 0.046). In evaluating VTE occurrence by malignancy type, patients with hepatic tumors had the highest occurrence of thrombosis (8/12; 87%) followed by patients with myeloid leukemia (10/36; 28%), and lymphoblastic leukemia (28/170; 16%). The CART model was able to accurately predict occurrence or non-occurrence of thrombus in 87% of patients in the dataset based on the risk factors of obesity, age, and cancer type. Discussion It is well-established that malignancy is a significant risk factor for the development of VTE in pediatric oncology patients. Yet due to concern for bleeding events in these patients who frequently have thrombocytopenia, pharmacologic prophylaxis may not be used despite additional high-risk factors for VTE. This study demonstrates that pharmacologic prophylaxis is rarely used, even among high-risk pediatric oncology patients. For each risk group, most patients prescribed prophylaxis did not develop thrombus, however VTE still occurred in some. Risk stratification for pediatric oncology patients is essential given potential bleeding risk. We were able to identify additional high-risk features such as obesity, type of CVC, and cancer type. The CART model for high-risk pediatric populations had high specificity (88%) but poor sensitivity (23%). Application of this model could inform appropriate use of thromboprophylaxis in pediatric oncology patients to reduce the incidence of HA-VTE in this population. Further research is needed regarding safety and efficacy of prophylaxis, but this study provides important data to guide future steps.

Stroke in patients with heart failure and reduced ejection fraction without atrial fibrillation: external validation of a risk model

Abstract Background Heart failure (HF) ranks only second to atrial fibrillation (AF) as a cause of cardio-embolic stroke. Although anticoagulation reduces this risk in HF patients not in AF, the risk/benefit profile in relatively unselected populations is not favourable. Identification of patients at high risk of stroke may allow targeted and safer use of prophylactic anticoagulant therapy. Previously, we proposed a simple risk model for stroke in patients with HF and reduced ejection fraction (HFrEF). However, this model was derived from the two older trials (published in 2007/2008) and was not externally validated. Purpose We aimed to evaluate the current incidence of stroke in patients with HFrEF not in AF receiving modern pharmacological therapy and to validate our stroke prediction model. Methods We examined patient-level data from the PARADIGM-HF, ATMOSPHERE, and DAPA-HF trials. The risk score was calculated following: 7.39×(insulin-treated diabetes) + 6.53×(previous stroke) + 2.80×[ln(NT-proBNP (pg/ml)) × 0.1182]). According to the tertile of risk score, we divided the patients into three groups. Patients with AF were defined as those with either AF on an ECG or a history of AF. Results Of the total of 20,159 patients (who experienced 590 strokes) enrolled in the three trials, 12,751 patients did not have AF at baseline. Of those, 1,143 patients (9%) had insulin-treated diabetes, 873 patients (6.8%) had a history of the previous stroke, and the median value of NT-proBNP was 1,243 pg/ml. During a median follow-up of 2.0 years, 346 (2.7%) experienced a stroke (11.7 per 1000 patient-years). Figure 1 shows cumulative incidence function plots for stroke according to the tertile of risk score in 12,331 patients whose risk score can be calculated. The number of strokes in tertile 1, 2 and 3 were 80, 102 and 149, respectively. The 3-year cumulative incidence function rates of stroke were 2.0 (95% CI: 1.5–2.5) % in tertile 1, 2.6 (95% CI: 2.1–3.2) % in tertile 2, and 4.3 (95% CI: 3.6–5.2) % in tertile 3, respectively. In patients with tertile 3, the stroke rate was 18.1 per 1000 patient-years (compared to 20.1 per 1000 patient-years in patients with AF not receiving anticoagulation). In the Cox model, risk for stroke increased according to the elevation in the risk score (tertile 2: HR 1.47 (95% CI 1.09–1.97), tertile 3: HR 2.53 (95% CI 1.92–3.33), with tertile 1 as reference). Figure 2 shows calibration plots by comparing observed and predicted probabilities of stroke at 1 to 3 years. Discrimination evaluated using the overall c-index 0.84 (95% CI: 0.75–0.91) was good. Conclusions These findings validate a previously described predictive model and confirm that it is possible to identify a subset of HFrEF patients without AF who have a risk of stroke that approximates to that in patients with AF. In these patients, the risk/benefit balance might justify the use of prophylactic anticoagulation, but this hypothesis needs to be tested prospectively. Funding Acknowledgement Type of funding sources: Foundation.

Current practices in pediatric hospital‐acquired thromboembolism: Survey of the Children's Hospital Acquired Thrombosis (CHAT) Consortium

BackgroundA rise in hospital‐acquired venous thromboembolism (HA‐VTE) in children has led to increased awareness regarding VTE prophylaxis and risk assessment. Despite no consensus exists regarding these practices in pediatrics. ObjectiveTo describe common practices in VTE prophylaxis, VTE risk assessment models, and anticoagulation dosing strategies in pediatric hospitals that are members of the Children's Hospital Acquired Thrombosis (CHAT) Consortium. MethodsAn electronic survey of 44 questions evaluating practices surrounding pediatric HA‐VTE risk assessment and prevention was distributed between August 9, 2021, and August 30, 2021, to the primary investigators from the 32 institutions within the CHAT Consortium. ResultsThe survey response rate was 100% (n = 32). In total, 85% (n = 27) of the institutions assess HA‐VTE, but only 63% (n = 20) have formal hospital guidelines. Within the institutions with formal guidelines, 100% (n = 20) include acute systemic inflammation or infection and presence of a central venous catheter (CVC) as risk factors for VTE. Pharmacologic prophylaxis is prescribed at 87% (28) of institutions, with enoxaparin being the most frequent (96%, n = 27). Variability in responses persisted regarding risk factors, risk assessment, thromboprophylaxis, dosing of prophylactic anticoagulation or anticoagulant drug monitoring. A majority of providers were comfortable providing thromboprophylaxis across all age groups. In addition, the global coronavirus disease 2019 increased the providers' use of prophylactic anticoagulation 78% (n = 25). ConclusionPractices among institutions are variable in regard to use of HA‐VTE prophylaxis, risk assessment, or guideline implementation, highlighting the need for further research and a validated risk assessment model through groups like the CHAT Consortium.

Predicting stroke in heart failure and reduced ejection fraction without atrial fibrillation.

Patients with heart failure with reduced ejection fraction (HFrEF) are at significant risk of stroke. Anticoagulation reduces this risk in patients with and without atrial fibrillation (AF), but the risk-to-benefit balance in the latter group, overall, is not favourable. Identification of patients with HFrEF, without AF, at the highest risk of stroke may allow targeted and safer use of prophylactic anticoagulant therapy. In a pooled patient-level cohort of the PARADIGM-HF, ATMOSPHERE, and DAPA-HF trials, a previously derived simple risk model for stroke, consisting of three variables (history of prior stroke, insulin-treated diabetes, and plasma N-terminal pro-B-type natriuretic peptide level), was validated. Of the 20 159 patients included, 12 751 patients did not have AF at baseline. Among patients without AF, 346 (2.7%) experienced a stroke over a median follow up of 2.0 years (rate 11.7 per 1000 patient-years). The risk for stroke increased with increasing risk score: fourth quintile hazard ratio (HR) 2.35 [95% confidence interval (CI) 1.60-3.45]; fifth quintile HR 3.73 (95% CI 2.58-5.38), with the first quintile as reference. For patients in the top quintile, the rate of stroke was 21.2 per 1000 patient-years, similar to participants with AF not receiving anticoagulation (20.1 per 1000 patient-years). Model discrimination was good with a C-index of 0.84 (0.75-0.91). It is possible to identify a subset of HFrEF patients without AF with a stroke-risk equivalent to that of patients with AF who are not anticoagulated. In these patients, the risk-to-benefit balance might justify the use of prophylactic anticoagulation, but this hypothesis needs to be tested prospectively.

Trends in post-discharge prophylactic anticoagulant use among stroke patients in the United States between 2006 and 2019

BackgroundStroke is an independent risk factor for venous thromboembolism (VTE). Although the risk of VTE persists after hospital discharge, information on the utilization of anticoagulants among stroke patients after discharge remains limited. ObjectiveTo evaluate changes in post-discharge thromboprophylaxis among stroke patients between 2006 and 2019. MethodsWe conducted a retrospective repeated cross-sectional analysis using a commercial healthcare insurance database in the United States. We included patients aged ≥ 18 years with incident stroke diagnosis and assessed prophylactic use of anticoagulants in the 30 days following hospital discharge including low-molecular-weight heparin (enoxaparin ≤40 mg/day, dalteparin ≤5000 IU/day), unfractionated heparin ≤5000 IU/ twice daily or 3 times a day, apixaban 2.5 mg twice daily, and rivaroxaban 10 mg/day. Patients with atrial fibrillation, VTE, mechanical heart valves, cancer, antiphospholipid antibody syndrome, and users of therapeutic doses of anticoagulants were excluded. We used the Cochrane-Armitage test to assess changes in the use of anticoagulants across the study period. ResultsThere was a small increase in the overall use of post-discharge prophylactic anticoagulants among stroke patients between 2006 and 2019 from 0.5% to 1.9%. The use of heparin decreased from 0.5% in 2006 to 0.3% in 2019 (P-value for trend = 0.001). In contrast, the use of apixaban or rivaroxaban increased from 0.1% in 2013 to 1.6% in 2019 (P-value for trend < 0.001). Apixaban was more commonly used than rivaroxaban. ConclusionsIn this population-based study of stroke patients, we found that post-discharge anticoagulant use remains low through 2019. Prophylactic use of heparin or rivaroxaban was relatively low but the use of apixaban increased over the study period. Further research is needed to determine if these agents are safe and effective for VTE prevention in stroke patients.

Predictors of venous thromboembolism in COVID-19 patients: results of the COVID-19 Brazilian Registry.

Previous studies that assessed risk factors for venous thromboembolism (VTE) in COVID-19 patients have shown inconsistent results. Our aim was to investigate VTE predictors by both logistic regression (LR) and machine learning (ML) approaches, due to their potential complementarity. This cohort study of a large Brazilian COVID-19 Registry included 4120 COVID-19 adult patients from 16 hospitals. Symptomatic VTE was confirmed by objective imaging. LR analysis, tree-based boosting, and bagging were used to investigate the association of variables upon hospital presentation with VTE. Among 4,120 patients (55.5% men, 39.3% critical patients), VTE was confirmed in 6.7%. In multivariate LR analysis, obesity (OR 1.50, 95% CI 1.11–2.02); being an ex-smoker (OR 1.44, 95% CI 1.03–2.01); surgery ≤ 90 days (OR 2.20, 95% CI 1.14–4.23); axillary temperature (OR 1.41, 95% CI 1.22–1.63); D-dimer ≥ 4 times above the upper limit of reference value (OR 2.16, 95% CI 1.26–3.67), lactate (OR 1.10, 95% CI 1.02–1.19), C-reactive protein levels (CRP, OR 1.09, 95% CI 1.01–1.18); and neutrophil count (OR 1.04, 95% CI 1.005–1.075) were independent predictors of VTE. Atrial fibrillation, peripheral oxygen saturation/inspired oxygen fraction (SF) ratio and prophylactic use of anticoagulants were protective. Temperature at admission, SF ratio, neutrophil count, D-dimer, CRP and lactate levels were also identified as predictors by ML methods. By using ML and LR analyses, we showed that D-dimer, axillary temperature, neutrophil count, CRP and lactate levels are risk factors for VTE in COVID-19 patients.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11739-022-03002-z.

Prophylactic Anticoagulant Use and Adverse Events with Bleeding in Critically Ill COVID-19 Patients

Prophylactic Anticoagulant Use and Adverse Events with Bleeding in Critically Ill COVID-19 Patients

Thromboembolic prevention and anticoagulant therapy during the COVID-19 pandemic: updated clinical guidance from the anticoagulation forum

Thromboembolism is a common and deadly consequence of COVID-19 infection for hospitalized patients. Based on clinical evidence pre-dating the COVID-19 pandemic and early observational reports, expert consensus and guidance documents have strongly encouraged the use of prophylactic anticoagulation for patients hospitalized for COVID-19 infection. More recently, multiple clinical trials and larger observational studies have provided evidence for tailoring the approach to thromboprophylaxis for patients with COVID-19. This document provides updated guidance for the use of anticoagulant therapies in patients with COVID-19 from the Anticoagulation Forum, the leading North American organization of anticoagulation providers. We discuss ambulatory, in-hospital, and post-hospital thromboprophylaxis strategies as well as provide guidance for patients with thrombotic conditions who are considering COVID-19 vaccination.

Venous Thromboembolic Complications in Pediatric Gastrointestinal Diseases: Inflammatory Bowel Disease and Intestinal Failure.

In children with gastrointestinal disorders such as inflammatory bowel disease (IBD) and intestinal failure (IF), the risk of venous thromboembolism (VTE) is increased. VTE may lead to pulmonary embolism, sepsis and central line infection, stroke and post-thrombotic syndrome. The purpose of this review is to summarize current knowledge and recent advances around VTE management in pediatric gastroenterology with a focus on IBD and IF. The VTE incidence in children with IBD is reported to be around 4–30 per 10,000 patient-years, with higher incidences for hospitalized children. While in general, IF is less common than IBD, the VTE incidence in children with IF is around 750 per 10,000 patient-years. The most common risk factors for development of VTE involve deviations leading to Virchow's triad (endothelial damage, stasis, and hypercoagulability) and include active inflammation, particularly with colonic involvement, presence of a central venous catheter, underlying thrombophilia, reduced mobility, surgery, and hospitalization. Classes of anticoagulants used for treatment of VTE are low molecular weight heparins and vitamin K antagonists. However, the use of direct oral anticoagulants for treatment or prevention of VTE has not been studied in this pediatric population yet. Pediatric gastroenterologists apply different VTE prevention and treatment strategies due to lack of literature and lack of consensus. We discuss the role of primary and secondary prophylactic use of anticoagulants, and provide tools and recommendations for screening, prevention and management for the specific pediatric populations.

COVID-19 and oral cavity - repercussions and post-vaccination care: a clinical case

Adverse event descriptions such as rare thromboses with concomitant thrombocytopenia, including venous thromboses at unusual sites such as cerebral venous sinus thrombosis (CVST), intestinal venous and arterial thromboses, have been reported following vaccination for COVID-19 based on recombinant adenoviral vector. The emergence of clinical features of moderate to severe thrombocytopenia and thrombotic complications, increasing fibrin formation in different parts of the body, approximately 1 to 2 weeks after vaccination against SARS-CoV-2 suggests a disorder that clinically resembles clinical presentations of long-term use of heparin. The case report consists of paroxysmal left-sided hemicrania after local vaccination protocol, in addition, the patient presents areas of retraction and papillary necrosis, hyperplastic regions with bleeding, not consistent with periodontal diseases associated with biofilm, during the physical examination. The possibility of ischemic stroke in vaccinated people as well as in patients with COVID-19 justifies the therapeutic and prophylactic use of anticoagulants, increasing post-vaccination safety. Although the phenomena related to thromboembolic complications induced by the vaccine for COVID-19 are rare, a careful evaluation including specific laboratory tests and a correct systemic diagnosis is necessary. In addition, the observation of certain pathologies caused by thrombus formation in the oral cavity can help in the preventive identification of vaccine-induced thrombotic thrombocytopenia (VITT).