Resumption Of Anticoagulation Research Articles

Timing of Anticoagulation Resumption and Risk of Ischemic and Hemorrhagic Complications in Patients With ICH and Mechanical Heart Valves.

In patients with mechanical heart valves and recent intracranial hemorrhage (ICH), clinicians need to balance the risk of thromboembolism during the period off anticoagulation and the risk of hematoma expansion on anticoagulation. The optimal timing of anticoagulation resumption is unknown. We aimed to investigate the relationship between reversal therapy and ischemic stroke, between duration off anticoagulation and risk of ischemic strokes or systemic embolism and between timing of anticoagulation resumption and risk of rebleeding and ICH expansion. We conducted a retrospective cohort observational study in 3 tertiary hospitals. Consecutive adult patients with mechanical heart valves admitted for ICH between January 1, 2000, and July 13, 2022, were included. The primary end points of our study were thromboembolic events (cerebral, retinal, or systemic) while off anticoagulation and ICH expansion after anticoagulation resumption (defined by the following criteria: increase by one-third in intracerebral hematoma volume, increase by one-third in convexity subdural hemorrhage diameter, or visually unequivocal expansion of other ICH locations to the naked eye). A total of 171 patients with mechanical heart valves who experienced ICH were included in the final analysis. Most of the patients (79.5%) received reversal therapy for anticoagulation. Patients who received anticoagulation reversal therapy did not have increased risk of thromboembolic complications. Time off anticoagulation was not associated with risk of ischemic stroke; only 2 patients had a stroke within 7 days of the ICH, and both had additional major risk factors of thromboembolism. The rate of ischemic stroke/transient ischemic attack while off anticoagulation was lower than the rate of ICH expansion once anticoagulation was resumed (6.4% vs 9.9%). Furthermore, patients who developed ICH expansion had higher mortality compared with patients who had ischemic stroke while being off anticoagulation (41% vs 9%). Use of intravenous heparin bridging upon resumption of warfarin was strongly associated with increased risk of ICH expansion as compared with restarting warfarin without a heparin bridge. Withholding anticoagulation for at least 7 days after ICH may be safe in patients with mechanical heart valves. Heparin bridging during anticoagulation resumption may be associated with increased risk of bleeding.

Anticoagulant in Acute Ischemic Stroke with Atrial Fibrillation: A Narrative Review

Embolic stroke due to atrial fibrillation is often underdiagnosed and has high morbidity and mortality among ischemic stroke. So it is of paramount importance to start anticoagulants as early as possible to prevent further ischemic stroke. However, early initiation of anticoagulants has created much debate, major & minor bleeding related to it are a major concern, and resumption of anticoagulants after intracranial hemorrhage is still a gray zone. Here, we described a narrative review to shed some light on the major concerns such as the optimal time to start an anticoagulant, the best agent to administer, the resumption of anticoagulant after a hemorrhagic stroke, and anticoagulant therapy in chronic rheumatic heart disease (CRHD) based on the recently published article. J MEDICINE 2024; 25: 155-158

Traumatic Brain Injury in Patients under Anticoagulant Therapy: Review of Management in Emergency Department.

The best management of patients who suffer from traumatic brain injury (TBI) while on oral anticoagulants is one of the most disputed problems of emergency services. Indeed, guidelines, clinical decision rules, and observational studies addressing this topic are scarce and conflicting. Moreover, relevant issues such as the specific treatment (and even definition) of mild TBI, rate of delayed intracranial injury, indications for neurosurgery, and anticoagulant modulation are largely empiric. We reviewed the most recent evidence on these topics and explored other clinically relevant aspects, such as the promising role of dosing brain biomarkers, the strategies to assess the extent of anticoagulation, and the indications of reversals and tranexamic acid administration, in cases of mild TBI or as a bridge to neurosurgery. The appropriate timing of anticoagulant resumption was also discussed. Finally, we obtained an insight into the economic burden of TBI in patients on oral anticoagulants, and future directions on the management of this subpopulation of TBI patients were proposed. In this article, at the end of each section, a "take home message" is stated.

Characteristics and incidence of peri-device leaks after left atrial appendage closure in patients with prior electrical isolation of left atrial appendage during catheter ablation

Abstract Background Patients who undergo electrical isolation of left atrial appendage (eLAAi) during atrial fibrillation (AF) ablation have a higher subsequent risk of thromboembolism. In post-ablation patients with eLAAi who undergo mechanical LAA closure (LAAC), there are limited data on imaging and clinical outcomes during follow-up, particularly peri-device leaks (PDLs). Purpose We investigated imaging outcomes on ~1 year follow up transesophageal echocardiography (TEE) for PDL and clinical outcomes in patients who had undergone LAAc after sustaining eLAAi from catheter ablation. Methods We analyzed data from TEEs at ~1 year follow up in patients who had undergone LAAC with either the Watchman or Watchman-FLX device. The images were analyzed for evidence of any discernible PDL which also which also included the absence of thrombosis/obliteration of the distal LAA. "Severe" PDL was categorized as the leak size of >5 mm on follow up TEE imaging. Baseline characteristics, imaging and clinical outcomes were compared with univariate comparison using Fisher’s exact test, between the two subgroups of LAAC patients stratified according to prior h/o eLAAi. Results A total of 532 patients underwent LAAC at our center between 03/2015 and 10/2022, with data available on ~1 year follow-up TEE imaging. Of these, 21 (3.9%) had undergone eLAAi during AF ablation prior to LAAC. At ~1 year follow up TEE imaging, the patients with prior h/o eLAAi had a numerically higher incidence of any PDL (42.9% vs 26.5%, p = 0.09). The incidence of severe PDL was significantly higher in the subgroup of patients with prior eLAAi as compared to patients without prior eLAAi (14.3% vs 3.3%, p = 0.04; Figure). There was no statistically-significant difference in the subsequent risk of thromboembolism between the eLAAi and control subgroups (4.8% vs 6.1%, p = 1.0) over an average follow-up of 577±331 days post-LAAC. Conclusions A prior history of eLAAi during AF ablation was associated with a higher risk of severe PDLs (>5mm) on follow up imaging after LAAC. The finding of severe PDL in the eLAAi subgroup might be attributable to ostial fibrosis as a result of ablation which might affect the LAA endocardial surface interaction with the device fabric. The occurrence of a higher risk of severe PDL in patients with prior eLAAi after LAAC might necessitate PDL closure or resumption of anticoagulation in such patients to mitigate the risk of subsequent thromboembolism.igure showing our study schema and compa

Optimal Timing for Resumption of Anticoagulation After Intracranial Hemorrhage in Patients With Mechanical Heart Valves.

Anticoagulation in patients with intracranial hemorrhage (ICH) and mechanical heart valves is often held for risk of ICH expansion; however, there exists a competing risk of acute ischemic stroke (AIS). Optimal timing to resume anticoagulation remains uncertain. We retrospectively studied patients with ICH and mechanical heart valves from 2000 to 2018. The primary outcome was a composite end point of symptomatic hematoma expansion or new ICH, AIS, and intracardiac thrombus up to 30 days post-ICH. The exposure was timing of reinitiation of anticoagulation classified as early (resumed up to 7 days after ICH), late (≥7 and up to 30 days after ICH), and never if not resumed or resumed after 30 days post-ICH. We included 184 patients with ICH and mechanical heart valves (65 anticoagulated early, 100 late, 19 not resumed by day 30 post-ICH). Twelve patients had AIS, 16 new ICH, and 6 intracardiac thromboses. The mean time from ICH to anticoagulation was 12.7 days. Composite outcomes occurred in 12 patients resumed early (18.5%), 14 resumed late (14.0%), and 4 never resumed (21.1%). There was no increased hazard of the composite outcome (hazard ratio [HR], 1.1 [95% CI, 0.2-6.0]), AIS, or worsening or new ICH among patients resumed early versus late. There was no difference in the composite among patients never resumed versus resumed. Patients who never resumed anticoagulation had significantly more severe ICH (median Glasgow Coma Scale: 10.6, 13.9, and 13.9 among those who resumed never, early, and late, respectively; P=0.0001), higher in-hospital mortality (56.5%, 0%, and 0%, respectively; P<0.0001), and an elevated 30-day AIS risk (HR, 15.9 [95% CI, 1.9-129.7], P=0.0098). In this study of patients with ICH and mechanical heart valves, there was no difference in 30-day thrombotic and hemorrhagic brain-related outcomes when anticoagulation was resumed within 7 versus 7 to 30 days after ICH. Withholding anticoagulation >30 days was associated with severe baseline ICH, higher in-hospital case fatality, and elevated AIS risk.

Application of Antithrombotic Drugs in Different Age-Group Patients with Upper Gastrointestinal Bleeding.

This study aimed at exploring the safety and timing of antithrombotic drugs in different age-group patients with UGIB. An observational study retrospectively based on the single-center database with 713 patients with UGIB. Among the 713 patients, 62.13% were elderly patients (aged > 60 years) and the mortality was 2.9%. In elderly patients with UGIB, we found that previous medication history, resumption of medication, and time of resumption did not affect the in-hospital mortality. The resumption of anticoagulants increased the risk of rebleeding. The independent risk factors of mortality were CHF, cirrhosis, creatine kinase, and albumin. The independent risk factors of rebleeding were the application of anticoagulants during hospitalization, variceal bleeding, black stool, red blood cells (lab), platelets (lab), and heart rate. In UGIB patients, a history of antiplatelet or antithrombotic drugs and the use of antiplatelet drugs after UGIB did not affect the patient's prognosis. In elderly UGIB patients, although antithrombotic drugs did not increase the risk of death, the increased risk of rebleeding after resumption of use deserved careful treatment. It was safe to recover anticoagulant drugs as soon as possible in young UGIB patients.

Comparison of inferior vena cava filter use and outcomes between cancer and non-cancer patients in a tertiary hospital

BackgroundWhile accepted indications for the use of inferior vena cava filter (IVCF) in patients with a venous thromboembolism (VTE) have remained stable, their use continues to be frequent. Retrieval rates are still low, being particularly notable in the population with cancer. This study aims to review the rate of adherence to guidelines recommendation and to compare retrieval rates and complications in both cancer and non-cancer patients. MethodsA retrospective study was performed including 185 patients in whom an IVCF was placed in Hospital Clinic of Barcelona. Baseline characteristics, clinical outcomes, and IVCF-related outcomes were analyzed. A strongly recommended indication (SRI) was considered if it was included in all the revised clinical guidelines and non-strongly if it was included in only some. ResultsOverall, 47 % of the patients had a SRI, without differences between groups. IVCF placement after 29 days from the VTE event was more frequent in the cancer group (46.1 vs. 17.7 %). Patients with cancer (48.1 % of the cohort) were older, with higher co-morbidity and bleeding risk. Anticoagulation resumption (75.3 % vs. 92.7 %) and IVCF retrieval (50.6 % vs. 66.7 %) were significantly less frequent in cancer patients. No significant differences were found regarding IVCF-related complications, hemorrhagic events and VTE recurrence. ConclusionsSRI of IVCF placement was found in less than half of the patients. Cancer patients had higher rates of IVCF placement without indication and lower anticoagulation resumption and IVCF retrieval ratios, despite complications were similar in both groups.

Dynamic Imaging of Blood Coagulation Within the Hematoma of Patients With Acute Hemorrhagic Stroke.

The dynamics of blood clot (combination of Hb [hemoglobin], fibrin, and a higher concentration of aggregated red blood cells) formation within the hematoma of an intracerebral hemorrhage is not well understood. A quantitative neuroimaging method of localized coagulated blood volume/distribution within the hematoma might improve clinical decision-making. The deoxyhemoglobin of aggregated red blood cells within extravasated blood exhibits a higher magnetic susceptibility due to unpaired heme iron electrons. We propose that coagulated blood, with higher aggregated red blood cell content, will exhibit (1) a higher positive susceptibility than noncoagulated blood and (2) increase in fibrin polymerization-restricted localized diffusion, which can be measured noninvasively using quantitative susceptibility mapping and diffusion tensor imaging. In this serial magnetic resonance imaging study, we enrolled 24 patients with acute intracerebral hemorrhage between October 2021 to May 2022 at a stroke center. Patients were 30 to 70 years of age and had a hematoma volume >15 cm3 and National Institutes of Health Stroke Scale score >1. The patients underwent imaging 3×: within 12 to 24 (T1), 36 to 48 (T2), and 60 to 72 (T3) hours of last seen well on a 3T magnetic resonance imaging system. Three-dimensional anatomic, multigradient echo and 2-dimensional diffusion tensor images were obtained. Hematoma and edema volumes were calculated, and the distribution of coagulation was measured by dynamic changes in the susceptibilities and fractional anisotropy within the hematoma. Using a coagulated blood phantom, we demonstrated a linear relationship between the percentage coagulation and susceptibility (R2=0.91) with a positive red blood cell stain of the clot. The quantitative susceptibility maps showed a significant increase in hematoma susceptibility (T1, 0.29±0.04 parts per millions; T2, 0.36±0.04 parts per millions; T3, 0.45±0.04 parts per millions; P<0.0001). A concomitant increase in fractional anisotropy was also observed with time (T1, 0.40±0.02; T2, 0.45±0.02; T3, 0.47±0.02; P<0.05). This quantitative neuroimaging study of coagulation within the hematoma has the potential to improve patient management, such as safe resumption of anticoagulants, the need for reversal agents, the administration of alteplase to resolve the clot, and the need for surgery.

Restarting anticoagulation after chronic subdural hematoma neurosurgical evacuation: a prospective observationaL

Abstract Introduction Management of anticoagulation (AC) in patients with chronic subdural hematoma (cSDH) lacks evidences, with uncertainties regarding outcomes after neurosurgical intervention. In patients with atrial fibrillation the interruption of an anticoagulant therapy can be a risk of thromboembolic event within the first 90 days. Purpose We aimed to define safety and effectiveness of AC resumption in a single center cohort undergoing neurosurgical intervention for cSDH. Methods Consecutive patients undergoing neurosurgical intervention for evacuation of cSDH and taking anticoagulants due to atrial fibrillation were included and followed-up over time (3 to 30 months) to define evolution of cSDH thickness depending on AC restart. Secondary outcomes included: (i)ischemic stroke and major bleeding (including intracerebral hemorrhage, ICH), assessed at each visit, and (ii) recurrent cSDH needing neurosurgical re-intervention. Results Overall, we included 47 consecutive patients, mean age 82.5±7.8 years. Previous trauma emerged in 68% of cases. Patients received warfarin (n=30, 64%), low molecular weight heparin (LMWH, n=6, 13%) or direct oral anticoagulants (DOAC, n=11, 23%). Oral AC was stopped before neurosurgery (7.9±16.7 days before intervention), and 42 (89%) underwent AC reversal. Mean cSDH thickness was 2.3±0.6 cm, midline shift was detected in 94% of patients. All patients survived surgical procedure and completed a minimum of 3-month follow-up. Over a mean 8-month follow-up (range 3-29), cSDH thickness substantially decreased (baseline 2.3±0.6 cm vs follow-up 0.7±0.6 cm, p&amp;lt;0.001). Restarting anticoagulation after chronic subdural hematoma neurosurgical evacuation: a prospective observational. Overall, 26 patients (55.3%) restarted AC, 15 with DOAC, 8 with warfarin, 3 with LMWH. Compared to no AC, AC resumption was not associated with changes in cSDH thickness (0.7±0.7 cm vs 0.9±0.6 cm, p=0.4) or modified Rankin scale at follow-up (2.6±1 vs 2±1.3, p=0.3). Four patients restarting AC had cSDH recurrence requiring re-intervention vs 0 in those avoiding AC (p=0.11); 3 of 4 were post-traumatic. No peri-interventional complications occurred. No ischemic stroke or major bleeding was detected during AC withdrawal. Conclusions The study has obviously limitations due to its preliminary nature. Even though, resumption of anticoagulation after neurosurgical intervention for cSDH seems safe, with no significant increase in recurrence rate and cSDH width over time. Longitudinal data from prospectively collected larger cohorts are needed to guide management.

Outcomes with oral anticoagulation resumption or discontinuation after an anticoagulation-related event in patients with atrial fibrillation

Abstract Background There are uncertainties on the resumption of anticoagulation therapy in patients with non-valvular atrial fibrillation who experience a thrombotic or haemorrhagic event while on oral anticoagulation. Purpose We assessed the cumulative incidence of recurrent stroke, major bleeding and all-cause mortality associated with restarting antithrombotic treatment, after stroke or major bleeding during anticoagulation therapy for atrial fibrillation. Methods We included anticoagulated patients with atrial fibrillation that were discharged (2013-2020) from hospital for stroke, intracranial haemorrhage (ICH), and major bleeding. To adjust for competing risk of death and reduce confounding, we started the follow up after 120-days blanking period, counting events in patients resuming oral anticoagulation versus those that did not. Risks of all-cause mortality, thromboembolism, intracranial haemorrhage, and major bleeding were estimated with multivariable Cox proportional hazard models and propensity score to adjust for differences in baseline characteristics. Results 1029 patients (mean age 77 years) were included in the final cohort: 23% were ischemic stroke, 18% were ICH, and 59% major bleeding; of these, 77% resumed anticoagulation. Among patients with stroke as the index event (92% resumed anticoagulation) the cumulative incidence of events was significantly lower in patients resuming therapy (HR 0.2, 95%CI 0.1-0.4, p&amp;lt;0.01). In patients with ICH (64% resumed therapy) the cumulative incidence of events was lower in patients resuming anticoagulation (HR 0.4, 95%CI 0.2-0.7, p&amp;lt;0.01). Same was true for patients with major bleeding, with patients resuming therapy (76%), experiencing fewer events (HR 0.5, 95%CI 0.2-0.7, p&amp;lt;0.01). In the multivariable analysis considering age, sex and propensity score as covariates, resumption of anticoagulation significantly reduced the cumulative event rate (HR 0.5, 95%CI 0.4-0.6, p&amp;lt;0.01). Conclusion In patients with atrial fibrillation who experienced an anticoagulation-related event, resuming oral anticoagulation was associated with better outcomes for all-cause mortality and subsequent events as compared with patients who did not resume treatment.Stacked Area Charts and Cox regression

Tranexamic Acid for Bleeding Management in Adult Patients on Extracorporeal Membrane Oxygenation.

This study described the outcomes of patients receiving topical, nebulized, endobronchial, or systemic tranexamic acid (TXA) for bleeding events while on extracorporeal membrane oxygenation (ECMO). We performed a single-center case series including adult patients >18 years old supported on either venovenous (VV) or venoarterial (VA) ECMO from January 1, 2014, to April 21, 2021. The primary outcome was hemostatic control defined as a composite of initial cessation of therapeutic interventions to mitigate bleeding or resumption of anticoagulation if previously held. Secondary outcomes included changes in transfusion requirements and lysis at 30-minute (LY30) values, venous thromboembolism (VTE) events, and seizures. In total, 47 patients were included for full analysis. There were 19 patients with surgical bleeds, 18 patients with medical bleeds, and 10 patients with multiple bleeds. Overall, initial hemostatic control was achieved in 79%, 67%, and 90% of patients, respectively. Pre- and post-TXA transfusion requirements were not significantly different ( p = 0.2), although the intraindividual change in median LY30 was -5.1% compared with baseline (95% confidence interval [CI], -12.4% to -1.5%, p = 0.005). The occurrence of VTE and seizures was relatively low and similar among patient bleeding groups. Tranexamic acid provided initial hemostatic control in roughly three quarters of patients with bleeding events on ECMO and side effects were infrequent.

ISCHEMIC STROKE AND MAJOR BLEEDING WHILE ON DIRECT ORAL ANTICOAGULANTS IN NAÏVE PATIENTS WITH ATRIAL FIBRILLATION: IMPACT OF RESUMPTION OR DISCONTINUATION OF ANTICOAGULANT TREATMENT. A population-based study.

AimsWe assessed the cumulative incidence of recurrent stroke, major bleeding and all-cause mortality associated with restarting antithrombotic treatment, in patients experiencing an anticoagulation-related event (stroke or major bleeding), occurred during anticoagulation therapy for AF.Methods and Results.We performed a retrospective population-based analysis on linked claims data of patients resident in the Veneto Region, treated with DOACs for AF and discharged (2013−2020) from the hospital for stroke, intracranial haemorrhage (ICH), and major bleeding. To adjust for competing risk of death and reduce confounding, we started the follow up after a 120-days blanking period, counting events in patients resuming oral anticoagulation versus those that did not. Risks of all-cause mortality, ischemic stroke (IS)intracranial haemorrhage (ICH), and other major bleeding events (MB) were estimated with multivariable Cox proportional hazard models and propensity score to adjust for differences in baseline characteristics. Overall, 1029 patients (mean age 77 years) were included in the final cohort: 23% experienced an IS, 18% an ICH, and 59% MB. Of these, 77% resumed anticoagulation. The cumulative incidence of events was significantly lower in patients resuming therapy. In the multivariable analysis considering age, sex and propensity score as covariates, resumption of anticoagulation significantly reduced the risk of a cumulative event (HR 0.45, 95%CI 0.35–0.57, p < 0.01). Stratifying for the index event, among patients with IS (92% resumed therapy), we observed a risk reduction of 81%; in patients with ICH (64% resumed therapy), we observed a risk reduction of 64% and for patients with MB (76% resuming therapy), we observed a risk reduction of 49%. ConclusionsIn patients with AF who experienced an anticoagulation-related event, resuming oral anticoagulation was associated with better outcomes for all-cause mortality and subsequent events as compared with patients who did not resume treatment.

Resumption of oral anticoagulation in patients with non-valvular atrial fibrillation after intracerebral hemorrhage: A sub-analysis of the PASTA registry study

PurposeTo investigate the rate and timing of oral anticoagulant (OAC) resumption and its safety in patients after intracerebral hemorrhage (ICH) in current clinical practice in Japan. MethodsWe conducted a sub-analysis of the PASTA registry, an observational, multicenter registry of 1043 patients with stroke receiving OACs in Japan, by including patients with ICH on OAC treatment for non-valvular atrial fibrillation (NVAF). The clinical characteristics of the patients in the resumption and non-resumption groups, rate and timing of OAC resumption, its safety, and switching of OACs after ICH were investigated. ResultsOf the 160 patients (women, n = 52; median age, 77 years) included, OACs were resumed in 108 (68%) at a median of 7 days (interquartile range, 4–11) after acute ICH onset. The non-resumption group had higher rates of hematoma expansion (21.2% vs. 7.4%; P = 0.0118) and modified Rankin Scale (mRS) scores at discharge (4 (Suda et al., 2019; Steiner et al., 2014 [3, 4]) vs. 4 (Suda et al., 2019; Steiner et al., 2014; Pasquini et al., 2014 [3–5]); P = 0.0302}. The resumption rate in the mRS 0–4 group was higher than that in the mRS 5 group (75.2% vs. 46.5%; P = 0.00006). The number of days to resumption after ICH onset was longer in the mRS 5 than that in the mRS 0–4 group (median 12 days vs. 7 days, P = 0.0065). There were no significant differences in new-onset ICH, symptomatic hematoma expansion, or gastrointestinal bleeding between groups (P > 0.05). ConclusionsEarly resumption of OAC for NVAF in patients after ICH appeared to be safe. Expected functional outcomes at discharge were associated with OAC resumption and with the timing of resumption. Registrationhttps://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000034958

Resumption of Anticoagulation in Patients with Gastrointestinal Bleeding: A Look into the If and When

Resumption of Anticoagulation in Patients with Gastrointestinal Bleeding: A Look into the If and When

Reduction in thrombolytic order‐to‐needle time with addition of a pharmacist to a pulmonary embolism response team

AbstractIntroductionPulmonary embolism (PE) is the third most common cause of cardiovascular death in the United States. Institutions have implemented pulmonary embolism response teams (PERT) to hasten clinical decision making and therapeutic interventions. The extent to which critical care pharmacists are included in PERTs is not known. Although improved outcomes with pharmacist involvement in other emergency response teams (e.g., stroke teams) is well described, literature surrounding the impact of pharmacist inclusion in PERTs is limited. The objective was to evaluate if direct pharmacist inclusion in a PERT resulted in reduced time to systemic thrombolysis from time of medication order release in appropriate PE candidates.MethodsThis was a retrospective, observational study of patients with submassive or massive PE who received systemic thrombolysis at a large academic medical center. Patients were divided into two groups based on if they received systemic thrombolysis before or after the intervention. This intervention was the addition of a pharmacist to the PERT with emphasis on early communication between the PERT pharmacist and other stakeholders at time of PERT activation, and a revised thrombolytic preparation workflow emphasizing bedside preparation by the pharmacist. The primary outcome was time to administration of thrombolytic from time of medication order release.ResultsThirty‐four patients were included. Median time to thrombolytic administration was reduced in the post‐intervention group compared to the pre‐intervention group (23 min [14.8–42] vs. 54 min [42.8–69], p = 0.007). Bleeding events were not different between groups. Time to resumption of systemic anticoagulation after systemic thrombolysis was greater in the post‐intervention group.ConclusionInclusion of a pharmacist in the PERT at this institution significantly reduced time to administration of systemic thrombolysis from time of medication order release in appropriate PE candidates. Larger studies should be conducted to expand upon and confirm these findings.

No Association between Gastrointestinal Rebleeding and DOAC Therapy Resumption: A Systematic Review and Meta-Analysis.

There are recommendations for anticoagulation resumption after gastrointestinal bleeding (GIB), although data addressing this topic by direct oral anticoagulants (DOACs)-treated patients is lacking. We aim to determine the safety and efficacy of restarting DOACs after GIB. Studies that reported rebleeding, thromboembolic events, and mortality after restarting or withholding DOACs were selected. The systematic research was conducted in five databases (MEDLINE, EMBASE, CENTRAL, Web of Science, and Scopus). The random effect model was implemented to calculate the pooled odds ratio (OR). The ROBINS-I tool was used for risk of bias assessment, and the certainty of the evidence was evaluated with the GRADE approach. Four retrospective cohort studies (1722 patients) were included in the meta-analysis. We did not find a significant increase in the risk of rebleeding in patients restarting DOACs after index GIB (OR = 1.12; 95% CI: 0.74-1.68). The outcomes of thromboembolic events and mortality data were not suitable for meta-analytic calculations. Single studies did not show statistically significant differences. Data quality assessment showed a serious overall risk of bias and very low quality of evidence (GRADE D). DOAC resumption after a GIB episode may not elevate the risk of rebleeding. However, the need for high-quality randomized clinical trials is crucial.

Abstract TMP83: Optimal Timing For Resumption Of Anticoagulation After Intracranial Hemorrhage In Patients With Mechanical Heartvalves

Introduction: Anticoagulation in patients with acute intracranial hemorrhage (ICH) and mechanical heart valves (MHV) is often held to mitigate the risk of ICH expansion or recurrence; however there exists a competing risk of acute ischemic stroke (AIS). Optimal timing to resume anticoagulation after ICH remains uncertain. Methods: We retrospectively studied ICH patients with MHV at two academic hospitals from April, 2000-August, 2018. The primary outcome was a composite endpoint of symptomatic hematoma expansion or new ICH, AIS, and intracardiac thrombus up to 30 days post-ICH. The exposure was timing of re-initiation of anticoagulation classified as early if therapeutic anticoagulation was resumed up to 7 days after ICH; late if ≥7 and up to 30 days after ICH; and never if not resumed or resumed after 30-days post-ICH. Cox proportional hazard models were built adjusted for age, sex, and covariates significantly different in univariate analysis at a pre-specified p-value threshold of 0.05. Results: We identified 184 patients with ICH and MHV (65 anticoagulated early, 100 resumed late, 19 not resumed by day 30 post-ICH). We observed 12 AIS, 16 new ICH, and 6 intracardiac thromboses. The mean time from ICH to anticoagulation in the cohort was 12.7 days. Patients resumed early versus late were more likely to have atrial fibrillation (62% versus 42%), and less likely to be reversed (75% versus 94%), to undergo hematoma evacuation (23% versus 43%), have midline shift (27% versus 52.9%), and to have intracerebral involvement (26% versus 49%). There was no significant difference in the hazard of AIS, new or symptomatic ICH expansion, or the composite outcome among those resumed early versus late. Patients not resumed within 30 days post-ICH had a significantly higher risk of AIS compared to those resumed within 30 days (HR 15.9; 95% C.I.1.9-129.7, p=0.0098). Discussion: In this study of ICH patients with MHV, there was no difference in the 30-day thrombotic and hemorrhagic brain-related outcomes in patients anticoagulated within 7 days versus 7-30 days. Withholding anticoagulation within the first 30 days was associated with a significantly higher risk of AIS. Our findings provide a discrete time window to guide resumption of anticoagulation in MHV patients with ICH.

Thrombosis in hereditary hemorrhagic telangiectasia

Thrombosis in hereditary hemorrhagic telangiectasia

Management of Anticoagulation Therapy in ECMO-Associated Ischemic Stroke and Intracranial Hemorrhage.

Despite the common occurrence of extracorporeal membrane oxygenation (ECMO)-associated acute ischemic stroke (AIS) and intracranial hemorrhage (ICH), there are little data to guide optimal anticoagulation management. We sought to describe antithrombotic therapy management after stroke and outcomes. A retrospective analysis was conducted of venoarterial (VA) and venovenous (VV) ECMO patients treated at a tertiary care center from June 2016 to February 2021. Patients with image-confirmed diagnosis of AIS or ICH while receiving ECMO were included for study with data collected regarding anticoagulation management and clinical outcomes. Overall, 216 patients (153 VA-ECMO, 63 VV-ECMO) were included in this study. Of the 153 patients on VA-ECMO, 13 (8.4%) had AIS and 6 (3.9%) had ICH. Of the 63 patients on VV-ECMO, none had AIS and 5 (7.9%) had ICH. One patient (9%) received anticoagulation reversal after ICH. Anticoagulation was discontinued and later resumed in all 5 ICH survivors (median cessation time, 30 h) and 1 of 2 (50%) AIS survivors (median cessation time, 96 h). While off anticoagulation, 2 of 11 patients (18%) had thromboembolic events and none had new AIS. Upon resumption, there were no cases of hemorrhagic transformation of AIS or ICH expansion. There was no difference in in-hospital mortality between patients with ICH and those without in both the VA-ECMO and VV-ECMO cohorts nor between VA-ECMO patients with AIS and those without. Early cessation and judicious resumption of anticoagulation appeared feasible in the cohort of patients with ECMO-associated AIS and ICH.

Bromelain-based enzymatic debridement in hand burns – an easier way to manage a difficult patient: case report

Introduction. Bromelain-based enzymatic debridement may be considered the standard in patients with upper extremity burns management, regarding the low risk of bleeding, wound infections, reduction of surgical timing, and the decreased risk of compartment syndrome development. Case presentation. We present the case of hand and face burns in a patient presenting deep venous thrombosis of the lower limb extended to the level of the vena cava, and bilateral pulmonary embolism. The enzymatic debridement reduced periprocedural bleeding and allowed a faster recovery and therefore the resumption of oral anticoagulation and antiplatelet medication in a patient with important cardiac, arterial, and renal comorbidities. Conclusion. Bromelain-based enzymatic debridement use is recommended in patients presenting upper limb deep burns, especially in anatomically challenging areas, like hand fingers, and especially in those with a previous medical history that predisposes them to periprocedural bleeding and increased risk of poor healing.