Resumption Of Oral Anticoagulation Research Articles

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<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<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<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<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

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

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.

CE-539-02 UTILIZATION OF ORAL ANTICOAGULATION AFTER BLEEDING EVENTS IN STROKE PATIENTS WITH ATRIAL FIBRILLATION

Oral anticoagulation (OAC) is recommended for stroke prophylaxis after diagnosis of atrial fibrillation (AF). However, the optimal strategy or timing for continuing OAC use after bleeding events in these patients has not been well established. This analysis seeks to characterize real-world patterns of OAC utilization after bleeding events in patients with prior ischemic stroke and diagnosed AF. Patients with a diagnosis code for a bleeding event between 1/01/2007-3/31/2021 were identified in the U.S. de-identified Optum® Clinformatics® claims database. Bleed events were identified based on the presence of an ICD-9/-10 diagnosis code for bleeding in any site of service, and included: hemorrhagic stroke (HS), other intracranial hemorrhage (ICH), or extracranial hemorrhage (ECH). Patients were required to have any prior evidence of AF diagnosis, and must have OAC prescription coverage within the 3 months prior to the index bleed event. Kaplan-Meier curves were created to estimate the rate at which OACs were restarted after index for each bleed type, including all available follow-up time in the database for each patient. A total of 44,207 patients were identified: 7,755 patients with HS, 781 with ICH, and 35,671 with ECH. After HS, an estimated 26% of patients resumed OAC early, within 30 days of the bleed event; 45% restarted later (36% between 30 days-1 year, 9% after 1 year), and the remaining 29% permanently discontinued. Overall, the median time to refill was 3.1 months. After an Other ICH event: 36% resumed early, 42% restarted later (36% within 1 year and 6% after 1 year), and 22% discontinued; median time to refill was 1.9 months. After ECH: 42% resumed early, 48% restarted later (40% within 1 year and 8% beyond 1 year), with 10% discontinuing; median time to refill was 1.4 months. Although the risk-benefit profile of OAC resumption after bleeding events in AF patients has not been definitively characterized to-date, our analysis of a large claims database indicates that resumption of OAC after bleeding is common in clinical practice, with 71%-90% of patients either continuing or restarting after a brief pause. Upcoming randomized trials aim to provide more information in this space and may enable development of a clearer clinical consensus.

Effectiveness and Safety of Restarting Oral Anticoagulation in Patients with Atrial Fibrillation after an Intracranial Hemorrhage: Analysis of Medicare Part D Claims Data from 2010-2016.

In patients with atrial fibrillation (AF) who survive an anticoagulant-related intracranial hemorrhage (ICH), the benefits of restarting oral anticoagulation (OAC) remain unclear. In this study, we sought to determine the effectiveness and safety associated with resumption of OAC in atrial fibrillation patients who survive an ICH. Using 2010-2016 Medicare claims data, we identified patients with non-valvular AF who experienced an OAC-related ICH and survived at least 6weeks after the ICH (n=1502). The primary outcomes included the composite of ischemic stroke and transient ischemic attack (TIA), thromboembolism (TE), a composite of ischemic stroke/TIA and TE, recurrent ICH, and all-cause mortality. We constructed Cox proportional hazard models to evaluate the association between post-ICH OAC resumption, which was measured in a time-dependent manner, and the risk of primary outcomes, while controlling for a comprehensive list of covariates. Among patients who survived an ICH, 69% reinitiated OAC within 6weeks of the event, and among those who resumed OAC, 83% restarted warfarin. There was no significant difference in the risk of ischemic stroke/TIA (hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.62-1.21), TE (HR 0.85, 95% CI 0.55-1.32), and ischemic stroke/TIA/TE (HR 0.81, 95% CI 0.61-1.07) between post-ICH OAC use and non-use. Post-ICH OAC use was associated with a lower risk of recurrent ICH (HR 0.62, 95% CI 0.41-0.95) and all-cause mortality (HR 0.48, 95% CI 0.37-0.62) compared with non-OAC use. In AF patients who survived an ICH, restarting OAC was not associated with a greater risk of recurrent ICH. Evidence from randomized controlled studies is needed to further clarify the clinical benefit of restarting OAC in this high-risk population. Further evaluation of which individuals benefit from restarting OAC is also needed to provide more clinical guidance.

288Thrombotic events in bleeding patients treated with andexanet alpha: an ANNEXA-4 sub-study

Abstract Background/Introduction Andexanet alfa (“andexanet”) was developed as a specific reversal agent for patients with major bleeding while using factor Xa (FXa) inhibitors. While thrombotic events (TEs) have been reported in patients receiving andexanet, the scope, nature, and timing of these events have not been fully characterized. Purpose The ANNEXA-4 study was a prospective, single-arm, open-label clinical trial that evaluated the safety and efficacy of andexanet in patients with acute major bleeding. In this secondary analysis, the occurrence of TEs was investigated. Methods Patients presenting with acute major bleeding within 18 hours after their last dose of FXa inhibitor were treated with andexanet. Safety outcomes, including TEs (reviewed by an adjudication committee), were evaluated at 30 days. Results Among 352 patients treated with andexanet, 34 (9.7%) experienced one or more TEs (Table). Strokes and deep vein thromboses were the most frequent TE types. Compared to patients with arterial TEs, patients with venous TEs were more likely to have been originally anticoagulated for venous thromboembolism. Median time to first TE was 10.5 days (Figure); time to event was shorter for arterial TEs than for venous TEs. TEs were nonfatal for most patients. Subgroups by age, bleed type, baseline anti-fXa activity, FXa inhibitor dose, and andexanet dose were not associated with the occurrence of TEs. Of the 34 TE patients, 26 (76.4%) had TEs before restart of any (full or prophylactic) anticoagulation; all first TEs occurred in patients not receiving oral anticoagulation. No TEs occurred after resumption of oral anticoagulation (N=100). Table 1. Thrombotic event characteristics Characteristic Result (n/N [%]) TE type Strokes 14/352 (4.0%) Deep vein thromboses 13/352 (3.7%) Myocardial infarctions 7/352 (2.0%) Pulmonary embolisms 5/352 (1.4%) Transient ischemic attacks 1/352 (0.3%) Bleed type Intracranial 23/227 (10.1%) Gastrointestinal 7/90 (7.8%) Other 4/35 (11.4%) Arterial TEs Anticoagulated for AF 17/22 (77.3%) Anticoagulated for VTE 6/22 (27.3%) Venous TEs Anticoagulated for AF 11/18 (61.1%) Anticoagulated for VTE 8/18 (44.4%) Median time to first TE 10.5 days Arterial 6 days Venous 15 days Outcome Fatal 7/34 (20.6%) Nonfatal 27/34 (79.4%) AF = atrial fibrillation; n = number of patients with TEs; N = total number of patients for each characteristic; TE = thrombotic event; VTE = venous thromboembolism. Figure 1. Thrombotic Events Over Time Conclusions In patients with FXa inhibitor-associated acute major bleeding treated with andexanet, TEs occurred a rate not unexpected given the high thrombotic risk of the population. No factors predictive of TEs were identified. Resumption of anticoagulation was associated with fewer TEs. Acknowledgement/Funding Study funded by Portola Pharmaceuticals, Inc.

Management of oral anticoagulation related intracerebral hemorrhage

The incidence of intracerebral hemorrhage(ICH) in patients using oral anticoagulation(OAC) will continue to increase with the demographic change of an aging population. As compared to primary spontaneous ICH, OAC-ICH is characterized by larger hematoma volumes, more frequent hematoma enlargement and intraventricular hemorrhage resulting in an even worse prognosis. Specific treatment should focus on immediate reversal of anticoagulation in addition to the basic acute management of ICH. In ICH patients using vitamin K antagonists(VKA), complete anticoagulant reversal with an international normalized ratio(INR) <1.3 should be achieved as quickly as possible using prothrombin complex concentrate(PCC) with additional substitution of vitamin K. Patients with ICH under dabigatran treatment should receive idarucizumab. In ICH patients using factor-Xa inhibitors, andexanet should be administered as soon as approved in Europe or within clinical studies and if unavailable alternatively high-dose PCC administration. Regarding OAC resumption, results from randomized trials are pending. In comprehensive observational studies and meta-analyses ICH patients resuming OAC showed a reduced incidence of thromboembolic events and mortality without significantly increased rates of hemorrhagic complications. Non-vitamin K dependent oral anticoagulants(NOAC) might further increase the safety of OAC resumption, which should be initiated after 4-8weeks for patients with atrial fibrillation. In contrast, VKA resumption in patients with mechanical heart valves should not take place earlier than 1 week after ICH. Generally, safety of OAC resumption appears to be affected by ICH localization along with the presence of cerebral microbleeding, cortical superficial siderosis and cortical/convexity subarachnoid hemorrhage, making it crucial to weigh up the individual patient risk with respect to thromboembolic versus hemorrhagic events.

Abstract P023: Predictors of Oral Anticoagulation Resumption Among Atrial Fibrillation Patients Surviving an Intracranial Hemorrhage

Background: The clinical benefit of resuming oral anticoagulation (OAC) in atrial fibrillation (AF) patients who have survived an intracranial hemorrhage (ICH) remains unclear. It is important to understand what patient characteristics affect whether patients are restarted on OAC after an ICH. Hypothesis: We hypothesized that younger patients, those without chronic kidney disease, and at high stroke risk would be more likely to restart OAC. Methods: Using claims data from a 5% random sample of Medicare beneficiaries, we selected patients with a diagnosis of non-valvular AF who experienced an ICH while using OAC (n=4,822). The primary outcome was OAC resumption at 12 weeks after ICH. Among patients who restarted OAC, we further evaluated the likelihood of resuming warfarin versus direct oral anticoagulants (DOACs). We constructed multivariate logistic regression to evaluate the association between a comprehensive list of demographics and clinical characteristics (list in table) and OAC resumption. Results: Among the 4,822 patients, 1,766 (37%) restarted OAC during the first 12 weeks. Among them, 280 (16%) started direct oral anticoagulants, and 1,486 (84%) started warfarin. Younger patients, those eligible for Medicaid, with a previous ischemic stroke and higher CHA 2 DS 2 -VASc score were more likely to restart OAC (Table). Among participants who resumed OAC in 12 weeks, patients with a history of ischemic stroke were less likely to use DOACs; however, those with a higher risk of bleeding, measured by HAS-BLED score, were more likely to use them. Conclusion: Around 35% of AF patients who survived an ICH restarted OAC within 12 weeks of the ICH, and, among them, most used warfarin. Although a history of ischemic stroke increased the odds of OAC resumption, it decreased the odds of using DOACs.

GEOGRAPHIC VARIATION IN ORAL ANTICOAGULATION RESUMPTION AFTER INTRACRANIAL BLEEDING

We sought to evaluate geographic variation in the resumption of oral anticoagulation (OAC) among patients with non-valvular atrial fibrillation (NVAF) who survived an intracranial hemorrhage (ICH). Using Medicare claims data, we identified patients with NVAF who had an ICH in 2006-2016, and

TIMING AND PREDICTORS OF ORAL ANTICOAGULATION RESUMPTION AFTER ANTICOAGULATION RELATED INTRACRANIAL HEMORRHAGE

For patients with atrial fibrillation (AF) who have survived an intracranial hemorrhage (ICH), whether or not they should resume oral anticoagulation (OAC) remains unclear. We evaluated what patient characteristics increase the likelihood of OAC resumption after an ICH. We used 2006-2016 claims

Management of oral anticoagulation after intracerebral hemorrhage.

The most recent years have significantly expanded knowledge regarding risks and benefits of resuming oral anticoagulation (OAC) after intracerebral hemorrhage (ICH). No randomized data is yet available, though several large observational studies and meta-analyses have investigated the impact of resuming OAC on thromboembolic versus hemorrhagic complications in these high-risk patients after ICH. The present review will summarize the most important studies conducted over the last years and will focus on relevant factors help guiding on decision-making on whether to start OAC after ICH. Several important factors (demographic, co-morbidities, clinical characteristics) need to be considered before individual decision-making for or against OAC is employed. Existing observational data suggest that patients after ICH with indication for long-term oral anticoagulation benefit from OAC given significant reductions of thromboembolic events without significantly increasing bleeding complications. Studies even suggest that thereby also clinical outcomes may be improved. Prospective trials currently recruiting patients will clarify whether OAC after ICH - or left atrial appendage closure as a meaningful alternative - is of clinical net-benefit. Large sized and well-executed investigations (moderate quality of evidence) are showing that OAC resumption after ICH decreases thromboembolic complications and long-term mortality without significantly increasing bleeding complications. Further, data suggest that resumption may be safer in non-lobar ICH compared to lobar ICH, but overall, thoughtful selection, strict blood pressure control, and precise communication are paramount before starting a patient on OAC after ICH.

Noninterventional Treatment Options for Stroke.

Given the need for early restoration of blood flow and preservation of partially damaged brain cells after ischemic stroke, the noninterventional treatment of stroke relies heavily on the speedy recognition and classification of the clinical syndrome. Initiation of systemic thrombolysis with careful observation of contraindications within the 3.0 (4.5)-hour time window is the approved therapy of choice. Management of hemorrhagic complications and resumption of oral anticoagulation if indicated are also discussed in this article.

Anticoagulation for atrial fibrillation after intracranial hemorrhage: A systematic review.

We summarize the existing evidence on the potential benefit of oral anticoagulation (OAC) in intracerebral hemorrhage (ICH) survivors with nonvalvular atrial fibrillation (NVAF). Systematic review of the literature to address the following issues: (1) prevalence of NVAF in ICH survivors, (2) current prescription of OAC, (3) factors associated with resumption of OAC, (4) risk of ischemic stroke (IS) and recurrent ICH, and (5) ideal timing for restarting OAC in ICH survivors with NVAF. After screening 547 articles, 26 were included in the review. Only 3 focused specifically on patients with ICH as primary event, NVAF as indication for OAC, and recurrent ICH and IS as primary endpoints. In addition, 19 letters to the editor/reviews/editorials/experts' surveys/experts' opinion were used for discussion purposes. NVAF is highly prevalent among ICH survivors. The risks of IS, recurrent ICH, and mortality are heightened in this group. Most published data show a net benefit in terms of IS prevention and mortality when anticoagulation is restarted. However, those studies are observational and mostly retrospective, therefore selection bias may play a major role in the results observed in these cohorts. Only randomized controlled trials, either pragmatic or explanatory, can provide more conclusive answers for this important clinical question.

Abstract TP349: Clinical Outcomes of Direct Oral Anticoagulants versus Warfarin in Patients With Atrial Fibrillation Who Have Had an Intracerebral Hemorrhage

Introduction: It has recently been demonstrated in a meta-analysis that patients with a history of intracerebral hemorrhage (ICH) and atrial fibrillation have a reduced risk of ischemic stroke (IS) with the initiation or resumption of oral anticoagulation (OAC). It remains uncertain if there is a difference in clinical outcomes between direct oral anticoagulants (DOAC) compared to warfarin (WF) in this patient population. We aimed to compare these two populations using data from the Southern California Kaiser Permanente (SCKP) health care system. Methods: Patient records with ICH and AF diagnosis were obtained from the SCKP Database, and divided into two cohorts: WF or DOAC. Subjects were included if the OAC was started after the index ICH. CT scans within 24 hours of symptom onset were examined for: ICH location, ICH size (Using the ABC/2 method), and leukoariosis. If available, an axial gradient echo sequence MRI scan taken within 180 days, either before or after the index ICH was examined for microbleeds. Differences in demographics, concurrent medications with an antithrombotic effect and statins, and traditional vascular risk factors were assessed using Kruskal-Wallis and Chi-Square tests. Results: Eighty-one subjects were identified (53 WF and 28 DOAC). In the DOAC group, 18 patients were on dabigatran, 9 on apixaban and 1 on rivaroxaban. There was no difference between WF and DOAC in baseline demographics, concurrent medications and location of ICH. The mean ICH volume was 15.4cc in DOAC and 5.6cc in WF (P=0.09). Time to start drug from ICH was 15.0 and 24.5 months for DOAC and WF respectively (P=0.26). More patients died in WF (28.3%) vs DOAC (10.7%) (P=0.0478). There was no difference in time to IS, ICH and major hemorrhage between the two groups. The composite outcome of IS, ICH, Major Hemorrhage and death was 35.8 % in WF vs 25% in DOAC group (P=0.32). Conclusion: Our results, while limited in size, suggest that patients with a previous ICH with AF, who are started on a DOAC have lower mortality compared to WF. There was a higher percentage of patients in the WF group who met the composite outcome of IS, ICH, major hemorrhage and death, but this did not reach statistical significance.

Resumption of oral anticoagulation following traumatic injury and risk of stroke and bleeding in patients with atrial fibrillation: a nationwide cohort study.

We examined the risks of all-cause mortality, stroke, major bleeding, and recurrent traumatic injury associated with resumption of vitamin K antagonists (VKAs) and non-VKAs oral anticoagulants (NOACs) following traumatic injury in atrial fibrillation (AF) patients. This was a Danish nationwide registry-based study (2005-16), including 4541 oral anticoagulant (OAC)-treated AF patients experiencing traumatic injury (defined as traumatic brain injury, hip fracture, or traumatic torso or abdominal injury). Within 90 days following discharge from traumatic injury, 60.6% resumed VKA (median age = 80, CHA2DS2-VASc = 4, HAS-BLED = 2), 16.7% resumed NOAC (median age = 81, CHA2DS2-VASc = 4, HAS-BLED = 2), and 22.7% did not resume OAC treatment (median age = 81, CHA2DS2-VASc = 4, HAS-BLED = 3). Switch from VKA to NOAC occurred among 9.5%. Since 2009, the trend in OAC resumption increased (P-value <0.0001), in particular with NOACs (P-value <0.0001). Follow-up started 90 days after discharge, and time-varying multiple Cox regression analyses were used for comparisons. Compared with non-resumption, VKA and NOAC resumption were associated with lower hazard [95% confidence interval (CI)] of all-cause mortality [hazard ratio (HR) 0.48 (0.42-0.53) and HR 0.55 (0.47-0.66), respectively] and ischaemic stroke [HR 0.56 (0.43-0.72) and HR 0.54 (0.35-0.82), respectively], increased major bleeding hazard [HR 1.30 (1.03-1.64) and HR 1.15 (0.81-1.63), respectively], and similar hazard of recurrent traumatic injury [HR 0.93 (0.73-1.18) and HR 0.87 (0.60-1.27), respectively]. AF patients resuming VKA and NOAC treatment following traumatic injury have lower hazard of all-cause mortality and ischaemic stroke, increased hazard of major bleeding but without additional hazards of recurrent traumatic injury. Withholding OAC following a traumatic injury in AF patients may not be warranted.

Resumption of Oral Anticoagulation after Intracerebral Hemorrhage is Associated with Decreased Mortality and Favorable Functional Outcome

Resumption of Oral Anticoagulation after Intracerebral Hemorrhage is Associated with Decreased Mortality and Favorable Functional Outcome

Resumption of Oral Anticoagulation after Intracerebral Hemorrhage is Associated with Decreased Mortality and Favorable Functional Outcome (CCI.003)

Resumption of Oral Anticoagulation after Intracerebral Hemorrhage is Associated with Decreased Mortality and Favorable Functional Outcome (CCI.003)

Timing of anticoagulant re-initiation following intracerebral hemorrhage in mechanical heart valves: Survey of neurosurgeons and thrombosis experts

BackgroundWhile oral anticoagulation (OAC) is universally indicated for patients with mechanical heart valves (MHVs), OAC resumption following anticoagulant-associated intracerebral hemorrhage (ICH) is an area of uncertainty. We sought to determine the practice preferences of North American neurosurgeons and thrombosis experts on optimal timing of OAC re-initiation. MethodsA cross-sectional survey was disseminated to North American members of the American Association of Neurological Surgeons and the International Society for Thrombosis and Haemostasis. Demographic factors, as well as a clinical scenario with 14 modifiable clinical risk factors were included in the survey. Results504 physicians completed our survey (response rate 34.3%). Majority of participants were affiliated with academic centres, and managed≤10 ICH patients with MHV per year. There was wide distribution in response in optimal timing for OAC resumption following an ICH: 59% and 60% preferred to re-start OAC between 3 and 14 days following the hemorrhagic event (median of 6–7 days). Smaller hemorrhages (<30cm2). CHADS2 score ≥2, concomitant venous thromboembolism, mitral valve prosthesis, caged-ball valves and multiple valves prompted earlier OAC resumption. ConclusionWide variation in the current practice of neurosurgeons and thrombosis specialists exist when they encounter patients with ICH and MHV, though decisions were influenced by patient- and valve-related factors. As our observed variation likely reflects the immense gap in current evidence, prospective randomized trials in this population are therefore urgently needed.

OSA Is a Risk Factor for Recurrent VTE

OSA is a risk factor for a first episode of pulmonary embolism (PE), although its impact on the risk of thromboembolism recurring is uncertain. Our objective was to explore the prognostic value of OSA after the discontinuation of oral anticoagulation (OAC) in patients with a first episode of PE. In 120 consecutive patients who had stopped OAC for a first episode of PE, we performed home respiratory polygraphy and recorded sleep characteristics, classic risk factors for PE, blood pressure measurements, spirometric parameters, physical activity, and levels of D-dimer and prothrombin fragment 1+2 (F1+2). Patients were followed for 5 to 8 years, and the main end point was PE recurrence. Restarting OAC for any thromboembolic event was evaluated as a secondary end point. During the follow-up period, 19 patients had a PE recurrence, and 16 of them hadan apnea-hypopnea index (AHI)≥ 10 h-1. In a multivariate Cox regression model, an AHI≥ 10 h-1 (hazard ratio [HR], 20.73; 95%CI, 1.71-251.28), mean nocturnal oxygen saturation (nSao2) (HR, 0.39; 95%CI, 0.20-0.78), time with Sao2< 90%(CT90%) (HR, 0.90; 95%CI, 0.82-0.98), and D-dimer level (HR, 1.001; 95%CI, 1.00-1.002) were identified as independent risk factors for recurrent PE. Twenty-four patients resumed OAC, and AHI≥10 h-1 (HR, 20.66; 95%CI, 2.27-188.35), mean nSao2 (HR, 0.54; 95%CI, 0.32-0.94), and Epworth Sleepiness Scale (ESS) (HR, 0.73; 95%CI, 0.56-0.97) were retained as independent risk factors for the resumption of OAC. After a first episode of PE, OSA is an independent risk factor for PE recurrence or restarting OAC for a new thromboembolic event.

Clinical Implications of Leaks Following Left Atrial Appendage Ligation WiththeLARIAT Device.

The aim of this study was to evaluate the incidence and clinical implications of leaks (acute incomplete occlusion, early and late reopenings) following LAA ligation with the LARIAT device. Percutaneous LAA ligation with the LARIAT device may represent an alternative for stroke prevention in high-risk patients with atrial fibrillation with contraindications to oral anticoagulation. This was a retrospective, multicenter study of 98 consecutive patients undergoing successful LAA ligation with the LARIAT device. Leaks were defined as the presence of flow as evaluated by transesophageal echocardiography (TEE). TEE was performed during the procedure, at 6 and 12 months, and after thromboembolic events. Leaks were detected in 5 (5%), 14 (15%), and 19 (20%) patients at the 3 time points. During follow-up, 5patients developed neurological events (4 strokes and 1 transient ischemic attack). Two occurred early (1 fatal stroke and 1 stroke with multiple recurrences in the following months), and TEE was not repeated after the events. The remaining 3occurred late (after 6 months) and were associated with small leaks (<5 mm). In 2 of 3 cases, such a small leak was missed by the standard evaluation on 2-dimensional TEE, being evident only with the aid of 3-dimensional imaging. Incomplete occlusion of the LAA after LARIAT ligation is relatively common and may be associated with thromboembolic events. Proper long-term surveillance with careful TEE should be considered to detect leaks, which can be managed with either resumption of oral anticoagulation or percutaneous transcatheter closure.