Thromboembolic Events In Patients Research Articles

Estimated Thresholds of Minimum Necessary Adherence for Effective Treatment with Direct Oral Anticoagulants - A Retrospective Cohort Study in Health Insurance Claims Data.

BackgroundAn essential contribution regarding the prevention of thromboembolic events in patients with (non-valvular) atrial fibrillation (AF) is good adherence to direct oral anticoagulants (DOACs). However, it is an open question what “good” adherence means for DOACs or below which threshold non-adherence is clinically relevant for AF patients. Ultimately, such a classification could prevent strokes and associated costs through adjusted treatment regimens or supportive measures.MethodsWe selected 10,092 AF patients from health insurance claims data between 2014 and 2018 who were issued a majority (at least half of the number) of maximum approved strength prescriptions of one of the following DOACs, namely rivaroxaban, apixaban, or dabigatran. Due to the limited sample size, the prescriptions of dabigatran had to be finally excluded for the cut-off analysis. DOAC adherence was calculated as the proportion of days covered (PDC) by dividing the days of theoretical use (days covered) of the drug by the duration in days of the observation interval. PDC cut-off values were derived from stroke risk as a function of continuous PDC values in time-to-event analyses and corresponding dose-response models. The influence of adherence-promoting interventions (targeted and untargeted) on the occurrence of strokes and related costs was then projected, considering intervention costs per patient.ResultsThe population had a mean age of 74.5 years and 50% were female. The median PDC was 0.79 ± 0.28 with a median follow-up time of 1218 days, in which 2% of all DOAC patients had a stroke. The adherence cut-offs for good adherence were identified at 0.78 for rivaroxaban and 0.8 for apixaban. Targeted interventions appeared to be far more cost-effective than untargeted interventions.ConclusionClear adherence cut-offs enable healthcare professionals to identify patients with clinically relevant non-adherence. Interventions based on these cut-offs appear to be a promising means to optimize DOAC treatment.

Poster:ABCL-230 Prevalence, Patterns, and Predictors of Venous Thromboembolic Events in Patients Undergoing Salvage Chemotherapy and Autologous Stem Cell Transplant for Relapsed Lymphomas

Poster:ABCL-230 Prevalence, Patterns, and Predictors of Venous Thromboembolic Events in Patients Undergoing Salvage Chemotherapy and Autologous Stem Cell Transplant for Relapsed Lymphomas

ABCL-230: Prevalence, Patterns, and Predictors of Venous Thromboembolic Events in Patients Undergoing Salvage Chemotherapy and Autologous Stem Cell Transplant for Relapsed Lymphomas

The majority of relapsed or refractory lymphoma patients undergo salvage chemotherapy and autologous stem cell transplant (ASCT). Data on venous thromboembolic events (VTEs) in this setting are scarce. This study aims to evaluate the incidence, pattern, and risk factors for VTEs in this group of patients across the continuum of their care. The medical records of adult patients, aged ≥ 18 years, who were diagnosed and treated at our institution from 2007 to 2017 with refractory or relapsed lymphoma and received salvage therapy followed by high-dose chemotherapy and autologous stem cell transplant were retrospectively reviewed. A total of 216 patients, with a median age of 31 (range: 19–60) years, were identified. In total, 36 (16.7%) patients had VTE, mostly in the upper extremity (n=28, 77.8%); 50.0% were related to central venous catheter. Thrombosis rates were higher among patients with high lactate dehydrogenase (LDH) (29.2% <i>vs</i> 5.9%, p< 0.001), mediastinal involvement (25.9% <i>vs</i> 11.5%, p=0.025) and in patients with longer hospital stay (22.1% <i>vs</i> 9.5%, p=0.036). In multivariate analysis, high LDH (OR: 7.66; 95% CI: 2.79–21.04, p<0.001) and mediastinal involvement (OR, 3.64; 95% CI: 1.53–8.70, p=0.002) were associated with significantly higher rates of VTE. In conclusion, patients with relapsed lymphoma undergoing ASCT are at higher risk for VTE, especially those with high LDH and mediastinal involvement. Thromboprophylaxis might be considered in these settings.

Application of adjusted global antiphospholipid syndrome score to risk assessment of new thromboembolic events in patients with systemic lupus erythematosus

Application of adjusted global antiphospholipid syndrome score to risk assessment of new thromboembolic events in patients with systemic lupus erythematosus

Neurochemical biomarkers to study CNS effects of COVID-19: A narrative review and synthesis.

Neurological symptoms are frequently reported in patients suffering from COVID‐19. Common CNS‐related symptoms include anosmia, caused by viral interaction with either neurons or supporting cells in nasal olfactory tissues. Diffuse encephalopathy is the most common sign of CNS dysfunction, which likely results from the CNS consequences of the systemic inflammatory syndrome associated with severe COVID‐19. Additionally, microvascular injuries and thromboembolic events likely contribute to the neurologic impact of acute COVID‐19. These observations are supported by evidence of CNS immune activation in cerebrospinal fluid (CSF) and in autopsy tissue, along with the detection of microvascular injuries in both pathological and neuroimaging studies. The frequent occurrence of thromboembolic events in patients with COVID‐19 has generated different hypotheses, among which viral interaction with perivascular cells is particularly attractive, yet unproven. A distinguishing feature of CSF findings in SARS‐CoV‐2 infection is that clinical signs characteristic of neurotropic viral infections (CSF pleocytosis and blood–brain barrier injury) are mild or absent. Moreover, virus detection in CSF is rare and often of uncertain significance. In this review, we provide an overview of the neurological impact that occurs in the acute phase of COVID‐19, and the role of CSF biomarkers in the clinical management and research to better treat and understand the disease. In addition to aiding as diagnostic and prognostic tools during acute infection, the use of comprehensive and well‐characterized CSF and blood biomarkers will be vital in understanding the potential impact on the CNS in the rapidly increasing number of individuals recovering from COVID‐19.

Circulating Protein Disulfide Isomerase Is Associated with Increased Risk of Thrombosis in JAK2-Mutated Myeloproliferative Neoplasms.

Thromboembolic events (TE) are the most common complications of myeloproliferative neoplasms (MPN). Clinical parameters, including patient age and mutation status, are used to risk-stratify patients with MPN, but a true biomarker of TE risk is lacking. Protein disulfide isomerase (PDI), an endoplasmic reticulum protein vital for protein folding, also possesses essential extracellular functions, including regulation of thrombus formation. Pharmacologic PDI inhibition prevents thrombus formation, but whether pathologic increases in PDI increase TE risk remains unknown. We evaluated the association of plasma PDI levels and risk of TE in a cohort of patients with MPN with established diagnosis of polycythemia vera (PV) or essential thrombocythemia (ET), compared with healthy controls. Plasma PDI was measured at enrollment and subjects followed prospectively for development of TE. A subset of patients, primarily those with JAK2-mutated MPN, had significantly elevated plasma PDI levels as compared with controls. Plasma PDI was functionally active. There was no association between PDI levels and clinical parameters typically used to risk-stratify patients with MPN. The risk of TE was 8-fold greater in those with PDI levels above 2.5 ng/mL. Circulating endothelial cells from JAK2-mutated MPN patients, but not platelets, demonstrated augmented PDI release, suggesting endothelial activation as a source of increased plasma PDI in MPN. The observed association between plasma PDI levels and increased risk of TE in patients with JAK2-mutated MPN has both prognostic and therapeutic implications.

Analysis of outcome of 6-month readmissions after percutaneous left atrial appendage occlusion

ObjectivePercutaneous left atrial appendage occlusion (LAAO) is an alternative strategy for prevention of thromboembolic events in patients with atrial fibrillation and unsuitable for long-term oral anticoagulation. The study aimed to...

Involvement of Inflammation in Venous Thromboembolic Disease: An Update in the Age of COVID-19.

The inflammatory process is strongly involved in the pathophysiology of venous thromboembolism (VTE) and has a significant role in disease prediction. Inflammation most probably represents a common denominator through which classical and nonclassical risk factors stimulate thrombotic process. Inflammation of the venous wall promotes the release of tissue factor, inhibits the release of anticoagulant factors, and hampers endogenous fibrinolysis. Systemic inflammatory response also inhibits restoration of blood flow in the occluded vessel. Recent studies indicate that increased inflammatory response ("cytokine storm") is related to prothrombotic state and thromboembolic events in patients with coronavirus disease 2019 (COVID-19). The growing evidence of involvement of inflammation in the pathogenesis of VTE indicates the importance of anti-inflammatory treatment and prevention of VTE. While aspirin was shown to be effective in prevention of recurrent venous thrombosis after treatment with anticoagulant drugs, some other anti-inflammatory drugs like nonsteroidal anti-inflammatory agents may have prothrombotic effect, thus potentially increasing the risk of VTE. Recently, new specific anti-inflammatory drug inhibitors of inflammatory markers that have been shown to be involved in the pathogenesis of VTE are being searched. As thrombogenesis is based on activation of coagulation provoked by inflammation, then prevention and treatment of VTE should include both anticoagulant and anti-inflammatory agents. Combined treatment is related to increased risk of bleeding complications, therefore subtherapeutic doses of both drugs should be used to improve the efficacy of management of VTE without increasing the risk of bleeding.

Safety and interaction of direct oral anticoagulants with antiarrhythmic drugs

The use of direct oral anticoagulants minimized the risks associated with vitamin K antagonist (warfarin) therapy. Currently, direct oral anticoagulants have priority over warfarin for the prevention of thromboembolic events in patients with atrial fibrillation and a number of other conditions requiring anticoagulant therapy. Direct oral anticoagulants along with antiarrhythmic therapy are the accepted strategy for atrial fibrillation treatment. At the same time, the effect of drug-drug interactions (DDI) between direct oral anticoagulants and antiarrhythmic drugs, which have common points of metabolic application, has not been fully elucidated. In order to provide effective and safe anticoagulant and antiarrhythmic therapy in patients with AF, it is important to understand the mechanisms and severity of DDI of direct oral anticoagulants and antiarrhythmic agents. This review discusses the issues of DDI of direct oral anticoagulants and antiarrhythmic drugs used to treat atrial fibrillation.

Incidence, timing and risk factors of venous thromboembolic events in patients with pancreatic cancer

IntroductionPancreatic cancer is associated with a high risk of venous thromboembolism (VTE). However, comprehensive data on incidence, timing and relevant determinants of VTE in this particular population are scarce. Current study assesses incidence, timing and predictors of VTE in pancreatic cancer through different phases of disease. MethodsAll pancreatic cancer patients treated in our tertiary referral center between 2013 through 2017 were studied. Occurrence of VTE was evaluated from diagnosis through end of follow-up or death. Relevant determinants of VTE were identified in logistic regression models. Hazard ratios were calculated to evaluate impact of VTE on overall survival. ResultsIn total, 361 patients were followed for a median period of 43 months; 64 were diagnosed with VTE (18%). Most were tumor related thrombosis (59%), incidental (75%) and occurred after anti-cancer treatment had been stopped (80%), only 1.6% occurred during remission phase. Stage IV pancreatic cancer was a predictor for VTE (hazard ratio (HR) 2.46, 95% confidence interval (CI) 0.9–6.8). Biliary drainage (HR 0.52, 95%CI 0.28–0.98) and tumor resection (HR 0.45, 95%CI 0.45–1.83) were protective factors. VTE was not associated with worse survival (HR 1.3; 95% CI 0.97–1.74). ConclusionsVTE in pancreatic cancer is disease-stage dependent, with 80% occurring in advanced phases of disease when patients no longer receive active treatment. We speculate that this is the main reason for the absence of a survival effect of VTE in our cohort. These practice-based findings should be taken into account when considering wide-spread introduction of primary thromboprophylaxis in patients with pancreatic cancer.

2021 Korean Heart Rhythm Society Guidelines for Stroke Prevention in Atrial Fibrillation

Atrial fibrillation (AF) is a strong risk factor for ischemic stroke and systemic embolism. To prevent thromboembolic events in patients with AF, anticoagulation therapy is essential. The anticoagulant strategy is determined after stroke and bleeding risk assessments using the CHA2DS2-VASc and HAS-BLED scores, respectively; both consider clinical risk factors. Vitamin K antagonists (VKAs) are the sole anticoagulant option in AF patients with a prosthetic mechanical valve or moderate-severe mitral stenosis; in all other AF patients VKA or non-vitamin K antagonist oral anticoagulants are therapeutic options. However, antiplatelet therapy should not be used for stroke prevention in AF patients. Anticoagulation is not needed in AF patients with low stroke risk but strongly recommended in those with a with low bleeding risk. Left atrial appendage (LAA) occlusion offers an alternative in AF patients in whom long-term anticoagulation is contraindicated. Surgical occlusion or the exclusion of LAA can be considered for stroke prevention in AF patients undergoing cardiac surgery. In this article, we review existing data for stroke prevention and suggest optimal strategies to prevent stroke in AF patients.

Profile of Coagulation Marker and The Influence Factors in Central Nervous System Tumor

Brain tumors have the highest percentage of thrombosis compared to other types of malignancies. Hypercoagulation is a risk for thromboembolic events in patients with malignancy. Hypercoagulation conditions are frequently found in patients with malignancy arising from the aptitude of tumor cells to activate the coagulation system. This condition can be detected through coagulation markers in the blood. This marker is PT, APTT, INR, Fibrinogen and D-Dimer. This research is a descriptive analytic study using secondary data from medical records of patients with central nervous system (CNS) tumors. The inclusion criteria were CNS tumor patients &gt; 18 years old and had been diagnosed with CNS tumor. Coagulation markers are recorded based on the results of the initial laboratory examination upon entering the hospital, consisting of D-Dimer, PT, APTT, Fibrinogen, INR. There were 124 research subjects, consisting of 60 men and 64 women. Most research subjects are in the age range of 40-49 years (54.8%). Hypercoagulation conditions were found in 92.74% of study subjects. The most common accompanying condition was hypertension (22.6%). There were no significant differences in the hypercoagulable conditions in groups with and without accompanying conditions. Hypercoagulation was found in most research subjects. There are no factors that influence the hypercoagulation condition in this study.

Prevention of Thromboembolic Events in Patients with COVID-19.

Background: COVID-19 has developed into a global pandemic with respiratory compromise and systemic coagulopathy causing significant morbidity and mortality. Methods: A retrospective analysis was performed on all COVID-19 patients hospitalized between March and June 2020. Findings: Of 1265 COVID-19 positive hospitalized patients identified, 138 (10.9%) had a thromboembolism. Mortality rate in COVID-19 patients with thrombosis was 31.9%, significantly higher than COVID-19 patients who did not have thrombosis 10% (p&lt;0.0001). The incidence of thrombosis was significantly less in those who received steroids at 14% as compared to other COVID-19 therapies: tocilizumab 25% (p=0.0031), hydroxychloroquine 42% (p&lt;0.0001), and remdesivir 72% (p&lt;0.0001). There was no difference in mortality in patients who had prophylactic enoxaparin 40.5% than therapeutic enoxaparin 51.7% (p= 0.3491). Adjusting for demographics, a logistics model showed no mortality difference in patients who had either dosing of anticoagulation (p=0.5810). The bleeding rate was 12.3%, significantly higher than reported bleeding rates for hospitalized nonCOVID-19 patients on anticoagulants at 7.2% (p&lt;0.05). Interpretation: Our study shows the incidence of thrombosis in hospitalized COVID-19 patients was higher than the general population. The lowest incidence of thrombosis occurred in COVID-19 patients who received steroids. There was no mortality difference in patients who received prophylactic versus therapeutic anticoagulation prior to thrombosis, but there was a high incidence of bleeding events. Funding: No outside funding was used

Incidence of Vascular Thromboembolic Events in Patients Receiving Immunotherapy: A Single Institution Experience

Introduction:Cancer is known to cause a hypercoagulable state predisposing to venous thromboembolism (VTE). In a retrospective study by Lyman et al., the incidence of VTE 3.5 months after starting chemotherapy was 7.3% rising to 13.5% at 12 months in a cohort of more than 27,000 patients. A two-fold increase in the incidence of deep venous thrombosis (DVT) and pulmonary embolism (PE) has also been reported in hospitalized cancer patients compared to non-cancer patients. Systemic cancer treatments are known to be associated with increased VTE risk but the incidence of vascular thromboembolic events with newer treatment modalities like immunotherapy has not been broadly investigated. This study aims to assess the incidence of vascular events including VTE, strokes and myocardial infarction in cancer patients receiving anti PD1/PDL1 therapy at a single institution.Methods:We retrospectively analyzed the data of 154 cancer patients over 18 years of ages, who were treated with anti PD-1/PDL-1 therapy at the University of Oklahoma from 2014 to 2016. We used descriptive statistics to describe the incidence of vascular thromboembolic events. Kaplan Meier Survival analysis was used to estimate the progression free survival (PFS) according to VTE occurrence.Results:The majority of patients were females (57%). The median age was 63 years (range 23-89). Median number of treatments received was 5 (range 1-30). Lung cancer was the most common diagnosis (20.8%) followed by melanoma (20.1%) and ovarian cancer (12.3%). 92% of patients had stage 4 cancer. Nivolumab was the most commonly used agent (47.4%) followed by Pembrolizumab (22.7%), other investigational agents (22.7%) and Atezolizumab (7.2%).The median follow up time was 198 days (approximately 7 months). VTE occurred in 16/154 patients (10%). Nine patients had DVT, 6 patients had PE and 1 patient had DVT and PE. VTE was most common in patients with lung cancer (17%) and patients with ovarian cancer (17%). The occurrence of VTE was not significantly associated with a worse progression free survival [150 days versus 146 days for VTE occurrence vs no occurrence respectively (p = 0.725)]. No cases of stroke or myocardial infarction were recorded.Conclusion:The incidence of VTE in this cohort of cancer patients receiving immunotherapy appeared to be similar to the incidence previously reported with other systemic therapies. No arterial thromboembolic events were recorded in our study. Large multicenter studies are needed to derive definite conclusions. DisclosuresNo relevant conflicts of interest to declare.

Venous Thromboembolism (VTE) in Adults with Non Hodgkin Lymphoma (NHL) a Retrospective Cohort Study

Introduction. One major complication of cancer and cancer treatment is venous thromboembolism (VTE). The incidence of thromboembolic complications in patients with hematological malignancies reaches up to 12.1% in patients with acute myeloid leukemia and ranges from 1.5% to 59.5% in patients with lymphoma and these patients had a 10-fold higher risk for the development of venous thrombosis, than patients with lung and gastrointestinal cancers. Known pro-thrombotic risk factors in patients with cancer include; older age, systemic inflammation, central venous catheters (CVCs), thrombophilia, infections/sepsis, obesity, immobilization and advanced disease, but the risk is further increased by chemotherapy, but the trade-off between safety and efficacy of primary thromboprophylaxis in cancer patients treated with chemotherapy is uncertain.Aim: Aim of our study was to determine incidence of thromboembolic events in patients with NHL and to establish the risk factors and identify patients with prophylactic therapy for thrombosis.Patients and Methods. We conducted a retrospective cohort study, including all patients registered in the Hematology Department over the age of 18 years diagnosed with NHL between January 2007 and June 2017 in Mexico city.Results. Data was retrieved from the medical records of all 262 patients (100%) (female 118 , male 149) in a Mexican Hematology Center. The median follow-up was 5.7 years (range 1-10). Only 6 patients (2.2-%) were treated with thromboprophylaxis. The incidence of symptomatic VTE was 1.5% (1- PE, 3- DVT), in the four patients VTE events occurred in the older age category (50-60 years) and all of them with NHL diffuse large B cell lymphoma (DLBCL) and clinical stage III-IV.In univariate analysis, DLBCL was associated with increased risk of VTE compared to follicular lymphoma (FL) in the first year after diagnosis; this association was no longer significant in adjusted analysis. Major risk factors for VTE included history of VTE before NHL diagnosis, stage III/IV disease and BMI ≥ 30. The cumulative incidence of VTE was highest in the period following diagnosis and decreased over time for both histologies.While the VTE did not significantly affect the treatment of NHL it caused increased morbidity.Conclusions. VTE is a relatively uncommon complication of NHL and its treatment, causing increased acute and long-term morbidity. DLBCL is associated with increased risk of VTE compared to FL. This risk is markedly attenuated when adjusting for additional risk factors.The strongest predictors for development of VTE included: time period during chemotherapy administration, history of VTE, clinical stage III/IV and BMI >30. This knowledge can assist clinicians in identifying NHL patients at high risk for VTE. DisclosuresNo relevant conflicts of interest to declare.

Risk of Thromboembolism in Non-Valvular Atrial Fibrillation With or Without Clinical Hyperthyroidism.

Background:Patients with hyperthyroidism have higher risk of atrial fibrillation (AF). However, the risk of thromboembolic event in patients with hyperthyroidism-related AF is controversial.Objectives:The aim of the study was to examine the risk of thromboembolic events in AF patients with/without hyperthyroidism.Methods:The national retrospective cohort study enrolled AF population was derived from the Taiwan National Health Insurance Research Database. The comparison between the AF patients with clinical hyperthyroidism (HT-AF group) and AF patients without hyperthyroidism (non-thyroid AF group) was made in a propensity score matched cohort and in a real-world setting, of which, the CHA2DS2-VASc level was treated as a stratum variable. The outcomes were ischemic stroke and systemic thromboembolism.Results:There were 3,880 patients in HT AF group and 178,711 in non-thyroid AF group. After propensity score analysis, the incidence of thromboembolism event and ischemic stroke were lower in HT AF patients than non-thyroid AF patients (1.6 versus 2.2 events per 100 person-years; HR, 0.73; 95% CI, 0.64–0.82 and 1.4 versus 1.8 events per 100 person-years; HR, 0.74; 95% CI, 0.64–0.84, respectively) in the 4.3 ± 3.2 year follow up period. The differences persistently existed in those receiving anticoagulants or not. In AF patients without anticoagulants, the incidence densities of ischemic stroke/systemic thromboembolism were significantly lower in HT AF group than those in non-thyroid AF group at CHA2DS2-VASc scores ≤ 4 (HR, 0.41; 95% CI, 0.35–0.48, p < 0.001), while the differences disappeared in case of score ≥ 5 (HR, 0.80; 95% CI, 0.63–1.02, p = 0.071).Conclusion:Patients with HT AF had lower incidence of thromboembolic events as compared to non-thyroid AF patients. The threshold of CHA2DS2-VASc score for anticoagulation in AF patients with clinical hyperthyroidism should be further evaluated.HighlightsThe incidence of thromboembolic event was different between hyperthyroidism-related atrial fibrillation (HT-AF) and non-thyroid AF patients.Hyperthyroidism did not confer additional risk of thromboembolic event at CHA2DS2-VASc of ≤ 4.The benefit of anticoagulation strategy in patients with hyperthyroidism-related AF should be further evaluated, especially at low CHA2DS2-VASc score.

Reporting of Thromboembolic Events with JAK Inhibitors: Analysis of the FAERS Database 2010-2019.

IntroductionA potentially elevated risk for pulmonary thrombosis with Janus kinase inhibitors (JAKinibs) was identified, as well as an increased risk for portal vein thrombosis, in ruxolitinib patients. Consequently, the objective of this investigation was to repeat a comprehensive analysis of the US FDA’s Adverse Event Reporting System (FAERS) database to assess postmarketing reporting rates of thromboembolic events (TEs) in patients treated with JAKinibs.MethodsFAERS data (1 January 2010 to 30 September 2019) were searched for reports of all FDA-approved JAKinibs across all indications. For each drug–adverse drug reaction (ADR) pair, the reporting odds ratio (ROR) [two-sided 95% confidence interval (CI)] and empirical Bayesian geometric mean (EBGM) [one-sided 95% lower bound] were calculated to detect drug–ADR pairs with higher-than-expected reporting rates within the FAERS. Significance was declared when both lower 95% CI bounds were > 1.ResultsSignificantly elevated reporting rates of pulmonary thrombosis were evident with tofacitinib (ROR 2.36 [1.69–3.31]; EBGM 2.01 [1.53]), as was pulmonary embolism with baricitinib (ROR 12.23 [8.35–17.89]; EBGM 7.72 [3.82]) and portal vein thrombosis with ruxolitinib (ROR 4.16 [2.70–6.40]; EBGM 4.52 [3.11]). Deep vein thrombosis reports were increased with baricitinib (ROR 14.84 [9.64–22.84]; EBGM 9.49 [5.91]), as was thrombosis with ruxolitinib (ROR 1.40 [1.20–1.63]; EBGM 1.72 [1.52]). The relationship between the time of treatment initiation and event occurrence indicated that time to events occurred randomly.ConclusionsThis study found significant reporting rates for TEs in patients treated with JAKinibs across brands and indications, providing additional evidence that JAKinibs may be contraindicated in patients at risk of TEs.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40264-021-01082-y.

Anticoagulation in COVID-19: reaction to the ACTION trial

Early in the COVID-19 pandemic, it became clear that coagulopathy leading to macrovascular and microvascular thrombotic events was a considerable potential complication for patients with COVID-19.1 Increased inflammation and coagulopathy were independently associated with critical illness and all-cause mortality and had a synergistic role in the pathogenesis of COVID-19.2 Early observations of a benefit from heparin3 in a selected cohort of severely ill patients with COVID-19 in China, followed by reports of increased thromboembolic events in patients with COVID-19 (both in and outside of intensive care units [ICUs]) despite the use of standard-dose venous thromboembolism prophylaxis,4,5 led many physicians to use increased anticoagulant doses, even without robust data available.

Direct Oral Anticoagulants in Asian Patients with Atrial Fibrillation: Consensus Recommendations by the Asian Pacific Society of Cardiology on Strategies for Thrombotic and Bleeding Risk Management.

The disease burden of AF is greater in Asia-Pacific than other areas of the world. Direct oral anticoagulants (DOACs) have emerged as effective alternatives to vitamin K antagonists (VKA) for preventing thromboembolic events in patients with AF. The Asian Pacific Society of Cardiology developed this consensus statement to guide physicians in the management of AF in Asian populations. Statements were developed by an expert consensus panel who reviewed the available data from patients in Asia-Pacific. Consensus statements were developed then put to an online vote. The resulting 17 statements provide guidance on the assessment of stroke risk of AF patients in the region, the appropriate use of DOACs in these patients, as well as the concomitant use of DOACs and antiplatelets, and the transition to DOACs from VKAs and vice versa. The periprocedural management of patients on DOAC therapy and the management of patients with bleeding while on DOACs are also discussed.

Unmet Clinical Needs in Elderly Patients Receiving Direct Oral Anticoagulants for Stroke Prevention in Non-valvular Atrial Fibrillation.

Vitamin K antagonists have been used for many years as the treatment of choice for long-term oral anticoagulation in patients with non-valvular atrial fibrillation. Unfortunately, the use of those drugs in the real-world setting, particularly among elderly patients, is suboptimal because of their limitations in management. Therefore, many patients were not adequately anticoagulated. Direct oral anticoagulants have been demonstrated to overcome almost all the limitations derived from the use of vitamin K antagonists. Direct oral anticoagulants are at least as effective as vitamin K antagonists in preventing thromboembolic events in patients with non-valvular atrial fibrillation and safer in reducing the risk of intracranial haemorrhage and all-cause mortality. However, as a result of the strict inclusion and exclusion criteria applied to patients, data coming from randomized controlled trials might not apply to the general population. Furthermore, elderly patients were scarcely represented in randomized controlled trials with direct oral anticoagulants. Therefore in elderly patients with non-valvular atrial fibrillation, unmet clinical needs still exist. This review article highlights some of them and provides potential answers based on the results coming from randomized clinical trials, real-world data, and the authors’ clinical experience.