Antiplatelet Use Research Articles

Long-Term Risks of Stroke in Patients With Type A Aortic Dissection: A Nationwide Cohort Study.

Background Patients with type A aortic dissection (TAAD) have a high short-term risk of stroke. However, whether patients with TAAD have an increased long-term risk of stroke is still undetermined, and our study aims to address this knowledge gap. Methods and Results A nationwide retrospective cohort study was conducted using Taiwan's National Health Insurance Research Database. We included patients with TAAD as well as age- and sex-matched aortic disease-free individuals between 2003 and 2016. Inverse probability of treatment weighting was performed to balance patient characteristics between the groups. The primary outcome was the development of stroke, regardless of subtype; the secondary outcomes were the risk of developing either ischemic or hemorrhagic stroke. The hazard ratios (HRs) of stroke were estimated using the Cox proportional hazards model. After inverse probability of treatment weighting, 3556 and 7023 patients were categorized into the TAAD and aortic disease-free cohorts, respectively. The mean follow-up period was 5.71 years. The HRs for overall, ischemic, and hemorrhagic strokes in the TAAD cohort were 3.01 (95% CI, 2.40-3.78), 3.18 (95% CI, 2.47-4.10), and 2.32 (95% CI, 1.58-3.41), respectively, compared with the aortic disease-free cohort. Consistent trends of higher stroke risk in patients with TAAD were revealed in the analyses stratified by age; sex; antiplatelet use; and history of hypertension, diabetes, or dyslipidemia. Conclusions Our study findings revealed that patients with TAAD had an increased long-term risk of both ischemic and hemorrhagic strokes. Further studies are warranted to establish optimal strategies for stroke prevention in these patients.

Oral Anticoagulants in Very Elderly Nonvalvular Atrial Fibrillation PatientsWith High Bleeding Risks: ANAFIE Registry.

Data on the effectiveness and safety of oral anticoagulant (OAC) agents in very elderly nonvalvular atrial fibrillation patients with high bleeding risk are lacking. This study examined 2-year outcomes and effects of OAC agents among these patients using the ANAFIE (All Nippon Atrial Fibrillation in the Elderly) registry (N=32,275) data. Patients were classified into high-risk (age:≥80 years; CHADS2 score:≥2; and presence of≥1 bleeding risk factor: creatinine clearance of 15-30mL/minute, prior bleeding at critical sites, body weight of≤45kg, or continuous antiplatelet use) and reference groups. In the high-risk (n=7,104) and reference (n=25,171) group patients, 89.0% and 93.4%, respectively, used OAC agents. Of these, respectively, 30.1% and 24.2% used warfarin, and 58.9% and 69.1% used direct-acting OAC (DOAC) agents. Compared with the reference group, the high-risk group had higher incidences of stroke/systemic embolism, major bleeding, intracranial hemorrhage, gastrointestinal bleeding, cardiovascular events, and all-cause death. In the high-risk group, DOAC agent use vs nonuse of OAC agents was associated with reduced incidences of stroke/systemic embolism (HR: 0.53; 95%CI: 0.36-0.79) and all-cause death (HR: 0.65; 95%CI: 0.52-0.81) but not with major bleeding (HR: 1.09; 95%CI: 0.63-1.89). DOAC agents were superior to warfarin in effectiveness and safety. For high-risk patients, history of major bleeding, severe liver dysfunction, and falls within 1 year were independent risk factors for major bleeding. High-risk elderly nonvalvular atrial fibrillation patients had higher event incidences. DOAC agents were associated with reduced risk of stroke/systemic embolism and all-cause death vs nonuse of OAC agents or warfarin. (Prospective Observational Study in Late-Stage Elderly Patients With Nonvalvular Atrial Fibrillation [ANAFIE registry]; UMIN000024006).

Antiplatelet Drugs on the Recurrence of Hepatocellular Carcinoma after Liver Transplantation.

Previous studies reported suppressive effects of antiplatelet agents on hepatocellular carcinoma (HCC); however, this has never been assessed in patients who underwent liver transplantation (LT). This retrospective observational study used data from LT recipients with pre-transplant HCC in a single tertiary hospital. The study population was divided into two groups according to the use of antiplatelet agents for >90 days within the study period (377 antiplatelet groups versus 91 non-antiplatelet groups). Matched groups containing 79 patients in each group were also compared regarding HCC-recurrence and HCC-related mortality, which were analyzed by treating non-HCC death as a competing risk. In Kaplan-Meier analyses of the matched cohort, the 5-year cumulative incidences of HCC recurrence and HCC-specific death were similar between the antiplatelet (p = 0.876) and non-antiplatelet groups (p = 0.701). All-cause and non-HCC deaths were also similar between the two groups (p = 0.867 and p = 0.413, respectively). In multivariable analyses of the entire cohort, antiplatelet use was not associated with HCC recurrence (hazard ratio [HR] 1.37, p = 0.300) or HCC-specific death (HR 1.54, p = 0.310). Therefore, unlike the usual setting with liver disease, antiplatelet therapy did not affect HCC recurrence or HCC-specific mortality when used after LT.

104 SPONTANEOUS ILIOPSOAS TENDON RUPTURE AND PSOAS HAEMATOMA ON ASPIRIN MONOTHERAPY: A CASE REPORT

Abstract Background Spontaneous Iliopsoas Tendon (IPT) rupture is a rare condition, with a prevalence of 0.66%, occurring most commonly in athletes. Risk factors for non-athletic IPT rupture include age, female gender and steroid use. Psoas haematomas are associated with surgery, anticoagulation and coagulopathies. Only a handful of case reports have associated psoas haematoma with single antiplatelet use. We present the case of a patient who developed psoas tendon rupture and psoas haematoma. Methods A 77-year-old female presented with a four week history of declining mobility and left hip pain, without history of trauma. Past medical history included chronic lymphoedema and an NSTEMI, for which she was taking aspirin monotherapy. On examination, she had reduced power on left hip flexion and a tender anterior thigh, with normal sensation. CT showed asymmetric thickening of the left iliacus muscle and surrounding fat stranding. MRI demonstrated partial IPT tear with oedema extending into the iliacus muscle. Results After several weeks of rehabilitation, her mobility deteriorated again. A second CT was performed, which showed new expansion and fat stranding of the right iliopsoas muscle and tendon compatible with acute haemorrhage. Aspirin was held for four weeks, and she was discharged after completing rehabilitation. Her baseline mobility had disimproved and she required assistance and a frame on discharge. Conclusion IPT rupture and psoas haematoma are atypical causes of atraumatic hip pain in older adults. Nevertheless, they can cause significant disability. MRI is recommended as the gold standard for diagnosis. Treatment is commonly conservative, focused on physiotherapy and pain control to maintain mobility. While aspirin is not commonly associated with tendon rupture or haemorrhage, it is widely used in primary prevention of cardiovascular disease and due consideration should be given to stopping it following the occurrence of haemorrhage.

Insurance status is associated with urgent carotid endarterectomy and worse postoperative outcomes

ObjectiveUnderinsured patients can experience worse preoperative medical optimization. We aimed to determine whether insurance status was associated with carotid endarterectomy (CEA) urgency and postoperative outcomes. MethodsWe analyzed the Society for Vascular Surgery Vascular Quality Initiative Carotid Endarterectomy dataset from January 2012 to January 2021. Univariable and multivariable methods were used to analyze the differences across the insurance types for the primary outcome variable: CEA urgency. The analyses were limited to patients aged <65 years to minimize age confounding across insurers. We also examined differences in preoperative medical optimization and symptomatic disease and postoperative outcomes. A secondary analysis was performed to examine the effect of CEA urgency on the postoperative outcomes. ResultsA total of 27,331 patients had undergone first-time CEA. Of these patients, 4600 (17%) had Medicare, 3440 (13%) had Medicaid, 17,917 (65%) had commercial insurance, and 1374 (5%) were uninsured. The Medicaid and uninsured patients had higher rates of urgent operation compared with Medicare (20.0% and 34.7% vs 14.4%; P < .001), with no differences in the commercial group vs the Medicare group. Additionally, Medicaid and uninsured patients had lower rates of aspirin, statin, and/or antiplatelet use (93.6% and 93.5% vs 95.8%; P < .001) and higher rates of symptomatic disease (42.1% and 57.6% vs 36.2%; P < .001) compared with Medicare patients. The rate of perioperative stroke/death was higher for the Medicaid and uninsured patients than for the Medicare patients (1.63% and 1.89% vs 1.02%; P = .017 and P = .01, respectively), with no differences in the commercial group. Multivariable analysis demonstrated that compared with Medicare, Medicaid and uninsured status were associated with increased odds of an urgent operation (odds ratio [OR], 1.3; 95% confidence interval [CI], 1.1-1.5; and OR, 2.3; 95% CI, 2.0-2.7, respectively), symptomatic disease (OR, 1.2; 95% CI, 1.1-1.4; and OR, 2.2; 95% CI, 1.9-2.5, respectively), and perioperative stroke/death (OR, 1.6; 95% CI, 1.1-2.4; and OR, 1.8; 95% CI, 1.1-3.0, respectively) and a decreased odds of aspirin, statin, and/or antiplatelet use (OR, 0.71; 95% CI, 0.6-0.9; and OR, 0.76; 95% CI, 0.6-0.99, respectively). Additionally, the rates of perioperative stroke/death were higher for patients who had required urgent surgery compared with elective surgery (2.8% vs 1.0%; P < .001). Multivariable analysis demonstrated increased odds of perioperative stroke/death for patients who had required urgent surgery (OR, 2.4; 95% CI, 1.9-3.1). ConclusionsMedicaid and uninsured patients were more likely to require urgent CEA, in part because of poor preoperative medical optimization. Additionally, urgent operation was independently associated with worse postoperative outcomes. These results highlight the need for improved preoperative follow-up for underinsured populations.

Subdural hematoma expansion in relation to measured mean and peak systolic blood pressure: A retrospective analysis.

Subdural hematomas (SDH) account for an estimated 5 to 25% of intracranial hemorrhages. Acute SDH occur secondary to rupture of the bridging veins leading to blood collecting within the dural space. Risk factors associated with SDH expansion are well documented, however, there are no established guidelines regarding blood pressure goals in the management of acute SDH. This study aims to retrospectively evaluate if uncontrolled blood pressure within the first 24 h of hospitalization in patients with acute SDH is linked to hematoma expansion as determined by serial CT imaging. A single center, retrospective study looked at 1,083 patients with acute SDH, predominantly above age 65. Of these, 469 patients met the inclusion criteria. Blood pressure was measured during the first 24 h of admission along with PT, INR, platelets, blood alcohol level, anticoagulation use and antiplatelet use. Follow-up CT performed within the first 24 h was compared to the initial CT to determine the presence of hematoma expansion. Mean systolic blood pressure (SBP), peak SBP, discharge disposition, length of stay and in hospital mortality were evaluated. We found that patients with mean SBP <140 in the first 24 h of admission had a lower rate of hematoma expansion than those with SBP > 140. Patients with peak SBP > 200 had an increased frequency of hematoma expansion with the largest effect seen in patients with SBP > 220. Other risk factors did not contribute to hematoma expansion. These results suggest that blood pressure is an important factor to consider when treating patients with SDH with medical management. Blood pressure management should be considered in addition to serial neurological exams, repeat radiological imaging, seizure prophylaxis and reversal of anticoagulation.

The Risk of Major Bleeding With Apixaban Administration in Patients With Acute Kidney Injury.

Apixaban is eliminated by the kidneys and in acute kidney injury (AKI) there is potential for an increase in apixaban exposure and bleeding events. In one instance, data have shown higher than normal bleed risk in patients with AKI, unless calibrated anti-factor Xa monitoring is used, which is not widely available. To evaluate bleeding with apixaban administration to hospitalized patients with an AKI in an unmonitored real-world scenario. We conducted a retrospective study of patients admitted to a large urban academic teaching hospital from April 2015 to March 2022, who received apixaban for venous thromboembolism or nonvalvular atrial fibrillation (NVAF). The primary outcome evaluated major bleeding when apixaban was administered to patients with or without an AKI. A total of 232 patients were evaluated (116 per group). Most patients (79.7%) were on apixaban for NVAF, 32.7% had chronic kidney disease, 58.2% were on a medication increasing bleed risk, and HAS-BLED score was a median of 2 in both groups. No differences were noted between groups for bleeding (AKI group 7.8% vs non-AKI 3.4%; P = 0.15), and on regression analysis, coadministration of a P2Y12 inhibitor was predictive of major bleeding (odds ratio = 5.9; 95% confidence interval = 1.4-23.6). Although no differences between groups were noted, apixaban use in the AKI group resulted in a higher than normally reported incidence of apixaban-associated major bleeding, and concomitant antiplatelet use increased bleed risk as well. Cautious use of apixaban and further investigation with larger studies are warranted in this area.

Anticoagulation Holiday: Resumption of Direct Oral Anticoagulants for Atrial Fibrillation in Patients with Index Traumatic Intracranial Hemorrhage

The optimal time to restart direct oral anticoagulants (DOACs) for nonvalvular atrial fibrillation (NVAF) after traumatic intracranial hemorrhage (tICH) is unknown. Physicians must weigh the risk of recurrent hemorrhage against ischemic stroke. We investigated rates of stroke while holding anticoagulation, hemorrhage after anticoagulation resumption, and factors associated with the decision to restart anticoagulation. Patients presenting to our level I trauma center for tICH while on a DOAC for NVAF were retrospectively reviewed over 2 years. Age, sex, DOAC use, antiplatelet use, congestive heart failure, hypertension, age, diabetes, previous stroke, vascular disease, sex score for stroke risk in NVAF, injury mechanism, bleeding pattern, Injury Severity Score, use of a reversal agent, Glasgow Coma Scale at 24 hours, hemorrhage expansion, neurosurgical intervention, Morse Fall Risk, DOAC restart date, rebleed events, and ischemic stroke were recorded to study rates of recurrent hemorrhage and stroke, and factors that influenced the decision to restart anticoagulation. Twenty-eight patients sustained tICH while on a DOAC. Fall was the most common mechanism (89.3%), and subdural hematoma was the predominant bleeding pattern (60.7%). Of the 25 surviving patients, 16 patients (64%) restarted a DOAC a median 29.5 days after tICH. One patient had recurrent hemorrhage after resuming anticoagulation. One patient had an embolic stroke after 118 days off anticoagulation. Age >80, Injury Severity Score ≥16, and expansion of tICH influenced the decision to indefinitely hold anticoagulation. The low stroke rate observed in this study suggests that holding DOACs for NVAF for 1 month is sufficient to reduce the risk of stroke after tICH. Additional data are required to determine optimal restart timing.

Literature Review: Drug Therapy in Ischemic Stroke Patients

Background: Ischemic stroke is the foremost common cause of stroke around the world, bookkeeping for 10 times more strokes than hemorrhagic strokes in higher pay nations. There are proof accessible for each antiplatelet sedate utilized in the treatment of ischemic stroke. The advertised recommendations for elective restorative choices when confronted with repetitive stroke. Aim: To know the use of antiplatelet in ischemic stroke patients. Method: This study used a systematic review that searched using the keyword Antiplatelet and Ischemic Stroke in Google Scholar, Crossref, and PubMed. Recent studies in English published in 2012-2022. Result: After the final screening, the author analyzed 4 articles that were published after the year 2012. Conclusion: In spite of the fact that great proof exists for the utilization of certain antiplatelet operators for postischemic stroke, there are significant openings for future investigation to examine personalized treatments. These incorporate screening patients for platelet polymorphisms that bestow antiplatelet resistance and for randomized trials counting more racially different populations.

Factors determining the use of NOACs vs. Warfarin in a Kenyan cohort of patients requiring anticoagulation

Abstract Background Non-Vitamin K oral anticoagulants (NOACs) are widely used for stroke prevention in atrial fibrillation (AF) and prevention and treatment of venous thromboembolism (VTE). Apart from conditions in which warfarin is still the anticoagulant of choice, other factors may influence the choice between NOACs and warfarin. Purpose This study aims to determine factors associated with the use of NOACs as compared to warfarin in Kenya. Methods The Heart Registry Kenya is a prospective record of patients from two public hospitals and one private hospital in Kenya, with acute coronary syndrome, heart failure, AF, and VTE from 2020 to date. Data of patients with AF and VTE was analyzed to determine if demographic, clinical, or other non-clinical factors influence the choice of anticoagulants. The Chi-Square test was used to identify statistically significant associations between independent variables and dependent variables (NOACs or warfarin), with a 95% confidence interval. Results Data was collected on 452 patients (165 with AF and 288 with VTE) from 3 centers; the mean age was 51 years, and 61.7% were female. The proportions of patients on NOACs among AF and VTE patients were 60.5% and 57.5%, respectively (χ2: 0.122, p: 0.727). Proportions of patients on NOACs at public hospital number 1, public hospital number 2, and private hospital, were 37%, 50%, and 87.7%, respectively (χ2: 45.2, p: &amp;lt;0.001). The use of NOACs in low, mid-low, mid-high, and high income groups was 50.4%, 31.3%, 75%, and 88.2%, respectively (χ2: 23.4, p: &amp;lt;0.0001). There was no statistically significant association between the choice of anticoagulant and age, gender, race, renal function, indication for anticoagulation, use of antiplatelets, or extended anticoagulation therapy. Conclusion Patients with high socioeconomic status, as determined by monthly income and treatment facility, were more likely to be discharged on NOACs than warfarin. This may signal socioeconomic disparities affecting the treatment of AF and VTE in Kenya. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Research Fund - The Government of Kenya

Combined anticoagulant and antiplatelet therapy is associated with an improved outcome in hospitalised patients with COVID-19: a propensity matched cohort study

Abstract Background COVID-19 is a respiratory disease that results in a prothrombotic state manifesting as thrombotic, microthrombotic and thromboembolic events. As a result, several antithrombotic modalities have been implicated in the treatment of this disease. Purpose Currently, prophylactic dose anticoagulation is considered the standard of care antithrombotic regimen in hospitalised patients with COVID-19. However, high-quality data about the subject is unavailable. This study aimed to identify if therapeutic anticoagulation (TAC) or concurrent use of antiplatelet and anticoagulants was associated with an improved outcome in this patient population. Methods A retrospective observational cohort study of adult patients admitted to a single university hospital for COVID-19 infection was performed. The primary outcome was a composite of in-hospital mortality, intensive care unit (ICU) admission or the need for mechanical ventilation. The secondary outcomes were each of the components of the primary outcome, in-hospital mortality, ICU admission, or the need for mechanical ventilation. Results 242 patients were included in the study and divided into four subgroups: Therapeutic anticoagulation (TAC), prophylactic anticoagulation+antiplatelet (PACAP), TAC+antiplatelet (TACAP) and prophylactic anticoagulation (PAC) which was the reference for comparison. Multivariable Cox regression analysis and propensity matching were done and showed when compared with PAC, TACAP and TAC were associated with less in-hospital all-cause mortality with an adjusted HR (aHR) of 0.113 (95% CI 0.028 to 0.449) and 0.126 (95% CI 0.028 to 0.528), respectively. The number needed to treat in both subgroups was 11. Furthermore, PACAP was associated with a reduced risk of invasive mechanical ventilation with an aHR of 0.07 (95% CI 0.014 to 0.351). However, the was no statistically significant difference in the occurrence of major or minor bleeds, ICU admission or the composite outcome of in-hospital mortality, ICU admission or the need for mechanical ventilation. Conclusion The use of combined anticoagulant and antiplatelet agents or TAC alone in hospitalised patients with COVID-19 was associated with a better outcome in comparison to PAC alone without an increase in the risk of major and minor bleeds. Sufficiently powered randomised controlled trials are needed to further evaluate the safety and efficacy of combining antiplatelet and anticoagulants agents or using TAC in the management of patients with COVID-19 infection. Funding Acknowledgement Type of funding sources: None.

Protective effect of proton pump inhibitor against gastrointestinal bleeding in patients receiving oral anticoagulants: a systematic review and meta-analysis

Abstract Background The concurrent use of proton pump inhibitor (PPI) in oral anticoagulant (OAC) treated patients may be associated with a lower risk of gastrointestinal bleeding (GIB), but evidence is still conflicting according to individual OACs. Purpose We conducted a meta-analysis to estimate the risk of GIB in patients with OAC and PPI co-therapy. Methods A systematic search of PubMed, EMBASE, and Cochrane was performed for studies reporting GIB risk in OAC and PPI co-therapy. Primary outcomes were total GIB and major GIB events. We calculated pooled estimates of GIB risk by a random-effect meta-analysis and reported as odds ratios (OR) and 95% CI. Stratified analyses according to the origin of GIB, ethnic groups, individual OACs, and the presence of underlying GIB risk factors were performed. Results A total of 10 studies (1 randomized controlled study and 9 observational studies) and 1,970,931 patients who received OAC were included. OAC and PPI co-therapy were associated with a lower risk of total GIB, and major GIB; OR (95% CI) was 0.67 (0.62–0.74) for total GIB and 0.68 (0.63–0.75) for major GIB, respectively. Among total GIB, only the risk of upper GIB was lower with OAC and PPI co-therapy (OR 0.67, 95% CI 0.64–0.70). No difference in the lower risk of primary GIB outcomes of PPI co-therapy was observed between Asians and non-Asians (p-for-difference, total GIB=0.695, major GIB=0.748, respectively) and among individual OACs except for edoxaban. The protective effect of PPI on total GIB was more significant in high-risk patients, defined as those with concurrent medication of antiplatelets or non-steroidal anti-inflammatory drugs (OR 0.62, 95% CI 0.52–0.73) and presence of high bleeding risk factors such as previous GIB history, HAS-BLED score ≥3, or underlying gastrointestinal diseases. (OR 0.65, 95% CI 0.61–0.70). Conclusion In patients who receive OAC, the use of PPI co-therapy was associated with a lower risk of total GIB and major GIB irrespective of ethnic group and OAC type except for edoxaban. PPI co-therapy can be considered particularly in patients on concomitant NSAID and antiplatelet use or patients with high GIB risk factors. Funding Acknowledgement Type of funding sources: None.

Decreased device related thrombus and enhanced neo-endocardial tissue maturation with a new generation left atrial appendage closure (LAAC) device. An anticoagulation and antiplatelet free canin study

Abstract Introduction Device related thrombus (DRT) has been reported in up to 7% of patients post LAAC even while on anticoagulation. Clinical predictors of DRT are poorly understood and may be related to patient, procedural and device factors. A next generation WATCHMAN LAAC device (NG) is identical in shape and geometry to the current WATCHMAN FLX device (CW) but has a device coating designed to make it hemocompatible and less thrombogenic. Objective To evaluate the incidence and burden of WM surface thrombus formation as detected longitudinally by TEE and at necropsy in a canine model implanted with the NG device. Methods The study included 12 canine (6 implanted with CW and 6 implanted with NG) that underwent serial TEE follow up at 14, 28 and 45 days to evaluate surface thrombus on WM face. This was a challenged canine model designed to induce thrombus with no anticoagulation or antiplatelet use throughout the study. D-dimer levels were measured at 7 days and 45 days and compared to baseline measurements. Results All devices were successfully implanted. TEE follow up at 14 days showed noticeably reduced thrombus burden on the NG device compared to CW (fig.1) with even further diminution by 28 days in the NG (6/6) as compared to only in 1/6 in the CW group (fig.2). After 45 days in-life, the post-fixation trim en-face images show a smooth, glistening neoendocardial covering (absence of acute thrombus material) in all (6/6) NG compared to only 2/6 in the CW (fig.3). The CW had 3/6 devices with exuberant, bulging calcified thrombus mass one of which was considered to be a mobile DRT. D Dimer levels at 7 and 45 days were significantly lower relative to baseline in the NG compared to CW. Conclusion The NG device compared to the CW device was associated with markedly less thrombus formation at 14 days and no thrombus formation at 28 days post implant on no anticoagulant and no antiplatelet therapy along with a more mature uniform tissue coverage at 45 days. The WATCHMAN FLX Pro device coating is a promising step to reduce DRT even without the use of anticoagulation and antiplatelets and merits further investigation in human studies. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Boston Scientific

S709 Proton-Pump Inhibitor Infusion Misuse in the Community Hospital Setting

Introduction: Proton pump inhibitors (PPIs) are the most potent acid suppressants available. Several studies have shown that in hospitalized patients with acute upper gastrointestinal (GI) bleeding from peptic ulcer disease, high-dose PPI therapy via continuous infusion reduces the rate of high-risk bleeding lesions (active bleeding, visible vessel, adherent clot) on initial endoscopy. While the benefits of PPI infusions have been clearly described for these specific indications, they are often over-prescribed to inpatients. Our study aim was to determine the rate of misuse in a tertiary care community hospital setting. Methods: A retrospective cohort study was conducted at Lankenau Medical Center, a 370 bed community hospital. The usage of pantoprazole infusion was determined among hospitalized patients between March 1, 2018 and March 1, 2021 through review of the EPIC electronic medical record system. Appropriate candidates for pantoprazole infusion were defined as patients with hematemesis, melena, coffee-ground emesis, or hematochezia with hemodynamic instability. All other indications were categorized as inappropriate. Variables including age, sex, race, serum hemoglobin at the time of PPI infusion initiation, and antiplatelet use were collected. The rate of PPI infusion misuse was determined. Factors which significantly affected utilization of PPI infusion were determined through multivariate analysis. Results: A total of 348 pre-endoscopic PPI infusions were ordered during the three-year period. Approximately 35% of these prescriptions were ordered without an appropriate indication. The mean age of patients who were prescribed PPI infusions was 68.8 years. 48.6% were on an antiplatelet agent. The only significant variable between patients who were given a PPI infusion for an appropriate versus inappropriate indication was age, where the mean patient age was 68.8 compared to 71.1 years (p=0.04). Patient sex, race, antiplatelet use, and hemoglobin value did not significantly affect PPI infusion use. (Table) Conclusion: Pre-endoscopic PPI infusion was prescribed inappropriately in 34.8% of patients in a community hospital setting. Misuse of this drug leads to unnecessary healthcare costs and reflects poor understanding among prescribers of its appropriate clinically indicated uses. While PPIs are generally regarded as safe, misuse can increase the risk of adverse side effects. A follow-up study looking at a quality improvement intervention will follow this study. Table 1. - Characteristics and Multivariate Analysis of PPI Infusion Misuse Inappropriate PPI Infusion No Yes Total p-value n = 227 n = 121 n = 348 Age (Mean/SD) 67.6 (14.8) 71.1 (15.1) 68.8 (15.0) 0.04 Sex 0.571 Male 131 (57.7%) 66 (54.6%) 197 (56.6%) Female 96 (42.3%) 55 (45.5%) 151 (43.4%) Race 0.705 White 104 (46.0%) 59 (48.8%) 163 (47.0%) Black 112 (49.6%) 55 (45.5%) 167 (48.1%) Other 10 (4.4%) 7 (5.8%) 17 (4.9%) Ethnicity 0.12 Not Hispanic 225 (99.6%) 116 (97.5%) 341 (98.8%) Hispanic 1 (0.4%) 3 (2.5%) 4 (1.2%) Total Number of Antiplatelets 0.629 0 121 (53.3%) 58 (47.9%) 179 (51.4%) 1 70 (30.8%) 41 (33.9%) 111 (31.9%) 2 36 (15.9%) 22 (18.2%) 58 (16.7%) Antiplatelet Type (n = 169 Yes Only) Aspirin 103 (45.4%) 61 (50.4%) 164 (47.1%) 0.37 Clopidogrel 36 (15.9%) 23 (19.0%) 59 (17.0%) 0.456 Ticagrelor 4 (1.8%) 4 (3.3%) 8 (2.3%) 0.456 Prasugrel 1 (0.4%) 0 1 (0.3%) 1 Last Hemoglobin (Mean/SD, g/dl) 8.9 (2.6) 8.6 (2.9) 8.8 (2.7) 0.344 Missing Hemoglobin 19 8 27 Transfusion Units (median/IQR) 2 (0-6) 2 (0-4) 2 (0-5) 0.478

Complications After Transthoracic Needle Biopsy of Pulmonary Nodules: A Population-Level Retrospective Cohort Analysis.

To provide recent population-based estimates of transthoracic needle biopsy (TTNB) complications and risk factors associated with these complications. This retrospective cohort analysis included adults from a nationally representative longitudinal insurance claims data set who underwent TTNB in 2017 or 2018. Complications that were evaluated included pneumothorax, hemorrhage, and air embolism. Separate logistic regression models estimated the association of pneumothorax or hemorrhage with the setting of care (ie, inpatient or outpatient) and selected baseline patient demographic and clinical characteristics including age, gender, history of chronic obstructive pulmonary disease, diagnosis of pleural effusion, tobacco use, use of oral anticoagulants and antiplatelet agents, prior lung cancer screening, previous bronchoscopy within 1 year, and Elixhauser comorbidity index. Among 16,971 patients who underwent TTNB, 25.8% experienced a complication within 3 days of the procedure (pneumothorax 23.3%, hemorrhage 3.6%, and air embolism 0.02%). Among patients who experienced pneumothorax, 31.9% required chest tube drainage. Among patients undergoing an outpatient TTNB (n= 12,443), 6.9% were hospitalized within 7 days. Biopsy in an inpatient setting, chronic obstructive pulmonary disease diagnosis, and prior bronchoscopy were associated with higher rates of both pneumothorax and hemorrhage. Prior lung cancer screening was associated with an increased risk of pneumothorax, and prior use of oral anticoagulants or antiplatelets was associated with higher rates of hemorrhage. This contemporary population-based cohort study demonstrated that approximately one-quarter of patients undergoing TTNB experienced a complication. Pneumothorax was the most frequent complication, and hemorrhage and air embolism were rare. Among outpatients, complications from TTNB are an important cause of hospitalization.

Risk factors for hematoma in patients undergoing cardiac device procedures: A WRAP-IT trial analysis.

Implant site hematoma is a known complication of cardiac device procedures and can lead to major consequences. To evaluate risk factors for hematoma and further understand the relationship between anticoagulant (AC), antiplatelet (AP) use, and hematoma development. We included 6800 patients from the WRAP-IT trial. To assess baseline and procedural characteristics associated with hematoma within the first 30 days postprocedure, a stepwise Cox regression model was implemented with minimal Akaike information criterion. Cox regressions were also used to evaluate AC/AP use and hematoma risk. The overall rate of hematoma was 2.2%. The model identified 11 baseline and procedural characteristics associated with hematoma risk. AC use (hazard ratio [HR]: 2.44, P < .001), lower body mass index (HR: 1.06, P < .001), and history of valve surgery (HR: 2.11, P < .001) were associated with the highest risk. AP use, male sex, history of coronary artery disease, existing pocket, history of nonischemic cardiomyopathy, number of previous cardiac implantable electronic device (CIED) procedures, procedure time, and lead revision were associated with moderate risk. Antithrombotic use was high overall (86%) and AC+AP use was highly predictive of hematoma risk. Regardless of AC status, AP use was associated with an almost doubling of risk vs no AP (HR = 1.85, P = .0006) in the general cohort. Interruption of AC was associated with the lowest hematoma risk (HR = 2.35) while heparin bridging (HR = 4.98) and AP use vs no AP use (HR = 1.85) was associated with the highest hematoma risk. The results of this analysis highlight risk factors associated with the development of hematoma in patients undergoing CIED procedures and can inform antithrombotic management.

Educational level differences in the primary and secondary prevention of stroke

The aim of this study is to estimate the educational level differences in the primary and secondary prevention of stroke among the Chinese population. Data were obtained from the China Kadoorie Biobank (CKB) survey of 512,891 people aged 30–79 years in 10 geographic regions of China, which was conducted from 2002 to 2008. The Prediction for Atherosclerotic Cardiovascular Disease Risk in China model was used to identify individuals with a high estimated 10-year stroke risk. A total of 8884 participants (1.7%) had established stroke and 218,972 (42.7%) had a high stroke risk. In both primary and secondary prevention, the participants' educational level was positively associated with the control of smoking, blood pressure, consuming a healthy diet, and the use of antiplatelet, BP-lowering medications but negatively associated with higher physical activity levels (all Ptrend < 0.001). In addition, the positive associations were observed with the control of drinking and use of anti-hyperglycaemia medication for primary prevention (all Ptrend < 0.001) and with the use of lipid-lowering medication for secondary prevention (Ptrend = 0.019). The results of the interaction between education level and prevention level showed that, compared with participants in primary prevention, educational level disparities in those with secondary prevention had significantly higher use of antiplatelets and lipid-lowering drugs, achieving the physical activity goal and non-current drinker (all Pfor interaction < 0.05). A higher education level was associated with an increased acceptance of primary and secondary prevention strategies (not smoking or drinking, consuming a healthier diet) except for engaging in a suitable level of physical activity.

Effect of specialist consultation on emergency department revisits among patients with uncomplicated recent-onset atrial fibrillation or flutter.

To examine the association between specialist consultation and risk of 30-day ED revisit in emergency department (ED) patients with recent-onset uncomplicated atrial fibrillation or flutter (AF/AFL). As a secondary analysis of a previously published trial, clinical experts identified predictors of consultation including age and sex, ED sinus conversion, thromboembolic risk, heart rate, rate control medication use, coronary artery disease and anti-platelet use, and chronic obstructive pulmonary disease. These were included in a propensity-matched hierarchical Bayesian model accounting for hospital site as a random effect, with 30-day ED revisit as the primary outcome. We also measured ED length of stay for consulted and non-consulted patients. We analyzed data from 11 sites for 829 ED patients with AF/AFL, of whom 364 (44%) had specialist consultation. A total of 128 patients (15.4%) had an ED revisit, 78 (16.8%) from the no consult group and 50 (13.7%) from the consult group. Consultation rates ranged from 8.8 to 71% between sites. Median length of stay was 591min (interquartile range [IQR] 359-1024) for consulted patients and 300min (IQR 212-409) for patients without consultation. After propensity-matching, consulted patients had a 0.6% (IQR -4 to 3%) lower risk of 30-day revisits than non-consulted patients (probability of lower risk 55%). In ED patients with uncomplicated AF/AFL, there was substantial between-site variation in specialist consultations; such consultation was unlikely to influence revisits within 30days while ED length of stay was nearly double. ED specialist consultations may not be necessary for uncomplicated patients.

Direct Oral Anticoagulants versus Vitamin K Antagonists for the Treatment of Left Ventricular Thrombosis: A Meta-Analysis.

Vitamin K antagonists (VKAs) have been recommended as first-line anticoagulants for patients with left ventricular thrombosis (LVT). Direct oral anticoagulants (DOACs) are used as an alternative to the standard of care in anticoagulation. The aim of this meta-analysis was to compare the efficacy and safety of VKAs and DOACs in the treatment of patients with LVT. Studies were identified by searching the PubMed, Web of Science, and Embase. The main outcomes included stroke or systemic embolism (SSE), thrombus resolution, and bleeding events. The pooled risk ratio (RR) with 95% confidence intervals (CIs) was estimated with fixed effect or random effect models. Seventeen studies were included. Pooled estimate showed that DOACs had comparable efficacy in prevention of SSE (RR = 0.96, 95% CI: 0.80, 1.16; p = 0.677) and thrombus resolution as compared with VKAs (RR = 1.07, 95% CI: 0.97, 1.18; p = 0.193). DOACs significantly decreased the risk of stroke in patients with LVT (RR = 0.68, 95% CI: 0.47, 1.00; p = 0.048). However, this effect was not observed in the sensitive analysis by high-quality studies (RR = 0.69, 95% CI: 0.47, 1.02; p = 0.06). In terms of safety outcomes, DOACs had similar risk of bleeding events (RR = 1.12, 95% CI: 0.80, 1.57; p = 0.386) and clinically relevant bleeding events (RR = 0.49, 95% CI: 0.23, 1.03; p = 0.060). Meta-regression analysis demonstrated that none of the variables (study design, concomitant antiplatelet medication, duration of follow-up, primary cause of LVT, sample size, types of DOACs) had an impact on the risk of SSE, thrombus resolution and bleeding events. Subgroup analysis based on the use of antiplatelet and treatment switching revealed that there were no significant differences among patients with different treatment regimens. Based on the present evidence, both DOACs and VKA offered similar effective and safe outcomes in patients with LVT.

Dual vs. mono antiplatelet therapy for acute ischemic stroke or transient ischemic attack with evidence of large artery atherosclerosis

Background and purposeCurrent pieces of evidence support the short-term use of dual antiplatelet (DAPT) in minor ischemic stroke or transient ischemic attack (TIA) based on the studies performed in patients with a broad range of non-cardioembolic stroke mechanisms. However, the efficacy and safety of DAPT use in ischemic stroke patients with large artery atherosclerosis (LAA) are still uncertain. We undertook a systemic search and formal meta-analysis to compare DAPT vs. mono-antiplatelet therapy (MAPT) in patients with etiology specifically presumed to be symptomatic LAA.MethodsWe conducted a systemic online search for completed randomized controlled trials that (1) compared DAPT vs. MAPT in patients with acute ischemic stroke or TIA, and (2) were confined to or had available subgroup data regarding population with symptomatic extra- or intracranial artery stenosis. Study-level meta-analysis was performed for outcomes, including ischemic stroke (IS) recurrence, intracranial hemorrhage (ICH), and major bleeding with the Mantel-Haenszel method and random effect models, and was described as risk difference (RD) and 95% CI.ResultsA total of 10 trials including 5,004 patients were pooled. Comparing to MAPT, DAPT significantly reduced IS recurrence (5.99 vs. 9.55%, RD: −3%, 95% CI: −5–0%). Across all agents, out of 100 treated patients, 3 fewer had a recurrent ischemic stroke with DAPT. The safety endpoints including ICH (0.28 vs. 0.32%, RD: 0%, 95% CI: −0–0%) and major bleeding (0.73 vs. 0.51%, RD: 0%, 95% CI: −0–0%) did not differ significantly.ConclusionIn patients with symptomatic large artery extracranial or intracranial atherosclerosis, DAPT was superior to MAPT in preventing IS recurrence without increasing bleeding risks. The optimal DAPT regimens and duration of treatment in this population need to be clarified in further studies.