Use Of Therapeutic Anticoagulation Research Articles

Management of isolated distal deep vein thrombosis.

Isolated distal deep vein thrombosis (DVT) represents up to 50% of all lower limb DVT in ultrasound series and is a frequent medical condition, which management is not well established. Data arising from registries and non-randomized studies suggest that most distal DVTs do not extend to the proximal veins and have an uneventful follow-up when left untreated. This data had some impact on international recommendations like the American College of Chest Physicians (ACCP), whose last version stated that ultrasound surveillance might be an option for selected low-risk patients. However, robust data arising from randomized studies are scarce. Indeed, only seven randomized trials assessing the need for anticoagulation for calf DVT have been published. Many of these trials had an open-label design and were affected by methodological limitations. When considering randomized placebo-controlled trials, one included low-risk patients and was hampered by a limited statistical power (CACTUS study). Nevertheless, data from this trial tend to confirm that the use of therapeutic anticoagulation in low-risk patients with symptomatic calf DVT is not superior to placebo in reducing VTE but is associated with a higher risk of bleeding. A second randomized placebo-controlled trial did not assess the necessity of anticoagulant treatment but rather the long-term risk of recurrence and compared 6 weeks versus 12 weeks of treatment with rivaroxaban (RIDTS study). Finally, the last available randomized trial compared a 3-month versus a 12-month edoxaban treatment in patients with cancer and mainly asymptomatic distal DVT, detected by systematic compression ultrasonography. Overall, available data suggest that the use of therapeutic anticoagulation in low-risk patients with symptomatic calf DVT is not superior to placebo in reducing VTE. High risk patients (previous VTE, active cancer, inpatients) might benefit from a course of anticoagulant treatment. However, the optimal anticoagulant intensity and duration are uncertain and further studies are needed.

Management of varices but not anticoagulation is associated with improved outcome in patients with HCC and macrovascular tumour invasion

Background & aimsThe value of bleeding prophylaxis and anticoagulation in patients with hepatocellular carcinoma (HCC) and macrovascular tumour invasion (MVI) is unclear. We evaluated the impact of anticoagulation on thrombosis progression, bleeding events, and overall mortality, and assessed the efficacy of adequate management of varices as recommended for patients with cirrhosis.MethodsHCC patients with MVI who had Child-Turcotte-Pugh A-B7 were included between Q4/2002 and Q2/2022. Localization of the tumour thrombus and changes at 3–6 months were evaluated by two radiologists. Univariable and multivariable logistic/Cox regression analyses included time-dependent variables (i.e., anticoagulation, systemic therapy, non-selective beta blocker treatment).ResultsOf 124 patients included (male: n = 110, 89%), MVI involved the main portal vein in 47 patients (38%), and 49 individuals (40%) had additional non-tumorous thrombus apposition. Fifty of 80 patients (63%) with available endoscopy had varices. Twenty-four individuals (19%) received therapeutic anticoagulation and 94 patients (76%) were treated with effective systemic therapies. The use of therapeutic anticoagulation did not significantly affect the course of the malignant thrombosis at 3–6 months. Systemic therapy (aHR: 0.26 [95%CI: 0.16–0.40]) but not anticoagulation was independently associated with reduced all-cause mortality. In patients with known variceal status, adequate management of varices was independently associated with reduced risk of variceal bleeding (aHR: 0.12 [95%CI: 0.02–0.71]). In the whole cohort, non-selective beta blockers were independently associated with reduced risk of variceal bleeding or death from any cause (aHR: 0.69 [95%CI: 0.50–0.96]).ConclusionAdequate bleeding prophylaxis and systemic anti-tumour therapy but not anticoagulation were associated with improved outcomes in patients with HCC and MVI.

Therapeutic anticoagulation for splanchnic vein thrombosis in acute pancreatitis: A national survey and case-vignette study.

Splanchnic vein thrombosis (SVT) is a major complication of moderate and severe acute pancreatitis. There is no consensus on whether therapeutic anticoagulation should be started in patients with acute pancreatitis and SVT. To gain insight into current opinions and clinical decision making of pancreatologists regarding SVT in acute pancreatitis. A total of 139 pancreatologists of the Dutch Pancreatitis Study Group and Dutch Pancreatic Cancer Group were approached to complete an online survey and case vignette survey. The threshold to assume group agreement was set at 75%. The response rate was 67% (n = 93). Seventy-one pancreatologists (77%) regularly prescribed therapeutic anticoagulation in case of SVT, and 12 pancreatologists (13%) for narrowing of splanchnic vein lumen. The most common reason to treat SVT was to avoid complications (87%). Acute thrombosis was the most important factor to prescribe therapeutic anticoagulation (90%). Portal vein thrombosis was chosen as the most preferred location to initiate therapeutic anticoagulation (76%) and splenic vein thrombosis as the least preferred location (86%). The preferred initial agent was low molecular weight heparin (LMWH; 87%). In the case vignettes, therapeutic anticoagulation was prescribed for acute portal vein thrombosis, with or without suspected infected necrosis (82% and 90%), and thrombus progression (88%). Agreement was lacking regarding the selection and duration of long-term anticoagulation, the indication for thrombophilia testing and upper endoscopy, and about whether risk of bleeding is a major barrier for therapeutic anticoagulation. In this national survey, the pancreatologists seemed to agree on the use of therapeutic anticoagulation, using LMWH in the acute phase, for acute portal thrombosis and in the case of thrombus progression, irrespective of the presence of infected necrosis.

Ballooning without Compaction Left Ventricular aneurysms in Noncompaction Cardiomyopathy

Left ventricular non-compaction cardiomyopathy (LVNC) is a congenital cardiomyopathy that occurs as a result of disruption in the early stages of cardiac development. It can occur in isolation, or in conjunction with other rare congenital disorders such as a congenital left ventricular aneurysm. In the presence of LVNC, left ventircular aneurysms are thought to occur due to lack of capillary formation. Overall, there are very limited cases documenting both together. Both conditions can result in arrhythmias, thromboembolic disease, ventricular dysfunction and sudden cardiac death. Diagnosis can be made with echocardiography, although cardiac magnestic resoncnance imaging has become increasingly used for diagnosis. Treatment involves treating heart failure symptoms, arrhythmias and implantation of cardioverter-defibrillators when appropriate. Despite the few case reports on the presence of both conditions occuring simulatenously, recommedenations on treatment, including the use of therapeutic anticoagulation in this patient population needs to be looked into further.

Performance of a Prospective Anticoagulation Stratification Algorithm After Liver Transplantation.

In a prospective management QI initiative for DVT management, we compared 87 LT historical patients (control group; January 2016-December 2017) to 182 LT patients (study group; January 2018-March 2021). We analyzed the rates of immediate therapeutic anticoagulation after DVT diagnosis within 14 d of LT, clinically significant bleeding, return to the operating room, readmission, pulmonary embolism, and death within 30 d of LT before and after the QI initiative. Ten patients (11.5%) in the control group and 23 patients (12.6%; P = 0.9) in the study group developed DVTs after LT. Immediate therapeutic anticoagulation was used in 7 of 10 and 5 of 23 patients in the control and study groups, respectively (P = 0.024). The study group had lower odds of receiving immediate therapeutic anticoagulation after VTE (21.7% versus 70%; odds ratio = 0.12; 95% confidence interval, 0.019-0.587; P = 0.013) and a lower rate of postoperative bleeding (8.7% versus 40%; odds ratio = 0.14, 95% confidence interval, 0.02-0.91; P = 0.048). All other outcomes were similar. Implementing a risk-stratified VTE treatment algorithm for immediate post-LT patients appears to be safe and feasible. We observed a decrease in the use of therapeutic anticoagulation and a lower rate of postoperative bleeding without adverse impacts on early outcomes.

Variation in Troponin I Measurement and the Cardiovascular Management Approach Following Elevated Troponin I Among Critically Ill Patients With Sepsis.

We aimed to describe the variation in troponin I measurement and the cardiovascular diagnostic and therapeutic approach to elevated troponin I among critically ill adults with sepsis. Observational cohort study of the hospital-level variation in serial troponin I measurement, trending troponin I to peak, echocardiography, cardiac stress test, cardiac catheterization, antiplatelet agents, therapeutic anticoagulation, beta-blockers, and statins quantified using hospital median odds ratios-the median odds of receiving an intervention at randomly selected higher versus lower rate hospitals-derived from multivariable-adjusted random-effects logistic regression models with hospital site as the random effect. The Premier Healthcare Database was used. Patients were adults aged greater than 18 years admitted to the ICU with sepsis from 2016 to 2020. The hospital-level median odds ratios of troponin I measurement as well as cardiovascular diagnostics and therapeutics. Among 85,830 adults with sepsis, 53,058 (61.8%) had a troponin I measured, with a median odds ratio of troponin measurement across hospitals of 5.30 (95% CI, 4.98-5.67). Among 27,665 adults (32.2%) with sepsis and an elevated troponin I level, 84.8% had serial troponin I measurements, 66.0% had troponin trended to peak level, 66.7% had an echocardiogram, 4.1% had a cardiac stress test, 6.6% underwent cardiac catheterization, 48.3% received antiplatelet agents, 8.3% received therapeutic anticoagulation, 50.5% received beta-blockers, and 38.1% received statins. The median odds ratios between hospitals for cardiovascular diagnostics and therapeutics ranged from 1.28 (95% CI, 1.24-1.32) for use of beta-blockers to 7.58 (95% CI, 6.43-8.77) for use of therapeutic anticoagulation. Both troponin I measurement and the approach to an elevated troponin I among critically ill adults with sepsis varied widely across hospitals consistent with disparate practice and care efficiency. Prospective studies are needed to guide an informed approach to troponin I measurement and cardiovascular evaluation in sepsis.

Asymptomatic Postoperative Cerebral Venous Sinus Thrombosis After Posterior Fossa Tumor Surgery: Incidence, Risk Factors, and Therapeutic Options.

Cerebral venous sinus thrombosis (CVST) is a known complication of posterior fossa surgery near the sigmoid and transverse sinus. The incidence and treatment of postoperative asymptomatic CVST are controversial. To analyze incidence, risk factors, and management of asymptomatic postoperative CVST after posterior fossa tumor surgery. In this retrospective, single-center study, we included all patients who underwent posterior fossa tumor surgery in the semisitting position between January 2013 and December 2020. All patients underwent preoperative and postoperative imaging using MRI with/without additional computed tomography angiography. We analyzed the effect of demographic and surgical data on the incidence of postoperative CVST. Furthermore, therapeutic anticoagulation or conservative treatment for postoperative CVST and the incidence of intracranial hemorrhage were investigated. In total, 266 patients were included. Thirty-three of 266 (12.4%) patients developed postoperative CVST. All patients were asymptomatic. Thirteen of 33 patients received therapeutic anticoagulation, and 20 patients did not. Univariate analysis showed that age ( P = .56), sex ( P = .20), American Society of Anesthesiology status ( P = .13), body mass index ( P = .60), and length of surgery ( P = .176) were not statistically correlated with postoperative CVST. Multivariate analysis revealed that meningioma ( P < .001, odds ratio 11.3, CI 95% 4.1-31.2) and vestibular schwannoma ( P = .013, odds ratio 4.4, CI 95% 1.3-16.3) are risk factors for the development of new postoperative CVST. The use of therapeutic anticoagulation to treat postoperative CVST was associated with a higher rate of intracranial hemorrhage (n = 4, P = .017). Tumor entity influences the incidence of postoperative CVST. In clinically asymptomatic patients, careful decision making is necessary whether to initiate therapeutic anticoagulation or not.

Dynamics of disease characteristics and clinical management of critically ill COVID-19 patients over the time course of the pandemic: an analysis of the prospective, international, multicentre RISC-19-ICU registry

BackgroundIt remains elusive how the characteristics, the course of disease, the clinical management and the outcomes of critically ill COVID-19 patients admitted to intensive care units (ICU) worldwide have changed over the course of the pandemic.MethodsProspective, observational registry constituted by 90 ICUs across 22 countries worldwide including patients with a laboratory-confirmed, critical presentation of COVID-19 requiring advanced organ support. Hierarchical, generalized linear mixed-effect models accounting for hospital and country variability were employed to analyse the continuous evolution of the studied variables over the pandemic.ResultsFour thousand forty-one patients were included from March 2020 to September 2021. Over this period, the age of the admitted patients (62 [95% CI 60–63] years vs 64 [62–66] years, p < 0.001) and the severity of organ dysfunction at ICU admission decreased (Sequential Organ Failure Assessment 8.2 [7.6–9.0] vs 5.8 [5.3–6.4], p < 0.001) and increased, while more female patients (26 [23–29]% vs 41 [35–48]%, p < 0.001) were admitted. The time span between symptom onset and hospitalization as well as ICU admission became longer later in the pandemic (6.7 [6.2–7.2| days vs 9.7 [8.9–10.5] days, p < 0.001). The PaO2/FiO2 at admission was lower (132 [123–141] mmHg vs 101 [91–113] mmHg, p < 0.001) but showed faster improvements over the initial 5 days of ICU stay in late 2021 compared to early 2020 (34 [20–48] mmHg vs 70 [41–100] mmHg, p = 0.05). The number of patients treated with steroids and tocilizumab increased, while the use of therapeutic anticoagulation presented an inverse U-shaped behaviour over the course of the pandemic. The proportion of patients treated with high-flow oxygen (5 [4–7]% vs 20 [14–29], p < 0.001) and non-invasive mechanical ventilation (14 [11–18]% vs 24 [17–33]%, p < 0.001) throughout the pandemic increased concomitant to a decrease in invasive mechanical ventilation (82 [76–86]% vs 74 [64–82]%, p < 0.001). The ICU mortality (23 [19–26]% vs 17 [12–25]%, p < 0.001) and length of stay (14 [13–16] days vs 11 [10–13] days, p < 0.001) decreased over 19 months of the pandemic.ConclusionCharacteristics and disease course of critically ill COVID-19 patients have continuously evolved, concomitant to the clinical management, throughout the pandemic leading to a younger, less severely ill ICU population with distinctly different clinical, pulmonary and inflammatory presentations than at the onset of the pandemic.

A retrospective cohort study assessing the incidence of inferior vena cava (IVC) occlusion following prophylactic IVC filter insertion: Is anticoagulation necessary during filter dwell?

BackgroundInferior vena cava (IVC) filters play a role in preventing venous thromboembolism after major trauma where deep venous thrombosis (DVT) risk is up to 80%. It has been suggested that IVC filters are thrombogenic and many patients are therefore placed on therapeutic anticoagulation during IVC filter dwell citing concern of in situ IVC thrombosis, even in the absence of existing DVT. MethodsBetween 1 June 2018 and 31 December 2021, this retrospective study assessed the incidence of IVC thrombosis following prophylactic IVC filter insertion. Groups were defined according to the presence or absence of therapeutic anticoagulation during filter dwell. The primary outcome was the presence or absence of IVC thrombus at retrieval. ResultsA total of 124 patients were included. Anticoagulation was prescribed in 29 and anticoagulation was not prescribed in 63. A further 32 patients developed a new thrombosis episode after the prophylactic IVC filter was placed, and 29 were prescribed anticoagulation part-way during filter dwell as a result of this diagnosis. No cases of IVC occlusion were observed in any patient group. ConclusionsCaval thrombosis was not observed after prophylactic filter placement, with or without the prescription of anticoagulation. While prospective trials are needed to increase the level of evidence, based on these results the use of therapeutic anticoagulation during IVC filter dwell should not be dictated by the presence of an IVC filter alone but rather by the presence of a related thrombosis event.

Management of anticoagulation in pregnant women with venous thromboembolism: An international survey of clinical practice

IntroductionVenous thromboembolism (VTE) is an important cause of maternal morbidity and mortality. During pregnancy, VTE is treated with low-molecular-weight-heparin (LMWH). Studies assessing the optimal duration and peripartum management of therapeutic anticoagulation are lacking. This survey aimed to assess clinician practices for the management of anticoagulation in pregnant women with acute VTE. MethodsAn electronic survey consisting of clinical scenarios addressing anticoagulation management for VTE in pregnancy was created. The target sample was clinicians likely to be involved in the management of pregnant women with acute VTE. The survey completion rate and proportion of individuals selecting a response were determined. Results96 respondents completed the survey including general internists (56.3%), hematologists (21.9%), and obstetricians (6.3%). In the management of a VTE in first or second trimester, most respondents preferred therapeutic LMWH until 6 weeks postpartum. In the first and second trimester, 48.0% and 37.5% of respondents, respectively, opted to reduce the dose of anticoagulation after 3 or 6 months. 29.2% of physicians opted for bridging with intravenous heparin around delivery when treating a VTE in the third trimester. 73.0% perceived an increased risk of clinically relevant non-major bleeding associated with the use of therapeutic anticoagulation in the peripartum and postpartum periods. ConclusionsThe survey highlights a wide variability of practice in the management of therapeutic anticoagulation in pregnancy. Larger scale studies with relevant clinical outcomes including thrombosis and bleeding risks are needed to inform clinical practice.

OR32. Efficacy and Safety of Therapeutic Versus Prophylactic Dose of Anticoagulation in Hospitalized Patients with Severe COVID-19 Pneumonia and Coagulopathy: An Open-Label, Randomized Controlled Trial

Background and AimsThe use of therapeutic anticoagulation to improve outcomes in COVID-19-associated coagulopathy remains unclear. We aimed to compare the efficacy and safety of therapeutic versus standard prophylactic anticoagulation in this population.Methods and ResultsThis was a single-center, open-label, two-arms, randomized controlled study conducted from 1st April to 15th July 2021. Two-hundred fifty severe COVID-19 patients with coagulopathy were randomly assigned (1:1 ratio) to receive either prophylactic anticoagulation (subcutaneous unfractionated heparin/UFH 5000IU b.i.d or fondaparinux 2.5mg o.d) or therapeutic anticoagulation (weight-adjusted dose UFH or fondaparinux). Anticoagulation was administered until hospital discharge or at the treating physician’s discretion. All patients received international COVID-19 guideline-driven therapy throughout the study. Baseline characteristics were not significantly different (p > 0.05) between both arms, except for the D-dimer and CRP level at admission (p = 0.04; p = 0.001; respectively). During a 30-day follow-up, therapeutic arm revealed significant higher need for NIV/invasive MV (41.3% vs. 29%, p = 0.02), higher progression to ARDS (34.1% vs. 16.1%, p = 0.001), and increased 30-day all-cause mortality (58.7% vs. 15.3%, p < 0.001) as compared with prophylactic arm. There was no significant difference between both arms in the incidence of acute MI (20% vs. 13.6%, p = 0.07), VTE (4.8% vs. 0.8%, p = 0.09), arterial thromboembolism (3.2% vs. 0%, p = 0.29) and overall bleeding (17.6% vs. 6.4%, p = 0.18) at 30-days.ConclusionTherapeutic anticoagulation was considered safe and effective in preventing thromboembolic events, but not in the need for NIV/invasive MV, progression to ARDS and 30-day all-cause mortality in hospitalized patients with severe COVID-19 and coagulopathy.

Clinical Outcomes in Critically-Ill Patients with COVID-19 Treated with Therapeutic Dose of Anticoagulants for Suspected Thromboembolism

IntroductionSince March 2020, the New York City hospitals have experienced a tremendous surge of COVID-19 cases. Our hospital admitted 877 patients in a 2-week period, from March 15 to Apr 1, 2020. The exact mechanism of how COVID-19 causes vascular injury is unclear but some experts attribute it to widespread vascular inflammation[2,3]. The limited understanding of the hypercoagulable mechanism has limited our treatment techniques. To date, whether therapeutic anticoagulation is the right choice in regard to optimal management of patients with COVID-19 in suspected but not confirmed DVT (deep vein thrombosis) or PE (pulmonary embolism) is still a question[4].MethodWe performed a retrospective observational cohort analysis of 145 adult ICU patients at an acute care teaching hospital located in Queens County, New York between March 15, 2020 to April 1, 2020. The study was approved by IRB. All patients >18 years of age with confirmed SARS-CoV-2 infection and determined to require admission to intensive care units between March 15, 2020 and April 1, 2020, inclusive of those dates, were included in the investigation, with the exclusion of pregnant patients. All data was collected from the electronic health record (Allscripts) and was compiled in REDCap software for data encryption. During that study period, therapeutic anticoagulants were used in hospitalized patients with COVID-19 with high clinical risk or suspicion for venous thromboembolism (VTE). As per hospital protocol, heparin continuous infusion with a target activated partial thromboplastin time of 50 to 70 seconds or enoxaparin 1mg/kilogram(kg) twice a day for creatinine clearance (CrCl) above 30 ml/min or once a day for CrCl below 30 ml/min were used to achieve therapeutic anticoagulation. The primary outcome of the study was 28-day in-hospital mortality for critically ill patients affected by COVID-19 with or without the use of therapeutic anticoagulation. Covariates included in analysis were hypertension, diabetes, hyperlipidemia, cardiac history, and use of antiplatelet and anticoagulant medications prior to admission. Statistical analysis was done using R version 4.0.2.ResultsOut of 145 ICU patients, 61 received therapeutic anticoagulation. Kaplan-Meier survival curves show the survival probability with respect to days after admission for the two groups (those who used anticoagulant therapeutic drugs and those who didn't) using 28-day in-hospital mortality.(Fig 1) Median age for patients was 61 years for patients who didn't receive therapeutic anticoagulants compared to 60 years for patients who received therapeutic doses. The mean D-dimer among patients who received therapeutic anticoagulation was 20462 ng/ml (D-dimer units) compared to 7872 ng/ml for those who did not. The median number of days of survival for those who did not take anticoagulant therapeutic drugs is 10 days, while the median for those who did take anticoagulant therapeutic drugs is 25 days. After adjusting for hypertension, diabetes, hyperlipidemia, cardiac history, home antiplatelet medication use and continuous response for peak d-dimer levels, the results also show that there is a causal effect of 22.2 % decreased risk of 28-day in-hospital mortality if one received the therapeutic anticoagulant in the hospital.ConclusionOur findings suggest that there is a significantly higher median survival time in critically ill patients who received therapeutic anticoagulants in the hospital compared to those who didn't. However, our study is limited by observational nature, possible unobserved confounding, lack of metrics to classify illness severity as well as lack of evidence based decision guideline in initiation of therapeutic anticoagulation. There is an urgent need for further evidence-based studies like clinical trials which are necessary to provide specific guidelines for use of therapeutic anticoagulants in patients with COVID-19 infection.

A CLOSER LOOK INTO THE DEMOGRAPHICS AND CLINICAL OUTCOME OF PATIENTS WITH COVID-19 IN THE ICU: A RETROSPECTIVE COHORT ANALYSIS

TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: COVID-19 is a major public health emergency with increasing mortality since the first case in December 2019. COVID-19 has multifaceted presentation and only about 15-20% required hospitalizations and a quarter of those required management in an intensive care unit (ICU). Herein, we reviewed the demographics, clinical outcomes, and identified the potential prognostic indicators in patients with COVID-19 who were admitted to our ICU. METHODS: A retrospective cohort study was conducted on patients ≥ 18 years old with confirmed COVID-19, who were admitted to our ICU between 03/17/2020 and 05/14/2020. Demographic, clinical, and laboratory data were reviewed and retrieved. Data was expressed as counts and percentages. T-test and chi-square (χ) were used for continuous and categorical variables respectively. Univariate analysis was also performed to identify the prognostic indicators associated with mortality. GraphPad PRISM was used for data analysis. RESULTS: Seventy-five patients were identified during the study period with an average age of 60.8 (ranged from 19-89), of which males were 99 (71%) and females were 41 (29%). Majority were Hispanic (45%) and African Americans (34%). The average body mass index was 30.6. Hypertension (47.9%) and chronic kidney disease (47.1%) were the most common comorbidities. Mechanical ventilation was required in 99 (70.7%) of the patients. Of those 99, 75 (76%) expired. There was no statistically significant difference between the survival and expired groups in term of age, gender, ethnicities and number of comorbidities. Need of mechanical ventilation (MV) and renal replacement therapy (RRT) were significantly associated with mortality (p<0.0001 for both parameters). Interestingly, use of therapeutic anticoagulation was associated with decrease risk of mortality (p-value 0.03865). When looking into the laboratory parameters, higher blood urea nitrogen (BUN) on Day 5 (p-value 0.0067), initial LDH (p<0.0001), initial CRP (p-value 0.0062), white blood cell counts (WBC) (p<0.0001), and high absolute neutrophil counts (ANC) (p-value 0.0002) were statistically associated with increased risk of mortality. SOFA scores did not predict mortality in these patients (p-value 0.9243) CONCLUSIONS: This retrospective cohort study on patients with COVID-19 who required ICU showed that need for Mechanical Ventilation and Renal Replacement Therapy were significantly associated with mortality. Surprisingly, use of therapeutic anticoagulation decreased the risk of mortality and initial LDH and CRP were the two inflammatory markers that may help predict mortality. This interesting finding need to be corroborated in a larger study. CLINICAL IMPLICATIONS: This study was done using the data during the initial two months of first wave of COVID-19 in the United States and the data represents our observations at that time. Several studies have been done on the use of Anticoagulation in COVID-19 patients thereafter, however there is no universally accepted protocol. This study helped us identify the differences in the outcome between first and second use with aggressive use of anticoagulation, Remdesivir, and dexamethasone during the second wave. DISCLOSURES: No relevant relationships by Sharath Bellary, source=Web Response No relevant relationships by Kok Hoe Chan, source=Web Response No relevant relationships by Joanna Crincoli, source=Web Response No relevant relationships by Claudia Komer, source=Web Response No relevant relationships by Sudha Lagudu, source=Web Response No relevant relationships by Richard Miller, source=Web Response No relevant relationships by Meenakshi Sindhuri Nali, source=Web Response No relevant relationships by Amy Paige, source=Web Response No relevant relationships by Rutwik Patel, source=Web Response No relevant relationships by Laxminarayan Prabhakar, source=Web Response No relevant relationships by Amr Ramahi, source=Web Response No relevant relationships by Divya Mounisha Thimmareddygari, source=Web Response

A New Device for Managing Refractory Epistaxis in ICU Patients with COVID-19

Epistaxis is a common and a well-known symptom. Nasal packing is an effective treatment in most cases [1]. The COVID-19 disease treatment includes conventional or high flow nasal oxygen therapy and systemic anticoagulation [2]. Patients in intensive care unit may require therapeutic anticoagulation for venous thromboembolism, hyperinflammatory status, extracorporeal membrane oxygenation (ECMO) and multiple other pathologies. The use of therapeutic anticoagulation increases risk of nose bleeding, and its management may be challenging. CAVI-T (Figures 1 &amp; 2) is a new asymmetrical low-pressure balloon that have shown promising results to control epistaxis in emergency. We report herein the management of severe epistaxis in two COVID-19 patients admitted to ICU for severe respiratory failure.

Anticoagulants and antiaggregants in the COVID-19 era

Review of the latest scientific data and the main provisions of clinical guidelines on the use of anticoagulants and antiaggregants in patients with COVID-19 is presented. A separate part of the paper focuses on the use of prasugrel in this group of patients. The main trend in the use of anticoagulants for the prevention of venous thromboembolism in COVID-19 infection can be considered as a decrease in drug activity. Thus, the experts of the American Hematological Society suggest using low doses of oral or parenteral anticoagulants for thromboprophylaxis in hospitalized patients, preferring them to intermediate or high doses. Virtually all experts agree that prophylactic anticoagulant use should be avoided in clinical practice in patients with COVID-19 who are on outpatient treatment (whether it was chosen as an initial tactic or was a continuation of inpatient treatment). The principles for the therapeutic use of anticoagulants in COVID-19 should be based on already existing clinical guidelines for the conditions that require anticoagulants (atrial fibrillation, venous thrombosis or thromboembolism, presence of mechanical valves, etc.). The use of antiaggregants in patients with COVID-19 outside their registered indications is currently continuing to be studied in several clinical trials. That said, as part of dual antiplatelet therapy after percutaneous coronary intervention for COVID-19, it is advisable to continue this treatment without cancelling any of its components without a specific indication. The same is true for prasugrel, which remains one of the first recommended potent P2Y12 inhibitors.

Prior use of therapeutic anticoagulation does not protect against COVID‐19 related clinical outcomes in hospitalized patients: A propensity score‐matched cohort study

The hypercoagulable state observed in COVID‐19 could be responsible for morbidity and mortality. In this retrospective study we investigated whether therapeutic anticoagulation prior to infection has a beneficial effect in hospitalized COVID‐19 patients. This study included 1154 COVID‐19 patients admitted to 6 hospitals in the Netherlands between March and May 2020. We applied 1:3 propensity score matching to evaluate the association between prior therapeutic anticoagulation use and clinical outcome, with in hospital mortality as primary endpoint. In total, 190 (16%) patients used therapeutic anticoagulation prior to admission. In the propensity score matched analyses, we observed no associations between prior use of therapeutic anticoagulation and overall mortality (risk ratio 1.02 [95% confidence interval; 0.80–1.30]) or length of hospital stay (7.0 [4–12] vs. 7.0 [4–12] days, P = .69), although we observed a lower risk of pulmonary embolism (0.19 [0.05–0.80]). This study shows that prior use of therapeutic anticoagulation is not associated with improved clinical outcome in hospitalized COVID‐19 patients.

Empiric use of anticoagulation in hospitalized patients with COVID-19: a propensity score-matched study of risks and benefits

BackgroundHospitalized patients with COVID-19 demonstrate a higher risk of developing thromboembolism. Anticoagulation (AC) has been proposed for high-risk patients, even without confirmed thromboembolism. However, benefits and risks of AC are not well assessed due to insufficient clinical data. We performed a retrospective analysis of outcomes from AC in a large population of COVID-19 patients.MethodsWe retrospectively reviewed 1189 patients hospitalized for COVID-19 between March 5 and May 15, 2020, with primary outcomes of mortality, invasive mechanical ventilation, and major bleeding. Patients who received therapeutic AC for known indications were excluded. Propensity score matching of baseline characteristics and admission parameters was performed to minimize bias between cohorts.ResultsThe analysis cohort included 973 patients. Forty-four patients who received therapeutic AC for confirmed thromboembolic events and atrial fibrillation were excluded. After propensity score matching, 133 patients received empiric therapeutic AC while 215 received low dose prophylactic AC. Overall, there was no difference in the rate of invasive mechanical ventilation (73.7% versus 65.6%, p = 0.133) or mortality (60.2% versus 60.9%, p = 0.885). However, among patients requiring invasive mechanical ventilation, empiric therapeutic AC was an independent predictor of lower mortality (hazard ratio [HR] 0.476, 95% confidence interval [CI] 0.345–0.657, p < 0.001) with longer median survival (14 days vs 8 days, p < 0.001), but these associations were not observed in the overall cohort (p = 0.063). Additionally, no significant difference in mortality was found between patients receiving empiric therapeutic AC versus prophylactic AC in various subgroups with different D-dimer level cutoffs. Patients who received therapeutic AC showed a higher incidence of major bleeding (13.8% vs 3.9%, p < 0.001). Furthermore, patients with a HAS-BLED score of ≥2 had a higher risk of mortality (HR 1.482, 95% CI 1.110–1.980, p = 0.008), while those with a score of ≥3 had a higher risk of major bleeding (Odds ratio: 1.883, CI: 1.114–3.729, p = 0.016).ConclusionEmpiric use of therapeutic AC conferred survival benefit to patients requiring invasive mechanical ventilation, but did not show benefit in non-critically ill patients hospitalized for COVID-19. Careful bleeding risk estimation should be pursued before considering escalation of AC intensity.

Safety profile of enhanced thromboprophylaxis strategies for critically ill COVID-19 patients during the first wave of the pandemic: observational report from 28 European intensive care units

IntroductionCritical illness from SARS-CoV-2 infection (COVID-19) is associated with a high burden of pulmonary embolism (PE) and thromboembolic events despite standard thromboprophylaxis. Available guidance is discordant, ranging from standard care to the use of therapeutic anticoagulation for enhanced thromboprophylaxis (ET). Local ET protocols have been empirically determined and are generally intermediate between standard prophylaxis and full anticoagulation. Concerns have been raised in regard to the potential risk of haemorrhage associated with therapeutic anticoagulation. This report describes the prevalence and safety of ET strategies in European Intensive Care Unit (ICUs) and their association with outcomes during the first wave of the COVID pandemic, with particular focus on haemorrhagic complications and ICU mortality.MethodsRetrospective, observational, multi-centre study including adult critically ill COVID-19 patients. Anonymised data included demographics, clinical characteristics, thromboprophylaxis and/or anticoagulation treatment. Critical haemorrhage was defined as intracranial haemorrhage or bleeding requiring red blood cells transfusion. Survival was collected at ICU discharge. A multivariable mixed effects generalised linear model analysis matched for the propensity for receiving ET was constructed for both ICU mortality and critical haemorrhage.ResultsA total of 852 (79% male, age 66 [37–85] years) patients were included from 28 ICUs. Median body mass index and ICU length of stay were 27.7 (25.1–30.7) Kg/m2 and 13 (7–22) days, respectively. Thromboembolic events were reported in 146 patients (17.1%), of those 78 (9.2%) were PE. ICU mortality occurred in 335/852 (39.3%) patients. ET was used in 274 (32.1%) patients, and it was independently associated with significant reduction in ICU mortality (log odds = 0.64 [95% CIs 0.18–1.1; p = 0.0069]) but not an increased risk of critical haemorrhage (log odds = 0.187 [95%CI − 0.591 to − 0.964; p = 0.64]).ConclusionsIn a cohort of critically ill patients with a high prevalence of thromboembolic events, ET was associated with reduced ICU mortality without an increased burden of haemorrhagic complications. This study suggests ET strategies are safe and associated with favourable outcomes. Whilst full anticoagulation has been questioned for prophylaxis in these patients, our results suggest that there may nevertheless be a role for enhanced / intermediate levels of prophylaxis. Clinical trials investigating causal relationship between intermediate thromboprophylaxis and clinical outcomes are urgently needed.

Association between electrocardiographic features and mortality in COVID-19 patients.

BackgroundCardiovascular events have been reported in the setting of coronavirus disease‐19 (COVID‐19). It has been hypothesized that systemic inflammation may aggravate arrhythmias or trigger new‐onset conduction abnormalities. However, the specific type and distribution of electrocardiographic disturbances in COVID‐19 as well as their influence on mortality remain to be fully characterized.MethodsElectrocardiograms (ECGs) were obtained from 186 COVID‐19‐positive patients at a large tertiary care hospital in Northern Nevada. The following arrhythmias were identified by cardiologists: sinus bradycardia, sinus tachycardia, atrial fibrillation (A‐Fib), atrial flutter, multifocal atrial tachycardia (MAT), premature atrial contraction (PAC), premature ventricular contraction (PVC), atrioventricular block (AVB), and right bundle branch block (RBBB). The mean PR interval, QRS duration, and corrected QT interval were documented. Fisher's exact test was used to compare the ECG features of patients who died during the hospitalization with those who survived. The influence of ECG features on mortality was assessed with multivariable logistic regression analysis.ResultsA‐Fib, atrial flutter, and ST‐segment depression were predictive of mortality. In addition, the mean ventricular rate was higher among patients who died as compared to those who survived. The use of therapeutic anticoagulation was associated with reduced odds of death; however, this association did not reach statistical significance.ConclusionThe underlying pathogenesis of COVID‐19‐associated arrhythmias remains to be established, but we postulate that systemic inflammation and/or hypoxia may induce potentially lethal conduction abnormalities in affected individuals. Longitudinal studies are warranted to evaluate the risk factors, pathogenesis, and management of COVID‐19‐associated cardiac arrhythmias.

A Global Survey of Splanchnic Venous Thrombosis Directed Treatment in Association with Acute Pancreatitis (LORDS-PANC)

Introduction: Splanchnic venous thrombosis (SpVT) is a rare but important complication of severe acute pancreatitis (AP). A literature review has demonstrated a lack of high-quality studies and evidence-based guidelines for the treatment of SpVT in AP. The aim of this study was to determine the current approaches to the management of SpVT in patient with AP. Methods: The on-line survey was constructed by a group of international experts in the management of acute pancreatitis. The 23 questions covered respondent's demography, seniority, and experience with the management of SpVT with a specific focus on approaches to therapeutic anticoagulation. Results: There were 224 respondents from 25 HPB units globally (Fig. 1). 92% of responders were from tertiary hospitals and predominantly consultants (86%) who regularly manage patients with AP. There were 85% of respondents who routinely prescribe prophylactic anticoagulation in patients with AP. Only 36% ‘routinely’ prescribe therapeutic anticoagulation for SpVT, while 25% ‘often’ prescribe and 32% ‘never’ prescribe therapeutic anticoagulation. There were 83% respondents to the questions regarding the need for higher-level evidence. 92% of responders considered a clinical trial was justified and 88% were willing to contribute patients to the trial. Their reasons for not being willing to contribute were concern about bleeding risk and/or logistic concerns. Conclusion: There is global variation in the use of therapeutic anticoagulation for SpVT associated with AP. The majority of respondents agree on the need for high-quality evidence and were prepared to participate in a clinical trial.