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Objectives: The aim of this study is to analyze the effectiveness and safety of medical treatment (MT) versus endovascular treatment (EVT) in acute large vessel occlusion patients with mild nondisabling stroke symptoms. Methods: This study is a multicenter observational study in which data from patients at three stroke centers were prospectively obtained and retrospectively analyzed. Patients were included if they arrived for treatment within 6 h of stroke onset or last known well time and had a baseline National Institutes of Health Stroke Scale (NIHSS) score of ≤5. Primary outcome was modified Rankin Scale (mRS) score 0–2 at 90 days. Secondary outcomes included symptomatic intracranial hemorrhage (sICH), discharge NIHSS score, 90-day all-cause mortality and length of stay. Clinical outcomes were compared through a multivariable logistic regression after adjusting for age, treatment type admission and discharge NIHSS score, admission Alberta Stroke Program Early CT (ASPECT) score and length of stay. Results: Of the 82 patients included in the study, 42 were in the EVT group and 40 were in the MT group. The groups were similar in age (MT:66, EVT:64 age; p =.62), gender (MT:55%, EVT:54.8%; male) admission NIHSS score (MT:2, EVT:3 points; p =.26), ASPECT score (MT:10, EVT:9; p =.15). While discharge NIHSS score was found to be statistically significant between the groups (MT:1, EVT:2; p =.04). There was no difference between the two groups in terms of 90-day mRS scores (MT:1, EVT:1, p =.86) and mortality rates (MT:4, EVT:4; p =.94). In unadjusted analysis, sICH rates were similar between the MT and EVT groups (MT 5%, EVT 7.1%, p =.52). Neurological intensive care unit length of stay (MT:5 days, EVT:2 days p <.001), inpatient clinic length of stay (MT:3, EVT:2 days p =.041), and total length of stay (MT:9 days, EVT:4 days p <.001) were significantly longer in the MT group. Conclusions: Our multicenter study demonstrated that MT with blood pressure augmentation and anticoagulation at hyperacute stage is an alternative option for emergency large vessel occlusion patients with nondisabling mild stroke symptoms. [ABSTRACT FROM AUTHOR]

Background: Patients with acute venous thromboembolism (VTE) need anticoagulation (AC) therapy for at least 3/6 months (primary treatment); after that period, they should receive a decision on the duration of therapy. Methods: This study examined the complications occurring during two years of follow-up (FU) in patients with a first VTE who were recruited in 20 clinical centers and had discontinued or prolonged AC. They were included in the START2-POST-VTE prospective observational study. Results: A total of 720 patients (53.5% males) who, after the completion of primary treatment, had received the decision to continue (n = 281, 39%; 76.1% with a DOAC) or discontinue (n = 439, 61%) AC were followed up for 2 years (total FU = 1318 years). The decision to prolong or suspend AC was made in similar proportions in patients with unprovoked or provoked index events. Courses of sulodexide treatment or Aspirin (100 mg daily) were prescribed to 20.3% and 4.5%, respectively, of the patients who discontinued AC. The bleeding rate was significantly higher in patients who extended AC (1.6% pt/y) than in those who stopped AC (0.1% pt/y; p = 0.001) and was higher in patients using standard-dose DOACs (3.1% pt/y) than in those using reduced-dose DOACs (0.4% pt/y). The recurrent VTE rates were similar between the two groups (2.2% pt/y during AC vs. 3% pt/y off AC). Conclusion: Physicians' decisions about AC duration were independent of the unprovoked/provoked nature of the index event. The bleeding rate was higher in patients who continued AC using standard-dose DOACs. Surprisingly, the rate of thrombotic recurrence was not different between those who continued or discontinued AC. Randomized studies comparing different procedures to decide on the duration of AC after a first VTE are needed. [ABSTRACT FROM AUTHOR]

Background: Nonpersistence in anticoagulation therapy is common and associated with undesirable clinical outcomes in patients with venous thromboembolism (VTE). Methods: We investigated preceding clinical events of treatment nonpersistence (e.g., switching, discontinuing, or restarting) in VTE patients with and without active cancer using Korean claims database. Results: Clinically significant events including thromboembolic events, hepatic function change and surgery preceded treatment nonpersistence, but heterogeneous distributions of clinical events were observed in the presence of active cancer. Patients with active cancer had a low rate of clinical events preceding treatment nonpersistence, and new active cancer diagnosis in the nonactive cancer group was most common before the switch to parenteral anticoagulants from warfarin or non‐vitamin K antagonist oral anticoagulants (NOACs). Conclusion: These findings suggest that clinically significant events can precede treatment nonpersistence and largely paralleled current guidelines for patients with VTE, whereas heterogeneous distributions of clinical events were observed in the presence of active cancer. [ABSTRACT FROM AUTHOR]

Iron deficiency anemia is a rare cause of intracranial venous sinus thrombosis. This study described the diagnosis and treatment of a young female with persistent headache for 3 weeks accompanied by transient loss of consciousness. The patient had long term heavy menstrual flow, no other vascular risk factors. Head CT and MRV confirmed thrombosis of the left transverse sinus and sigmoid sinus. Blood routines revealed iron deficiency anemia. Her intracranial venous sinus thrombosis caused by iron deficiency anemia. The patient was given ferrous succinate for anemia and anticoagulant treatment for venous sinus thrombosis. She was improved rapidly discharged later. [ABSTRACT FROM AUTHOR]

Background: In case of heparin-induced thrombocytopenia (HIT), the switch to a non-heparin anticoagulant is mandatory, at a therapeutic dose. Such a treatment has limitations though, especially for patients with renal and/or hepatic failure. Candidate laboratory tests could detect the more coagulable HIT patients, for whom therapeutic anticoagulation would be the more justified. Patients and methods: This was a monocentre observational prospective study in which 111 patients with suspected HIT were included. Nineteen were diagnosed with HIT (ELISA and platelet activation assay), among whom 10 were classified as HITT + when a thrombotic event was present at diagnosis or during the first following week. Two plasma prethrombotic biomarkers of in vivo activation of the haemostasis system, procoagulant phospholipids (ProcoagPPL) associated with extracellular vesicles and fibrin monomers (FM test), as well as in vitro thrombin potential (ST Genesia; low picomolar tissue factor) after heparin neutralization (heparinase), were studied. The results were primarily compared between HITT + and HITT- patients. Results: Those HIT + patients with thrombotic events in acute phase or shortly after (referred as HITT+) had a more coagulable phenotype than HIT + patients without thrombotic events since: (i) clotting times related to plasma procoagulant phospholipids tended to be shorter; (ii) fibrin monomers levels were statistically significantly higher (p = 0.0483); (iii) thrombin potential values were statistically significantly higher (p = 0.0404). Of note, among all patients suspected of suffering from HIT, we did not evidence a hypercoagulable phenotype in patients diagnosed with HIT compared to patients for whom the diagnosis of HIT was ruled out. Conclusion: The three tests could help identify those HIT patients the most prone to thrombosis. [ABSTRACT FROM AUTHOR]

• 24.1 % of older hospitalized patients were affected by AF, of them 97.3 % were at HTR. • About half of patients was not treated with OACs, 21.5 % used NOACs and 30.4 % VKA. • Lower probability of OAC treatment was found in patients with high CIR.S and cancer. • Hospital stay, cancer diagnoses and high INR value increased OAC discontinuation. • In NOAC users a not significant decreased mortality than VKA or not users was found. Atrial fibrillation (AF) prevalence increases in older patients which also show a high thromboembolic risk. Oral anticoagulants (OACs) are recommended to prevent cardioembolic events and direct oral anticoagulants (DOACs) improved anti-thrombotic treatment. However, the benefits/risks of anticoagulant in older patients still need to be completely defined. This retrospective observational study aimed to describe the treatment with OACs in older AF hospitalized patients, and to identify factors influencing OAC therapy or discontinuation using the REgistro Politerapie SIMI. Univariate and multivariate logistic regression models were applied to identify predictors of OACs treatment and discontinuation. Cox proportional hazards models were performed to evaluate one-year mortality by treatment groups. AF patients were 1,128(26.5 %) at discharge and 1,098(97.3 %) required OAC treatment; about half of them (N = 528;48.1 %) were no-OACs users; 236(21.5 %) and 334(30.4 %) used DOACs and VKA, respectively. Increasing DOACs use was observed during the study period. Predictors of OACs treatment were: BMI (OR:1.04; 95 %CI:1.01–1.07), Barthel index (OR:1.01; 95 %CI:1.01–1.02), medications number (OR:1.07; 95 %CI:1.01–1.13). Conversely, a lower probability was found in patients with a high CIR.S (OR:0.59; 95 %CI:0.36–0.97) and neoplasm (OR:0.57; 95 %CI:0.37–0.88). Hospital stay (OR:1.02; 95 %CI:1.01–1.05), neoplasm (OR:2.25; 95 %CI:1.07–4.70) and INR (OR:1.21; 95 %CI:1.05–1.40) increased OACs discontinuation. A lower discontinuation was observed in dyslipidemic patients (OR:0.18; 95 %CI:0.04–0.82) and heart failure (OR:0.38; 95 %CI:0.21–0.70). Among AF patients, 157(14.3 %) died during the follow-up year. Age (HR = 1.05; 95 %CI = 1.03–1.08) and CIR.S (HR = 2.54; 95 %CI = 1.53–4.21) were associated with a greater mortality risk. In conclusion, critical issues related to the underuse and discontinuation of OACs therapy in hospitalized older patients were highlighted. [Display omitted] [ABSTRACT FROM AUTHOR]

Portal vein thrombosis, in the clinical setting of liver cirrhosis, is a complication which increases mortality rate by leading to specific complications. Its presence also serves as a negative prognostic factor for these patients. Specialized literature, although rich in papers on this subject, presents loose and sometimes contradictory information regarding its prognosis and specific treatment. This paper brings into discussion the issue of recent portal vein thrombosis in cirrhotic patients, with emphasis on indications for initiation of anticoagulant therapy and the optimal drug of choice. It also highlights the utility of using correct terminology for facilitating clinical approach of guideline recommendations as well as increasing the quality of published scientific papers. The coagulation homeostasis of the cirrhotic patient presents many particularities that can make the optimal therapeutic choice extremely difficult when portal vein thrombosis is established. Absence of randomized clinical trials and lack of consensus regarding anticoagulant treatment in these patients leaves it up to the clinician to decide when and what anticoagulant to use. Analysis of the newest guidelines and recent meta-analysis made it possible to identify the right context for initiating therapy with the most used anticoagulants currently: low molecular weight heparin, vitamin K antagonists and direct oral anticoagulants. [ABSTRACT FROM AUTHOR]

Acute ischemic stroke (AIS) due to cerebral artery occlusion is often treated by thrombolytics or antithrombotic drugs. Thromboelastography (TEG) is a noninvasive test that provides a dynamic overview of the coagulation process. TEG may help guide thrombolytic and antithrombotic therapy in AIS. This article aims to highlight the potential use of TEG in AIS patients by reviewing available studies. We conducted a literature review, including PubMed and Cochrane library databases. The following keywords were used to find relevant studies: thromboelastography, TEG, acute ischemic stroke, stroke, coagulopathy, antiplatelet, and anticoagulant treatment. We identified 142 papers and after abstract review, we included 24 studies in this report. TEG identified a hypercoagulable state in AIS patients represented by short R, K, and greater α angle in all papers included. Modification of TEG parameters induced by intravenous thrombolysis was inconsistent but prolonged lysis (increased LY30) and weaker clots (lower maximum amplitude) were most frequent. TEG detected hypo-coagulopathy induced by dual antiplatelet therapy as well as antiplatelet drug resistance, with ticagrelor and aspirin having greater inhibition of platelet activity. A prolonged R-value seems to be the most reliable TEG parameter in detecting the anticoagulant effect of factor Xa inhibitor treatment. TEG might represent a useful point-of-care test for emergency decision-making in AIS patients and a tool for individualized treatment options. This hypothesis needs validation in a large cohort of prospectively studied AIS patients. [ABSTRACT FROM AUTHOR]

Background: The prevalence of anticoagulant therapy-associated hemorrhagic complications in hospitalized patients with pulmonary embolism (PE) has been scarcely investigated. Aim: To evaluate the prevalence of hemorrhages in hospitalized PE patients. Methods: The Information System "ASKLIPIOS™ HOSPITAL" implemented in the Respiratory Medicine Department, University of Thessaly, was used to collect demographic, clinical and outcome data from January 2013 to April 2021. Results: 326 patients were included. Males outnumbered females. The population's mean age was 68.7 ± 17.0 years. The majority received low molecular weight heparin (LMWH). Only 5% received direct oral anticoagulants. 15% of the population were complicated with hemorrhage, of whom 18.4% experienced a major event. Major hemorrhages were fewer than minor (29.8% vs. 70.2%, p = 0.001). Nadroparin related to 83.3% of the major events. Hematuria was the most common hemorrhagic event. 22% of patients with major events received a transfusion, and 11% were admitted to intensive care unit (ICU). The events lasted for 3 ± 2 days. No death was recorded. Conclusions: 1/5 of the patients hospitalized for PE complicated with hemorrhage without a fatal outcome. The hemorrhages were mainly minor and lasted for 3 ± 2 days. Among LMWHs, nadroparin was related to a higher percentage of hemorrhages. [ABSTRACT FROM AUTHOR]

Background: The anticoagulant treatment and clinical efficacy of heparin in sepsis remains controversial. We conducted a meta-analysis to estimate the clinical efficacy of unfractionated heparin (UFH) in adult septic patients. Method: A systematic review of Medline, Cochrane Library, PubMed, Embase, WEIPU database, CNKI database, WANFANG database was performed from inception to January 2021. We included Randomized controlled trials (RCTs) and the main outcome was 28 d mortality. Data analysis was performed with Review Manager (RevMan) version 5.3 software. The meta-analysis included 2617 patients from 15 RCTs. Results: Comparing to control group, UFH could reduce 28 d mortality (RR: 0.82; 95% CI: 0.72 to 0.94) especially for patient with Acute Physiology and Chronic Health Evaluation II (APACHE II) > 15, (RR: 0.83; 95% CI: 0.72 to 0.96). In UFH group, the platelet (PLT) (MD: 9.18; 95% CI: 0.68 to 17.68) was higher, the activated partial thromboplastin time (APTT) was shorter (MD: -8.01; 95% CI: − 13.84 to − 2.18) and the prothrombin time (PT) results (P > 0.05) failed to reach statistical significance. UFH decreased multiple organ dysfunction syndrome (MODS) incidence (RR: 0.61; 95% CI: 0.45 to 0.84), length of stay (LOS) in ICU (MD: -4.94; 95% CI: − 6.89 to − 2.99) and ventilation time (MD: -3.01; 95% CI: − 4.0 to − 2.02). And UFH had no adverse impact on bleeding (RR: 1.10; 95% CI: 0.54 to 2.23). Conclusion: This meta-analysis suggests that UFH may reduce 28 d mortality and improve the clinical efficacy in sepsis patients without bleeding adverse effect. [ABSTRACT FROM AUTHOR]

Background: To evaluate the anticoagulant treatment response in venous thrombi with different morphologies (size, shape, and echogenicity) by measuring the change in thrombus thickness. Materials and methods: This was a retrospective cohort study of 97 lower extremity DVT patients diagnosed by venous ultrasound between March 2014 and February 2018. The demographics, clinical risk factors, anticoagulant treatment, and ultrasound findings at the first diagnosis and 2–6 months after treatment were evaluated. Results: The anticoagulant treatment with LMWH followed by VKAs showed a significant decrease in the mean maximum difference in lower extremity DVT thrombus thickness compared with VKAs alone (P-value < 0.001). After adjustment by treatment, the thrombi found in dilated veins showed a significant decrease in the thickness of such thrombi compared with those found in small veins: 4 mm vs. 0 mm (Coef. = 3, 95% CI: 1.9, 4.1 and P-value < 0.001). Anechoic and hypoechoic thrombi showed a significant decrease in the thickness compared with hyperechoic thrombi: 5 mm vs. 0 mm (Coef. = 4, 95% CI: 3.25, 4.74 and P-value < 0.001) and 3 mm vs. 0 mm (Coef. = 2, 95% CI: 1.34, 42.66 and P-value < 0.001), respectively. Concentric thrombi showed a significant decrease in thickness compared with eccentric thrombi: 4 mm vs. 0 mm (Coef. = 2, 95% CI: 1.45, 2.55 and P-value < 0.001). Conclusion: The anticoagulant treatment with LMWH followed by VKAs shows a significant decrease in lower extremity DVT thrombus thickness compared with VKAs alone. After adjustment by treatment, the morphologic finding of acute thrombi shows a significantly decreased thickness compared with the morphologic finding of chronic thrombi. [ABSTRACT FROM AUTHOR]

Valvular heart disease affects more that 100 million people worldwide. Valvular replacement remains the only definite treatment for most of the patients with severe disease. Careful medical management and periodic followup of valve function is mandatory in order to prevent or diagnose prosthesis-related complications. We present a case of extensive mitral and aortic valve thrombosis and possible recurrent endocarditis in a 44-year-old woman non-adherent to anticoagulation therapy, presented with stroke. She also had a history of two mitral and aortic valvular heart replacement surgeries. Comprehensive and repeated imaging was used to evaluate and monitor the patient progression and outcome. Failure of adequate anticoagulation therapy to improve prosthesis function during hospitalization required third re-do surgery for mitral and aortic valve replacement with mechanical prosthesis. [ABSTRACT FROM AUTHOR]

Introduction: Pulmonary embolism (PE) is a serious condition with high mortality. Despite the knowledge of risk factors, it is still underdiagnosed and often left without preventive measurements. Major risk factors include: postoperative conditions (after major interventions in the abdominal, pelvic or orthopedic area), peripheral venous disease, pregnancy in the third trimester, malignancies, lack of mobility (especially in the elderly), heart diseases, chronic obstructive pulmonary disease (COPD), sepsis, thrombophilia, inflammatory bowel diseases, chronic dialysis, central catheters etc. Case Report: We present an 82-year-old male patient known with COPD, a chronic smoker, atrial fibrillation with an implantable cardioverter-defibrillator (ICD), coronary artery disease (CAD) with a percutaneous coronary intervention (PCI) for myocardial infarction, dilated cardiomyopathy (DCM), chronic heart failure (CHF) not undergoing anticoagulant treatment. He was admitted to the Pulmonology Clinic for rest dyspnea, with a SpO2 of 92%, productive cough, wheezing and chest discomfort. Radiological examination showed right middle lobe pulmonary consolidation and right pleural effusion. Under chest ultrasound guidance, a thoracentesis was performed (700 ml of serocitrin transudate liquid). Echocardiography revealed a global dilated heart, with right overload, severely depressed left ventricular systolic function with global hypokinesia (EF 20%) and severe valvular damage. Venous Doppler ultrasound of the lower limbs didn't reveal signs of deep vein thrombosis. The multiple comorbidities and the clinical appearance raised the suspicion of pulmonary thromboembolism, with a Wells criteria score of 4.5 (moderate risk). Angio-CT examination confirmed acute thrombosis of the right main pulmonary artery and right atrium, right middle lobe pneumonia and pleural effusion. Case management included treatment with anticoagulant, antibiotics, oxygen therapy, combined inhaled bronchodilators (for COPD) and transfer to the cardiology field for further treatment. Discussions : The case report underlines an undiagnosed pulmonary embolism through clinical-radiological suspicion and confirmed by angioCT. In a COPD patient, dyspnoea can result from disease exacerbation and complications (thrombosis, pulmonary embolism, heart failure) within the context of systemic inflammation of COPD, advanced age, and complex cardiovascular comorbidities. Conclusions: Considering the age, complex respiratory and cardiovascular comorbidities, the patient must be under anticoagulants and closely followed-up. Favorable evolution was made possible by multidisciplinary team management and complex investigations. Wells criteria for PE may always be quantified in people with risk factors and clinical suspicion. [ABSTRACT FROM AUTHOR]

Background: When superficial temporal artery-middle cerebral artery bypass is combined with indirect methods (e.g., revascularization surgery) to treat Moyamoya disease (MMD), antiplatelet treatment can impact bypass patency, infarction, or hemorrhage complications. Recently, heparin has been proposed as an anticoagulant treatment against white thrombus at the anastomosis site. The study aims to evaluate the effect of aspirin on the perioperative outcomes and investigate the results of heparin treatment for white thrombus. Methods: This retrospective study included 74 procedures of combined revascularization surgery for MMD patients who either received or did not receive aspirin. Perioperative outcomes were compared between the two groups. In addition, the effects of heparin treatment for white thrombus were evaluated. Results: The rate of white thrombus at the anastomosis site was significantly higher in the non-aspirin medication group (univariate: p = 0.032, multivariate: p = 0.044) and, accordingly, initial bypass patency was lower in the non-aspirin medication group (p = 0.049). Of the 17 patients with white thrombus development, five received heparin injections, and all white thrombi disappeared; however, there was one case of epidural hematoma and another of subdural hematoma. The risk of hemorrhagic complications was significantly higher in the surgical procedures that received heparin injections (p = 0.021). Conclusions: In MMD patients who received combined revascularization surgery, aspirin medication lowered the occurrence of white thrombus. Heparin injections help to treat white thrombus but can enhance the risk of hemorrhagic complications. [ABSTRACT FROM AUTHOR]

Background and Objective: Pyrrolizidine alkaloid-induced hepatic sinusoidal obstruction syndrome (PA-HSOS) is a rare disease with no specific treatment. Anticoagulants, antithrombotics, and microcirculation therapy can alleviate the progression of PA-HSOS. The application of rivaroxaban in patients with PA-HSOS has not yet been reported. The aim of this study was to analyze the efficacy and safety of rivaroxaban in the treatment of PAHSOS caused by Gynura segetum. Methods: A retrospective analysis was conducted using the clinical data of patients with PA-HSOS in the acute/subacute phase caused by the administration of Gynura segetum. The patients were divided into warfarin and rivaroxaban groups according to the anticoagulant therapy they received. The related biochemical indicators were monitored during hospitalization. Liver ultrasound, liver elastography, and related biochemical indicators were reviewed every two weeks or one month after discharge. The patients were followed until 1 year after complete remission or death. The efficacy and safety of rivaroxaban was compared with that of warfarin according to the patients' hepatic venous recanalization rates and the occurrence of bleeding events. Results: The study included 20 patients, with 10 in the warfarin group and 10 in the rivaroxaban group. The results show that the average anticoagulant course in the rivaroxaban group was significantly shorter than that in the warfarin group (P = 0.007). With treatment, the remission rates of the rivaroxaban and warfarin groups reached 90%. There was no significant difference in the incidence of adverse reactions or bleeding events between the t wo groups (P > 0.05). Conclusions: Compared with warfarin, rivaroxaban, a new oral anticoagulant, is convenient and safe for clinical use. It has a significant effect on PA-HSOS and a low risk of bleeding. This provides a new anticoagulant treatment for PA-HSOS. [ABSTRACT FROM AUTHOR]

Coronavirus disease 2019 (COVID-19) causes a hypercoagulable state. Several autopsy studies have found microthrombi in pulmonary circulation. In this randomized, open-label, phase II study, we randomized COVID-19 patients requiring mechanical ventilation to receive either therapeutic enoxaparin or the standard anticoagulant thromboprophylaxis. We evaluated the gas exchange over time through the ratio of partial pressure of arterial oxygen (PaO2) to the fraction of inspired oxygen (FiO2) at baseline, 7, and 14 days after randomization, the time until successful liberation from mechanical ventilation, and the ventilator-free days. Ten patients were assigned to the therapeutic enoxaparin and ten patients to prophylactic anticoagulation. There was a statistically significant increase in the PaO2/FiO2 ratio over time in the therapeutic group (163 [95% confidence interval – CI 133–193] at baseline, 209 [95% CI 171–247] after 7 days, and 261 [95% CI 230–293] after 14 days), p = 0.0004. In contrast, we did not observe this improvement over time in the prophylactic group (184 [95% CI 146–222] at baseline, 168 [95% CI 142–195] after 7 days, and 195 [95% CI 128–262] after 14 days), p = 0.487. Patients of the therapeutic group had a higher ratio of successful liberation from mechanical ventilation (hazard ratio: 4.0 [95% CI 1.035–15.053]), p = 0.031 and more ventilator-free days (15 days [interquartile range IQR 6–16] versus 0 days [IQR 0–11]), p = 0.028 when compared to the prophylactic group. Therapeutic enoxaparin improves gas exchange and decreases the need for mechanical ventilation in severe COVID–19. REBEC RBR-949z6v. • COVID-19 is associated with microthrombi in pulmonary circulation. • We randomized severe COVID-19 patients to receive either therapeutic enoxaparin or the standard thromboprophylaxis. • Therapeutic enoxaparin resulted in improved gas exchange over time. • Larger clinical trial is urgently needed to evaluate the anticoagulant therapy in severe COVID-19. [ABSTRACT FROM AUTHOR]

Keywords: coagulation parameter; D-dimer; COVID-19; anticoagulant treatment EN coagulation parameter D-dimer COVID-19 anticoagulant treatment e24 e27 4 07/01/20 20200701 NES 200701 Since December 2019, the severity of the coronavirus disease 2019 (COVID-19) pandemic has been escalating.[1] Coagulopathy is common in critically ill patients with COVID-19.[2] Systemic microvascular thrombosis may occur in most deaths, and was corroborated by a recent autopsy.[3] However, less is known about the coagulation parameter D-dimer in the progression of COVID-19. Moreover, it is well documented that abnormal D-dimer is helpful in indicating deep venous thrombosis in cardiovascular diseases.[8] Thus, we analysed the correlation between D-dimer level with clinical prognosis in patients with and without cardiovascular disease. Anticoagulant treatment may benefit severe COVID-19 patients, especially those without cardiovascular disease. [Extracted from the article]

Introduction: Indications for left atrial appendage occlusion (LAAO) are varied and patients require individual management strategies. However, currently no guidelines exist for postprocedure oral anticoagulation (OAC) after an LAAO procedure. Aim: To evaluate the effect of OAC on thromboembolism, bleeding and mortality following the LAAO procedure for patients with AF. Material and methods: One hundred and thirty-nine consecutive patients with nonvalvular atrial fibrillation (NVAF) who underwent LAAO with the LARIAT device were followed for at least 40 months. Decisions about OAC and its modifications were individualized based on clinical presentation, patient and physician preferences. Results: Following LAAO, 52 (41%) patients did not receive OAC (No-OAC group) and 75 (59%) patients received OAC (OAC group), without any intergroup differences in CHADS2, CHA2DS2-VASc score or other thromboembolic risk factors. The median HAS-BLED score was higher in the OAC-group (median 3 (3-4) vs. 3 (2-4), p = 0.014). During a median follow-up time of 51 (43-57) vs. 55 (48-59) months in the No-OAC group and in the OAC group (p = 0.19) there were no significant differences between groups in ischemic stroke/TIA, 0 (0%) vs. 2 (2.7%), other thromboembolic events, 0 (0%) vs. 1 (1.3%), life-threatening, disabling or major events, 2 (3.7%) vs. 2 (2.7%), or annual mortality rate, 1.9% vs. 0.9%, respectively. Conclusions: There is no need for OAC after the LAAO procedure. Omitting OAC after an LAAO procedure in AF patients: (1) has similar stroke prevention rates as patients on OAC, (2) has similar bleeding prevention rates as patients on OAC, (3) has similar safety endpoints and long-term efficacy as patients on OAC. [ABSTRACT FROM AUTHOR]

Left ventricular thrombus poses a major risk of thromboembolism. It may be diagnosed incidentally, with echocardiography as the modality of choice. Choosing an optimal treatment strategy is of key importance. In the following text, two case reports are presented in which aggressive treatment failed to correlate with a desired reduction in the risk of thromboembolism. [ABSTRACT FROM AUTHOR]

Hemorrhagic strokes (ICH) affects mainly young active people, with increasing incidence in developing countries. Mortality is high in acute phase, and patients are prone to complications related to stroke itself and to coexisting medical conditions. Patients with ICH are at high risk in developing deep venous thrombosis (DVT) with secondary pulmonary embolism (PE). Prevention of venous thrombotic events in hemorrhagic stroke patients requires intermittent pneumatic compression and preventive doses of low molecular weight heparins (LMWH) in high-risk patients. If DVT and/or PE occurs, the therapeutic management should balance the risk of recurrent cerebral bleeding and the life-threatening risk of PE, making the decision to start anticoagulation challenging. We present a case of a young patient with a large hypertensive capsulolenticular hemorrhage, who was diagnosed with pulmonary embolism 21 days after stroke onset. The decision was for anticoagulant treatment initial with LWMH, and switch to direct oral anticoagulants (DOAC) after 10 days; strict control of vascular risk factors of the patients (hypertension, diabetes and obesity) was achieved. Rehabilitation treatment, delayed until day 21, was recommended with progressive intensity. Evolution of the patient was favorable, with complete hematoma resorbtion under DOAC treatment at 10 weeks follow-up and important motor recovery. Rehabilitation program was intensive during this interval, and strongly contributive to neurologic improvement. [ABSTRACT FROM AUTHOR]

Introduction: Trauma is the most frequent cause of splenic rupture. In contrast to traumatic rupture of the spleen, spontaneous splenic rupture (SSR) is a rare and life-threatening condition. Aim: To present the cases of patients with SSR, who had no history of trauma, and who had been receiving anticoagulant and/or antiaggregant treatment while hospitalised for cardiac reasons. Material and methods: The cases of 6 patients with SSR at Gastroenterological Surgery Department, Kartal Koşuyolu High Speciality and Training Hospital were retrospectively evaluated. The clinicodemographic factors and the diagnostic and therapeutic methods utilised for these patients with SSR while hospitalised were investigated as well. Results: Five (83.3%) of the patients were male and 1 (16.6%) was female. The median age of the patients was 71 (61-73) years. Three of the patients had only been receiving antiaggregant treatment, while 2 had only been receiving anticoagulant treatment; only 1 patient had been receiving both anticoagulant and antiaggregant treatments. The decrease in haematocrit (HCT) levels ascertained on the day of SSR diagnosis and the HCT levels ascertained on the day of hospitalisation were statistically significant. All the patients received a blood transfusion. While 5 (83.33%) of the 6 patients had splenectomy, 1 (16.66%) patient received conservative treatment. Mortality was seen in 4 (66.6%) patients. Conclusions: Spontaneous splenic rupture is a condition that should be taken into consideration in the differential diagnosis of patients hospitalised for cardiac reasons, who are receiving anticoagulant and/or antiaggregant treatment in cases of newly developed abdominal pain and low HCT levels. [ABSTRACT FROM AUTHOR]

Background: One of the most common arrythmias, associated with an increased risk of thromboembolic events, is atrial fibrillation (AF). The challenges in addressing thromboembolic risks are heightened in cases of permanent atrial fibrillation due to the sustained nature of the arrhythmia. The management of this condition and its related complications poses a genuine challenge to the healthcare system, as it has the capacity to impact cardiac function, overall health, and quality of life. Objective: This study aims to explore and observe the prevalence of coexisting conditions in patients with permanent atrial fibrillation alongside the current strategies and therapeutic approaches in the management of thromboembolic risks . Material and methods: The study group consisted of 140 patients with permanent AF. Data on patients were gathered from the discharge records of individuals who were admitted to Targu Mures County Clinic Hospital clinic during the period spanning from September to December 2020. We examined the relevant data that we collected, such as associated cardiac comorbidities, thromboembolic events, and anticoagulant / antiplatelet treatments. Results : The findings underscore the percentage of patients that received anticoagulant treatment (71%), and which agent was used, as well as the administration path. Moreover, we observed the prevalence of cardiac comorbidities, such as congestive cardiac failure, left ventricular failure, chronic ischaemic cardiopathy, pericarditis and pulmonary hypertension. Furthermore, we analysed the relationship between the thromboembolic events and the anticoagulant treatment, observing that subcutaneous LMWH was the most used anticoagulant agent for patients with or without thromboembolic events, followed by oral coumarin anticoagulants and oral NOAC anticoagulants. Conclusions: The key takeaway is the imperative for individualized risk stratification, considering patient-specific factors like comorbidities, risk factors, and treatment protocols. This approach is crucial in tailoring thromboembolic risk management strategies to the unique needs and preferences of each patient. As we navigate the future of managing thromboembolic risks in permanent AF, further research is warranted to refine risk stratification models and explore personalized anticoagulation regimens. [ABSTRACT FROM AUTHOR]

Cellular microparticles are plasma membrane vesicles of <1 μm in diameter, mainly composed of lipids and proteins, which are released into the blood circulation by blood cells and vascular cells during cellular activation or apoptosis. Microparticles play an important procoagulant role in several diseases, especially in thrombotic accidents. In the present study, we assess the effect of anticoagulant treatment on microparticles in patients having thrombotic accidents for better monitoring of the anticoagulant therapy. We collected blood samples from 20 patients with myocardial infarction at the time of diagnosis and four weeks after suffering the MI. All patients were subjected to full clinical evaluation, revision of their archived clinical progress reports, radiological and laboratory data. In addition assay of circulating, microparticles for both quantitation and determination of cell of origin using flow cytometry technique was performed. The following fluorescent monoclonal antibodies were assayed: Endothelial: CD 62 E, Platelet: CD 61p. Comparing MP assay data in MI patients versus controls revealed a significantly higher Coexpression of CD61p and CD62E and highly significant expression of CD 61p in MI patients compared to controls. In comparison of MP assay data in patients at time of diagnosis as MI and after a month of surviving the MI and receiving anticoagulant treatment, there was no statistically significant difference in MP markers following intervention in all cases, from (22.39±9.41 to 21.72±7.77) for CD 62E/61, from (62.12±14.25 to 61.18±13.18) for CD 61, and from (0.040±0.043 to 0.034±0.037) for CD 62E (p >0.05). A cutoff value for the expression of CD61p as a marker of thrombotic MI was suggested to be (58.70) revealed (70%) sensitivity and (85%) specificity and as regards CD 62E/61, taking (22.25) as a cut-off point revealed (60%) sensitivity and (95%) specificity using ROC curve statistical method. In conclusions, the antithrombotic properties of low dose antiplatelet or anticoagulant therapy are not strong enough to suppress shedding of the microparticles. A cut off value for expression of CD61 and coexpression CD 62E/61 in MI patients can contribute to the clinical applications as using MP assay in early diagnosis of thrombotic propensity, monitoring of anticoagulant therapy, and detection the risk of ischemic heart diseases in high-risk patients. [ABSTRACT FROM AUTHOR]

Background – Anticoagulant therapy stands for one medical field that undergoes rapid development and evolution. Quite frequently, the fear of not having a hemorrhagic episode triggers the failure to recommend the anticoagulant treatment or the ungrounded ceasing of such anticoagulant treatment in the proximity of some invasive maneuvers, with hemorrhagic potential. Aim – Determination of the level of information of patients suffering from atrial fibrillation (AF) on oral anticoagulant treatment. Method – 155 patients (aged 70.75 ± 10.57) with a diagnosis of AF, have replied to a questionnaire on the social – demographic conditions and the education level, so as to for one to be able to establish the latter’s influence of the incidence of failure to comply with the indications and the complications occurred during treatment. Results – More than half of the patients (53.5%) were aware of a personal medical condition called atrial AF, and yet 40 % of them have answered by „I don’t know”. Only 64.8% of the patients having received oral anticoagulant drugs were aware of the possible hemorrhagic complications associated with the therapy. Conclusions – Of the patients being questioned, less than half are aware of the risk of the possibility for the occurrence of hemorrhagic complications while undergoing the antithrombotic treatment. In terms of the anticoagulant treatment being preferred among our subjects, the Acenocoumarol drug remains the most frequently used drug, although monitoring the therapeutic efficiency is cost – involving, without adding the further visits one has to pay to the doctor’s office. [ABSTRACT FROM AUTHOR]

Abstract Introduction The benefits and harm caused by anticoagulant treatments for sepsis induced disseminated intravascular coagulation (DIC) remain unclear. Therefore, we performed a network meta-analysis to assess the effect of available anticoagulant treatments on patient mortality, DIC resolution and the incidence of bleeding complication in patients with septic DIC. Materials and methods We considered all studies from four recent systematic reviews and searched the PubMed, MEDLINE, and Cochrane databases for other studies that investigated anticoagulant treatment for septic DIC using antithrombin, thrombomodulin, heparin, or protease inhibitors in adult critically ill patients. These four anticoagulants and placebo were compared. The primary outcome in this study was patient mortality, and the secondary outcomes were the DIC resolution rate and incidence of bleeding complications. Results The network meta-analysis included 1340 patients from nine studies. There were no significant differences in the risks of mortality and bleeding complications among all direct comparisons and the network meta-analysis. Using a placebo was associated with a significantly lower rate of DIC resolution, compared to antithrombin in the direct comparison (odds ratio [OR]: 0.20, 95% credible interval [95% CrI]: 0.046–0.81) and in the network meta-analysis (OR: 0.20, 95% CrI: 0.043–0.84). Conclusions Our study revealed no significant differences in the risks for mortality and bleeding complications when a placebo and all four anticoagulants were compared in septic DIC patients. The results also indicated that antithrombin was associated with a five-fold higher likelihood of DIC resolution, compared to placebo. Highlights • We performed a network meta-analysis to assess effect of anticoagulants in septic DIC. • Risks of mortality and complications were similar among 4 anticoagulants and placebo. • There is insufficient evidence regarding the effects of anticoagulants for septic DIC. [ABSTRACT FROM AUTHOR]

The aim of this study was prospective evaluation of the performance of the HAS-BLED score in predicting major bleeding complications in a real-world outpatient cohort, during long-term anticoagulation for venous thromboembolism (VTE), treated with a broad spectrumof anticoagulants.We analyzed 111 outpatients objectively diagnosed with VTE and treated long-term with various anticoagulants. Patients were grouped in three cohorts based on the anticoagulant regimen. Calculation of the HAS-BLED score and documentation of bleeding events were performed every 6 months for 1 year. Patients with a HAS-BLED score ≥ 3 had an increased risk for major bleeding events (odds ratio [OR]: 13.05, 95% confidence interval [CI]: 0.96-692.58, p ¼ 0.028) and a trend to higher risk for minor bleeding events as well (OR: 2.25, 95% CI: 0.87-5.85, p ¼ 0.091) when compared with patients with a HAS-BLED score < 3.This indicates that a HAS-BLED score ≥ 3 allows for identification of patients with VTE on long-term anticoagulation at an increased risk for major bleeding events, irrespective of the anticoagulant agent used. [ABSTRACT FROM AUTHOR]

Hemorrhagic transformation (HT) may occur as a part of the natural history of acute ischemic stroke, with incidence between 13- 43% in computer-tomography (CT) studies. Detection of HT in a patient with ischemic stroke is important in establishing treatment in the acute phase in assessing prognosis and in taking therapeutical decisions for secondary stroke prevention. There were controversies regarding optimal treatment in acute ischemic stroke with HT, especially if the patient needs further anticoagulant or antiplatelet treatment. Rehabilitation treatment needs to be continued for post-stroke patients who developed HT, because HT does not decrease rehabilitation outcome. We present rehabilitation treatment and prognosis in a case of hemorrhagic transformation after an embolic ischemic stroke treated with anticoagulants, which required reinitiation of anticoagulant treatment. [ABSTRACT FROM AUTHOR]

Venous Thromboembolism (VTE) frequently complicates the course of hematologic malignancies (HM) and its incidence is similar to that observed in high-risk solid tumors. Despite that, pharmacologic prophylaxis and treatment of VTE in patients with HM is challenging, mainly because a severe thrombocytopenia frequently complicates the course of treatments or may be present since diagnosis, thus increasing the risk of bleeding. Therefore, in this setting, safe and effective methods of VTE prophylaxis and treatment have not been well defined and hematologists generally refer to guidelines produced for cancer patients that give indications on anticoagulation in patients with thrombocytopenia. In this review, besides to summarize the incidence and the available data on prophylaxis and treatment of VTE in HM, we give some advices on how to use antithrombotic drugs in patients with HM according to platelets count. [ABSTRACT FROM AUTHOR]

Splanchnic vein thrombosis (SVT) and cerebral vein thrombosis (CVT) are two manifestations of unusual site venous thromboembolism (VTE). SVT includes thrombosis in the portal, mesenteric or splenic veins, and the Budd-Chiari syndrome. CVT encompasses thrombosis of the dural venous sinuses and thrombosis of the cerebral veins. Unusual site VTE often represents a diagnostic and therapeutic challenge because of the heterogeneity in clinical presentation, the limited evidence available in the literature on the acute and long-term prognosis of these diseases, and the lack of large randomized controlled trials evaluating different treatment options. This narrative review describes the approach to patients with SVT or CVT by examining the diagnostic process, the assessment of potential risk factors and the appropriate anticoagulant treatment. [ABSTRACT FROM AUTHOR]

Aims and objectives To elicit the perceptions of patients, who self-tested their international normalized ratio and communicated their results via a text or phone messaging system, to determine their satisfaction with the education and support that they received and to establish their confidence to move to self-management. Background Self-testing of international normalized ratio has been shown to be reliable and is fast becoming common practice. As innovations are introduced to point of care testing, more research is needed to elicit patients' perceptions of the self-testing process. Design This three site study used a cross-sectional prospective descriptive survey. Methods Three hundred and thirty patients who were prescribed warfarin and using international normalized ratio self-testing were invited to take part in the study. The anonymous survey examined patient profile, patients' usage, issues, perceptions, confidence and satisfaction with using the self-testing system and their preparedness for self-management of warfarin dosage. Results The response rate was 57% ( n = 178). Patients' confidence in self-testing was high (90%). Patients expressed a high level of satisfaction with the support received, but expressed the need for more information on support groups, side effects of warfarin, dietary information and how to dispose of needles. When asked if they felt confident to adjust their own warfarin levels 73% agreed. Chi-squared tests for independence revealed that none of the patient profile factors examined influenced this confidence. The patients cited the greatest advantages of the service were reduced burden, more autonomy, convenience and ease of use. The main disadvantages cited were cost and communication issues. Conclusion Patients were satisfied with self-testing. The majority felt they were ready to move to self-management. Relevance to clinical practice The introduction of innovations to remote point of care testing, such as warfarin self-testing, needs to have support at least equal to that provided in a hospital setting. [ABSTRACT FROM AUTHOR]

Atraumatic acute carpal tunnel syndrome is a rare type of median nerve neuropathy caused by etiologies that increase compartment pressure in the carpal tunnel. This report describes a patient with flexor tendon abrasion as an unusual complication of distal radioulnar joint arthritis. This abrasion caused a hematoma to form in the carpal tunnel during anticoagulant treatment with apixaban, resulting in recurrent acute carpal tunnel syndrome. [ABSTRACT FROM AUTHOR]

Atrial fibrillation (AF) represents one of the most common preventable causes of stroke, conferring a fivefold increased risk of stroke. The risk of stroke caused by AF is underestimated, many AF episodes being asymptomatic. Embolic strokes caused by AF can be prevented using anticoagulant therapy. The ESC (European Society of Cardiology) guidelines for patients with AF recommend anticoagulant therapy if the risk for embolic stroke / systemic embolism, evaluated with the CHA2DS2-VASc score, is high. Bleeding is the major complication of anticoagulant therapy. For every patient taking anticoagulant medication, HAS-BLED score assessing the risk of bleeding needs to be performed. The priorities in treating patients with atrial fibrillation are protection against embolic events and minimal risk of hemorrhagic events. Vitamin K antagonists, despite their accessibility and long term use, have important limitations. New/direct oral anticoagulants are better options, with alt least identical efficacy and higher safety profile. In real life, the choice of the appropriate anticoagulant agent could be challenging. [ABSTRACT FROM AUTHOR]

Introduction: Spontaneous spinal epidural hematomas are rare. However, in patients on anticoagulant treatment the risk may increase. Symptomatically patients may present with radiculopathy and even progressive neurological deficits. Case description: We present a case of a warfarin treated patient with left L5 radiculopathy. MRI was evaluated as showing a lumbar disc prolapse or synovial cyst at L4-L5 level. The patient was operated and an organized material was removed and analysed as a hematoma. No prolapsed disc or synovial cyst was found. The patient was neurologically restored following the operation. Discussion and Evaluation: This case illustrates how spontaneous epidural spinal hematomas can present with symptoms of radiculopathy and radiologically be misinterpreted as a protruding disc or cyst. Conclusion: Warfarin treated patients may have an increased risk of spontaneous spinal epidural hematomas. [ABSTRACT FROM AUTHOR]

Cerebral venous thrombosis (CVT), also known as a venous stroke, is relatively rare, more common in young people, and about 3/4 of patients are women. This disease may contribute to focal brain damage. The paper presents a case of a young man after a fall from a height with associated polytrauma (including basilar skull fracture), in which on the basis of magnetic resonance imaging transverse and sigmoid sinus thrombosis of the right side was diagnosed. Despite long-term anticoagulation, complete regression of thrombotic lesions has not been achieved. The clinical course of the described case raises a number of doubts about how to proceed in this group of patients, especially in the case of possible complications. Because so far clear standards of behavior therapy in venous thrombosis and cerebral sinus have not been established, it is still an important diagnostic and therapeutic problem. [ABSTRACT FROM AUTHOR]

Objective: To investigate the effect of anticoagulant treatment and perinatal outcomes in patients with primary or secondary recurrent pregnancy loss without cause other than inherited trombophilia. Methods: A total of 143 pregnant patients with recurrent pregnancy loss (≥2 abortus) and had no detected cause other than thrombophilia, were included in the study. Patients with no livebirth history were accepted as primary and patients with at least one livebirth were as secondary recurrent spontaneous aborters (PrimRSAs and SecRSAs). Inherited thrombophilia genetic results of the patients in both groups were compared. The effects of low-molecular weight heparin (LMWH) and low-dose aspirin (LDA) treatments alone or together, livebirth rates and pregnancy outcomes were investigated. Results: Sixty-eight patients were in PrimRSAs and 75 were in SecRSAs. Ages, numbers of total, early and late pregnancy loss of both groups were similar. In PrimRSAs 49 (72.1%) and in SecRSAs 50 (66.6%) patients had three or more inherited thrombophilia genetic mutations. Of 113 patients who used LMWH+LDA during pregnancy 88 (77.6%) had livebirth; however, of 19 patients who used LMWH 6 (31.6%) and of 11 women who used LDA 8 (72.7%) had livebirth. Livebirth rate was significantly higher in patients who used LMWH+LDA together (p=0.001). Livebirth rates were higher in SecRSAs than PrimRSAs irrespective to the anticoagulant treatment (p=0.002). Conclusion: LMWH and LDA treatment together may increase livebirth rates in patients with recurrent pregnancy loss and inherited thrombophilia. Having at least one livebirth of the patients is a good prognostic factor. [ABSTRACT FROM AUTHOR]

The use of non-vitamin K antagonist oral anticoagulants (NOACs) has become a breakthrough in anticoagulant treatment and it is expected to rise significantly in upcoming years. The use of conventional anticoagulants have several limitations: subcutaneous administration of heparin, or close monitoring of INR during application of vitamin K antagonists. In the last decade, target-specific oral anticoagulants (TSOAC) including dabigatran, rivaroxaban, apixaban, edoxaban have been marketed for prophylaxis and treatment. Therefore, it is crucial to understand the potential uses, side effects, and management of these agents in routine practice. NOACs have major pharmacologic advantages, including a rapid onset and offset of action, fewer drug interactions than conventional anticoagulants, and predictable pharmacokinetics. These agents are gaining popularity among both physicians and patients because of their easiness of administration and the eliminating the requirement for regular coagulation monitoring. In this review, we focus on discussing practical recommendations for the use of NOACs and the risks and benefits of incorporating them into routine practice. [ABSTRACT FROM AUTHOR]

Purpose: This study evaluated the benefits of and possible contraindications to warfarin treatment in patients with atrial fibrillation (AF) prior to the introduction of new oral anticoagulants using health registry data from inpatient care, specialist ambulatory care, and primary care. Methods: This is a cohort study including all patients in the region of Stockholm, Sweden (2.1 million inhabitants) with a diagnosis of non-valvular AF ( n = 41 810) recorded during 2005-2009. The risks of suffering ischemic stroke, bleeding, or death with warfarin, aspirin, or no antithrombotic treatment during 2010 were related to CHADSVASc scores, age, and complicating co-morbidities. Results: One-year risks for ischemic stroke were 1.0-1.2 % with aspirin, 0-0.3 % with warfarin, and 0.1-0.2 % without treatment at CHADSVASc scores 0-1. Among the aspirin-treated patients with CHADSVASc scores ≥2, half had possible contraindications and high risks for ischemic stroke (5.2 %), bleeding (5.0 %), and death (19.3 %). The other half of the patients with no identified contraindications had a high risk for ischemic stroke (4.0 %) but a low bleeding risk (1.8 %) and a moderate mortality rate (8.4 %). Conclusions: The present observations confirm earlier findings of undertreatment with warfarin and half of the high-risk patients treated with aspirin were obvious candidates for anticoagulant treatment. However, the other half of the patients had complicating co-morbidities, high bleeding risk, and poor prognosis. This and possible overtreatment of low-risk patients should be taken into account when considering more aggressive use of anticoagulant treatment. [ABSTRACT FROM AUTHOR]

Cancer and hypercoagulability are two of the most common causes of morbidity and mortality worldwide. Their relationship was first reported in the mid 1800s, but it is only during the last 30 years that its mechanism has started to be elucidated. The risk of venous thromboembolism (VTE) among cancer patients is 4-6 times higher than among non-cancer patients and the likelihood of thrombosis is associated with parameters related to the patient and to the disease and its treatment. Malignancy affects all the parameters of the Virchow's triad: Blood-flow, coagulation procedure and endothelium. Cancer cells induce a hypercoagulant state by secreting procoagulant, antifibrinolytic and proaggregational factors and inflammatory mediators. Tissue factor production leads via coagulation-dependent and -independent pathways, to the creation of a vicious circle by which malignancy induces a thrombophilic state and thrombophilia, in turn, promotes tumor growth and metastasis. The spectrum of clinical and laboratory manifestations of cancer-related thrombosis is wide. In recent years efforts have been made to set up prognostic models to identify cancer patients at high risk for developing VTE, for whom the use of thromboprophylaxis would be beneficial. Meanwhile, guidelines on thromboprophylaxis and the treatment of cancer-related thrombosis are being drawn up, and the use of anticoagulants as antineoplasmatic agents is under investigation. [ABSTRACT FROM AUTHOR]

The case report of a 58 years patient with a history of idiopathic ulcerous colitis who was admitted in the Intensive Care Unit of "Dr. Juan Bruno Zayas Alfonso" Teaching General Hospital from Santiago de Cuba for presenting signs of neurological changes is presented. It was identified as a cerebral venous thrombosis through the computerized axial tomography. After confirming the absence of symptoms of his initial disease by means of an endoscopic study, an anticoagulant treatment with low molecular weight heparin was began, with which the complete regression of the neurological signs was achieved. [ABSTRACT FROM AUTHOR]

Chronic anticoagulant treatment in patients with nonvalvular AF that also have renal failure is an important issue in therapeutic practice. About 1/3 of AF patients have a chronic renal disease (CKD stage 3 or higher) and 15% of CKD patients develop AF. CKD patients with varying degrees of renal dysfunction and nonvalvular AF have an increased risk of AVC and also of bleeding, both spontaneously and under anticoagulant treatment. This paper analyses: 1) the relationship between CKD (stages 3,4 and 5) and AF; 2) the implications of this association on embolic and hemorrhagic risk; 3) the results of the main studies on chronic treatment with antivitamins K (AVK) and the new oral anticoagulants (NOAC) in nonvalvular AF with CKD. For chronic anticoagulant treatment in AF, AVK remain the therapeutic agents with the broadest indications, irrespective of the degree of renal dysfunction. Benefits of AVC prevention are above hemorrhagic risk with correct monitoring. The new oral anticoagulants (dabigatran, rivaroxabam, apixaban) have similar indications as AVK in AVC prevention in AF, but their use is limited in severe renal dysfunction (GFR =30 ml/min). For AF patients with CKD-stage 2 and 3, NOAC have equal or superior antithrombotic efficiency compared with AVK, but significantly less thrombotic risk. The selection of patients for one or the other oral anticoagulant treatment for non-valvular AAF can be achieved on the base of risk scores (CHADS2, HASBLED), but also based on the other individual factors, among which the presence of moderate or severe renal dysfunction is a major one. [ABSTRACT FROM AUTHOR]

Tromboembolismul venos (TEV) poate avea evoluţie şi complicaţii variate: extensia trombozei, recurenţa TEV, sindromul post-trombotic, hipertensiunea pulmonară tromboembolică cronică. Recurenţa TEV se poate produce în timpul tratamentului anticoagulant activ sau după întreruperea tratamentului, având o valoare estimată, la şase luni, de 3,6% pentru TVP şi de 4,9% pentru EP. La zece ani, recurenţa TEV se produce la 30-40% dintre cazuri. Recurenţa TEV are implicaţii directe pentru durata tratamentului anticoagulant şi pentru tactica de tratament. Venous thromboembolism (VT) may have various evolution and complications: thrombosis extension, recurrent VT, post-thrombotic syndrome, chronic thromboembolic pulmonary hypertension. Recurrent VT may occur during anticoagulant treatment or after its interruption; it's estimated incidence is 3,6% at six months for the DVT (deep venous thrombosis) and 4,9% for PE (pulmonary embolism). At ten years, recurrent VT occurs in 30-40% of cases. Recurrent VT has direct implications for the anticoagulant treatment durations and for the management approach. This paper analyses general recurrence data, the risk factors for the recurence and bleeding. It mentions: idiopathic ("unprovoked") VT versus transient risk VT ("provoked"), VT in surgical versus non-surgical patients, active cancer versus non-cancer, proximal versus distal DVT, the first or multiple VT episodes. Laboratory risk factors (D-dimers, thrombophilic factors) and imaging elements contribute to the estimation of the recurrence risk. The Wien prediction model estimates recurrence probability for the individual. Two other chapters of the paper present anticoagulant treatment alternatives, after the initial interval (5-7 days) (VKA, LMWH, new anticoagulants) and the management of the anticoagulant treatment: standard course, prolonged 6-12 months treatment and treatment on undetermined duration. The need to individualize the duration and type of treatment is underlined, especially for patients with serious clinical, biological and imaging recurrence factors. [ABSTRACT FROM AUTHOR]

Abstract: Background: Earlier validation studies of risk scoring by CHA2DS2VASc for assessments of appropriateness of warfarin treatment in patients with atrial fibrillation have been performed solely with diagnoses recorded in hospital based care, even though many patients to a large extent are managed in primary care. Methods: Cross-sectional registry study of all 43 353 patients with a diagnosis of non-valvular atrial fibrillation recorded in inpatient care, specialist ambulatory care or primary care in the Stockholm County during 2006–2010. Results: The mean CHA2DS2VASc score was 3.82 (4.67 for women and 3.14 for men). 64% of the entire cohort of patients with atrial fibrillation had the diagnosis in primary care (12% only there). The mean CHA2DS2VASc score of patients with a diagnosis only in inpatient care or specialist ambulatory care increased from 3.63 to 3.83 when comorbidities registered in primary care were added. In 2010 warfarin prescriptions were claimed by 47.2%, and ASA by 41.6% of the entire cohort. 34% of patients with CHA2DS2VASc=1 and 20% with CHA2DS2VASc=0 had warfarin treatment. ASA was more frequently used instead of warfarin among women and elderly patients. Conclusions: Registry CHA2DS2VASc scores were underestimated without co-morbidity data from primary care. Many individuals with scores 0 and 1 were treated with warfarin, despite poor documentation of clinical benefit. In contrast, warfarin appears to be underused and ASA overused among high risk atrial fibrillation patients. Lack of diagnoses from primary care underestimated CHA2DS2VASc scores and may thereby have overestimated treatment benefits in low-risk patients in earlier studies. [Copyright &y& Elsevier]

Objectives Antithrombotic treatment for retinal vein occlusion ( RVO) is controversial, although RVO has been surmised as a predictor of a subsequent vascular event. We aimed to evaluate risk factors, the effects of antithrombotic therapy and the occurrence of subsequent vascular events in patients with a first episode of RVO, according to age of RVO onset. Methods In this prospective cohort study, patients with central ( CRVO) and branch RVO ( BRVO) confirmed by fluorescein angiography were studied; they were divided according to age. Cardiovascular risk factors and thrombophilia were evaluated. Anticoagulants or aspirin were given for at least 3 months. Patients were followed every 6-12 months and vascular events were recorded. Results One hundred CRVO and 32 BRVO patients were enrolled. Five of 60 (8.3%) patients <50 yr and 4/72 (5.5%) over 50 yr had a hereditary thrombophilic defect. One or more cardiovascular risk factors were found in 35 (58%) patients of the younger group, and in 66 (91%) of the older group ( P < 0.001). Antithrombotic treatment led to both a satisfactory recanalization of occluded veins and visual acuity improvement especially in younger patients. Vascular events occurred in 19 (14%) cases after 4 ± 3.3 yr from RVO, more frequently in older than in younger patients (22% vs. 5%, P = 0.005). Conclusions Distribution of cardiovascular, but not of thrombophilic risk factors seems to be influenced by age in RVO patients. Patients with a first RVO, especially those >50 yr, are likely at risk of a subsequent vascular event. [ABSTRACT FROM AUTHOR]

An international normalized ratio (INR) higher than 9 is associated with a high risk of bleeding, yet most studies have focused on outpatients with lower INR. We retrospectively analyzed diagnosis, bleeding, treatment, and mortality in 162 patients with INR higher than 9, including inpatients and outpatients with and without warfarin treatment. Patients without anticoagulant treatment with INR higher than 9 had a poor prognosis, 67% experienced bleeding and 74% died. Among outpatients receiving warfarin with INR higher than 9, 11% had bleeding, but none died. Among inpatients receiving warfarin, 35% had bleeding and 17% died. Factors associated with bleeding were older age, renal failure, and alcohol use. Withholding warfarin or giving vitamin K treatment was ineffective at reducing the INR within 24 hours, whereas plasma infusion immediately dropped the INR to 2.4 ± 0.9. Because of underlying disease, comorbidities, and medications, hospitalized patients with INR higher than 9 may not respond quickly to withholding warfarin or vitamin K treatment, and plasma infusion may be needed to reduce INR and the risk of bleeding within 24 hours. [ABSTRACT FROM AUTHOR]

When blood reaches an extracorporeal surface, a drying process is initiated. Properties of this drying process may be crucial for the correct assessment of case-specific time lapses, however, there is a lack of systematic studies concerning the drying times of blood. We present a study on drying properties of small blood droplets with a standardized size of 25 μl (resembling droplets originating from pointed and sharp objects, e.g. the tip of a knife) under different environmental conditions to elucidate the effect of different ambient temperatures, indoor surfaces and anticoagulant treatment. As a rule of thumb, wiping a typical small blood droplet will not lead to a macroscopically visible smear after a time period of approximately 60 min (time = 45 min; time = 75 min) at an average room temperature of 20 °C. Alteration of the ambient temperature has a remarkable effect, as the time needed for the drying process leading to wipe resistance of the droplets decreases to 30 min (time) at an ambient temperature of 24 °C, and is prolonged up to >120 min (time) at an ambient temperature of 15 °C. As for the surface materials in our study, significant differences in drying periods were only found between wood and linoleum (80th percentile 45 vs. 75 min). Treatment with anticoagulants did not influence extracorporeal drying times. In synopsis, the present study shows that ambient temperature is a major determinant of the drying process of blood droplets and should always be documented accurately and continuously on a crime scene. In certain situations, an estimation of the time elapsed since bloodstain origination may be of importance to answer questions related to the time course of actions. However, further systematic studies are needed to clarify the effect of other properties such as droplet size, humidity, or evaporation. [ABSTRACT FROM AUTHOR]

Purpose: Vitamin K antagonist (VKA) treatment can successfully prevent thromboembolic complications, but the modality has a narrow therapeutic window and numerous interactions with other pharmaceuticals. The aim of the study reported here was to describe the use of co-medications and the prevalence of polypharmacy among patients treated with VKA. Methods: In a cross-sectional study, 250 consecutive patients (65% male, median age 68 years, most common indication for VKA treatment: atrial fibrillation) in the maintenance phase of VKA treatment were interviewed about their use of prescription medications, over-the-counter drugs and alternative medicines during the last 7 days. Results: The interviewed patients used a median of five medications (range 1-13), including VKA. Approximately 50% of the patients also took alternative medicines. A wide range of conventional and alternative medicines were used, several of which harbour possible interactions with VKA. Polypharmacy was defined as the use of five or more medications, excluding alternative medicines. The group of polypharmacy patients included 53% of the study population. The use of amiodarone, age >50 years, the indication for VKA treatment being atrial fibrillation or mechanical heart valves and diabetes were independent predictors of polypharmacy. Conclusions: The results of this study highlight that polypharmacy is a common phenomenon among patients on anticoagulant medication, particularly among elderly patients or those suffering from cardiovascular disease or diabetes. [ABSTRACT FROM AUTHOR]

Although, globally, there is a steady increase in the ageing population and thromboembolic disease has a high prevalence in this geriatric segment, the correct antithrombotic treatment is not yet sufficiently standardized and raises difficulties. Th is article discusses the pharmacological and biological features of the elderly, the effects, indications and guideline recommendations for the different antithrombotic medications with specifi c application in elderly patients. [ABSTRACT FROM AUTHOR]

Even though new classes of anti-coagulants are needed, from the category of the X-factor inhibitors (apixaban, rivaroxaban) or of the thrombin direct inhibitors (dabigatran) that pose a low bleeding risk and that do not need INR monitoring, the class of coumarinic anticoagulants (acenocoumarol, hydroxycoumarin) still remain precious anticoagulants. That is why the patients' education in relation to their home administered treatment for the control of its efficacy and the prevention of bleeding-related complications is compulsory. This education is supposed to start in hospital and continue thereafter, but the real testing of the patients' knowledge after they are released is not a part of the usual protocols. This study assesses the level of this knowledge for the purpose of optimizing the educational process and of strengthening the clinician-patient relationship. [ABSTRACT FROM AUTHOR]