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With many available data sources, clinicians need to consider the benefit‐risk profile of individual anticoagulants when balancing the need for anticoagulation, including evaluating the risks in patients with comorbidities and potential drug‐drug interactions. This narrative review presents clinical data across multiple phases of drug development for the use of apixaban, a selective factor Xa inhibitor, when taken concomitantly with other agents, and evaluates the benefit‐risk profile of apixaban with these interacting medications. Key subgroup analyses from the phase 3 ARISTOTLE trial (NCT00412984) are presented using data from patients who received either concomitant inhibitors or inducers of cytochrome P450 3A4 and/or P‑glycoprotein. We also review the available evidence for the use of apixaban in patients with cancer‐associated thromboembolism, as well as the use of apixaban in patients with COVID‐19. [ABSTRACT FROM AUTHOR]

To evaluate the impact of inflammation on anticoagulation monitoring for patients supported with extracorporeal membrane oxygenation (ECMO). Prospective single-center cohort study. University-affiliated tertiary care academic medical center. Adult venovenous and venoarterial ECMO patients anticoagulated with heparin/ C-Reactive protein (CRP) was used as a surrogate for overall inflammation. The relationship between CRP and the partial thromboplastin time (PTT, seconds) was evaluated using a CRP-insensitive PTT assay (PTT-CRP) in addition to measurement using a routine PTT assay. Data from 30 patients anticoagulated with heparin over 371 ECMO days was included. CRP levels (mg/dL) were significantly elevated (median, 17.2; interquartile range [IQR], 9.2-26.1) and 93% of patients had a CRP of ≥5. The median PTT (median 58.9; IQR, 46.9-73.3) was prolonged by 11.3 seconds compared with simultaneously measured PTT-CRP (median, 47.6; IQR, 40.1-55.5; p < 0.001). The difference between PTT and PTT-CRP generally increased with CRP elevation from 2.7 for a CRP of <5.0 to 13.0 for a CRP between 5 and 10, 17.7 for a CRP between 10 and 15, and 15.1 for a CRP of >15 (p < 0.001). In a subgroup of patients, heparin was transitioned to argatroban, and a similar effect was observed (median PTT, 62.1 seconds [IQR, 53.0-78.5 seconds] vs median PTT-CRP, 47.6 seconds [IQR, 41.3-57.7 seconds]; p < 0.001). Elevations in CRP are common during ECMO and can falsely prolong PTT measured by commonly used assays. The discrepancy due to CRP-interference is important clinically given narrow PTT targets and may contribute to hematological complications. [ABSTRACT FROM AUTHOR]

Aims This study aimed to compare the effects of the combination of rivaroxaban and aspirin with aspirin alone on health-related quality of life in the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial. Methods and results Health-related quality of life assessed using the EQ-5D-3L. The treatment effects on health utility and EQ visual analogue scale (EQ VAS) scores were compared between rivaroxaban plus aspirin and aspirin alone in terms of adjusted mean difference in change from baseline and odds ratio of having deterioration events. Nine thousand forty-nine (98.9%) and 6916 (75.5%) completed the EQ-5D-3L at baseline and at final visit, respectively. Nine thousand twenty-eight (98.9%) and 6887 (76.3%) completed the EQ-5D-3L at baseline and final visit, respectively. Mean (standard deviation) health utility and EQ VAS scores at baseline were 0.871 (0.141) and 76.0 (15.3), respectively, for the rivaroxaban plus aspirin group, compared with 0.873 (0.139) and 75.8 (15.1) for the aspirin group. Adjusted mean difference in change from baseline utility was −0.002 [95% confidence interval (CI), −0.006, 0.002, P = 0.30] between the combination therapy group and the aspirin group. The odds ratio (95% CI) of experiencing deterioration in health utility was 1.01 (95% CI, 0.93, 1.10, P = 0.81) between the two groups. Adjusted mean difference in change from baseline EQ VAS was 0.02 (95% CI, −0.43, 0.47, P = 0.93) between the two groups. Conclusion This analysis of the COMPASS trial demonstrated that the quality of life of patients was similar between the rivaroxaban plus aspirin group and the aspirin alone group. Registration Trial registration number: ClinicalTrials.gov number (NCT01776424). Trial protocol and statistical analysis plan: https://www.nejm.org/doi/full/10.1056/NEJMoa1709118#APPNEJMoa1709118PRO. [ABSTRACT FROM AUTHOR]

Introduction: Patients who undergo percutaneous coronary intervention (PCI) with stenting usually require a period of dual antiplatelet therapy (DAPT) but, when an indication for long-term oral anticoagulation (OAC) such as atrial fibrillation (AF) coexists, triple antithrombotic therapy (TAT) with DAPT and OAC causes concern for excessive bleeding. Achieving the right balance between bleeding and adequate protection from ischemic events remains an issue of debate and subject to ongoing investigation of various antithrombotic regimens and durations. Areas covered: This review describes the landmark clinical trials comparing TAT to a period of dual antithrombotic therapy (DAT) and subsequent meta-analyses. It also describes the international recommendations that have been derived from this evidence and identifies outstanding issues that could be addressed in upcoming or future trials. Expert opinion: The current recommended default strategy of a short period of TAT with clopidogrel followed by the withdrawal of aspirin faces a challenge from the prospect of more consistent P2Y12 inhibition provided by ticagrelor and prasugrel. Ticagrelor monotherapy has already been trialed in patients after PCI without an indication for OAC. DAT with ticagrelor or prasugrel immediately post-procedure could emerge as a comparably safe and more efficacious regimen than one involving clopidogrel in the right setting. [ABSTRACT FROM AUTHOR]

Background Aortobronchial fistulas (ABFs) are rare but potentially life-threatening conditions, often presenting with haemoptysis. They can develop following various thoracic aortic conditions or procedures. Case Presentation A 70-year-old patient with a history of descending aorta replacement and ischaemic stroke presented with chest pain and upper gastrointestinal bleeding. Imaging revealed a fistula between the aortic prosthesis and the lung, along with other cardiovascular abnormalities. Despite the indication for anticoagulant therapy, tranexamic acid was initiated due to bleeding risk. The patient showed clinical improvement with tranexamic acid treatment but experienced recurrence of bleeding after discontinuation. Endovascular treatment for the contained rupture at the proximal stent anastomosis was indicated. Discussion Haemoptysis is the primary symptom of ABFs, often recurring until the fistula enlarges. Postoperative aortic fistulas into the airways are uncommon and can occur years after surgery. Thoracic endovascular aortic repair has become the primary treatment for high-risk patients with thoracic aortic disease. Various diagnostic modalities can visualize a fistula tract, but practical visualization is rare. Untreated ABFs invariably lead to death. Conclusion This case highlights the challenges in diagnosing and managing ABFs, emphasizing the need for a multidisciplinary approach and regular follow-up. Patient education and prompt reporting of symptoms are essential. Early intervention upon suspicion of recurrence is crucial for optimizing patient outcomes. [ABSTRACT FROM AUTHOR]

Atrial fibrillation (AF) in the postoperative phase is a manifestation of numerous factors, including surgical stress, anesthetic effects, and underlying cardiovascular conditions. The resultant cardiac hyperactivity can induce new onset or exacerbate existing AF. A common phenomenon, postoperative atrial fibrillation (POAF) affects nearly 40% of patients and is associated with longer hospitalization stays, and increased mortality, heart failure, stroke, and healthcare costs. Areas of controversy in POAF include whether to anticoagulate patients who have short-lived POAF, especially given their higher bleeding risk in the postoperative period, and the identification of patients who would benefit the most from preventive drug therapy for POAF. This review discusses the pathophysiology and management of POAF, and strategies to reduce its occurrence. [ABSTRACT FROM AUTHOR]

Background: This study aimed to evaluate the application value and safety of Warfarin, Rivaroxaban, and Dabigatran in elderly patients with atrial fibrillation. Methods: A total of 180 elderly patients with atrial fibrillation admitted to our hospital were retrospectively analyzed. According to their anticoagulant treatment regimen, patients were divided into three groups: Warfarin (57 cases), Rivaroxaban (61 cases), and Dabigatran (62 cases). General demographic information was collected, and coagulation function indicators—including fibrinogen (FIB), thrombin time (PT), activated partial thrombin time (APTT), and D‐dimer (D‐D)—as well as liver function indexes—including total bilirubin (TbiL), alkaline phosphatase (ALP), aspartate aminotransferase (AST), and alanine transferase (ALT)—were compared before and after 4 weeks of treatment. Results: There were no significant differences in demographic characteristics such as gender, age, body mass index, or disease course among the three groups. The total effective rate in the Warfarin group (84.21%) was significantly lower than in the Rivaroxaban (98.36%) and Dabigatran (96.77%) groups (p < 0.05). However, there was no significant difference in the total effective rate between the Rivaroxaban and Dabigatran groups (p > 0.05). Additionally, no significant differences were found in the effects of the three drugs on coagulation function, liver function, or the incidence of bleeding (p = 0.052). Conclusion: Warfarin, Rivaroxaban, and Dabigatran can effectively prevent thrombosis in elderly patients with atrial fibrillation, with Rivaroxaban and Dabigatran showing superior effectiveness. All three drugs demonstrated similar low rates of bleeding events and had no significant impact on coagulation and liver function. [ABSTRACT FROM AUTHOR]

Background: This review article discussed the use of bridging therapy with low‐molecular‐weight heparin (LMWH) in patients who undergo noncardiac surgery (NCS) after percutaneous coronary intervention (PCI). Hypotheses: Patients who undergo PCI are at an increased risk of thrombotic events due to their underlying cardiovascular disease. However, many of these patients may require NCS at some point in their lives, which poses a significant challenge for clinicians as they balance the risk of thrombotic events against the risk of bleeding associated with antithrombotic therapy. Results: This review evaluates the current evidence on the use of bridging therapy with LMWH in patients undergoing NCS after PCI, focusing on outcomes related to the efficacy and safety of antithrombotic therapy. The article also discusses the limitations of the current evidence and highlights areas where further research is needed to optimize the management of antithrombotic therapy in this patient population. Conclusion: The goal of this review was to provide clinicians with a comprehensive summary of the available evidence to guide clinical decision‐making and improve patient outcomes. [ABSTRACT FROM AUTHOR]

BACKGROUND: A transfeminine patient is a 79-year-old with past medical history significant for type 2 diabetes mellitus, hypertension, gender dysphoria, chronic kidney disease, dyslipidemia, total left hip replacement, and recent provoked deep venous thromboembolism (DVT). She was seen by a pharmacist in a primary care clinic after her discharge from a skilled nursing facility. The patient was experiencing symptoms of gender dysphoria after discontinuation of her estradiol in setting of her DVT. ASSESSMENT: Her renal function was calculated to ensure she was on appropriate dosing of her medications. Because her DVT was provoked, providers determined she would require only 3 months of anticoagulation. Her laboratory test results showed a subtherapeutic estradiol level and her estradiol was restarted. Additionally, aspirin was being prescribed for primary prevention of atherosclerotic cardiovascular disease and was discontinued. OUTCOME: She has significant improvement in her gender dysphoria symptoms with resuming her estradiol and now has a therapeutic estradiol level. She is tolerating her direct oral coagulant well and reports good quality of life. CONCLUSION: When reviewing medications for patients it is important to take several factors into account, including dose, appropriate indication, and patient preference. Pharmacists play a key role, through collaboration with providers, in assessing these medication-specific factors. Estradiol was stopped in this patient because of her DVT, but given her DVT was provoked after a recent surgery, it was unlikely that estradiol was the cause of her clot. Weighing the risks and benefits for any patient is important when determining what medications are appropriate to continue. Additionally, calculating renal function appropriately in a gender-non-conforming patients ensures appropriate and safe dosing. [ABSTRACT FROM AUTHOR]

Introduction: Heparin, a commonly used anticoagulant in cardiac surgery, binds to antithrombin III (ATIII) to prevent clot formation. However, heparin resistance (HR) can complicate surgical procedures, leading to increased thromboembolic risks and bleeding complications. Proper diagnosis and management of HR are essential for optimizing surgical outcomes. Methodology: Diagnosis of HR involves assessing activated clotting time (ACT) and HR assays. Management strategies were identified through a comprehensive review of the literature, including studies exploring heparin dosage adjustments, antithrombin supplementation, and alternative anticoagulants in cardiac surgery patients with HR. A thorough search of relevant studies on HR was conducted using multiple scholarly databases and relevant keywords, resulting in 59 studies that met the inclusion criteria. Discussion: HR occurs when patients do not respond adequately to heparin therapy, requiring higher doses or alternative anticoagulants. Mechanisms of HR include AT III deficiency, PF4 interference, and accelerated heparin clearance. Diagnosis involves assessing ACT and HR assays. HR in cardiac surgery can lead to thromboembolic events, increased bleeding, prolonged hospital stays, and elevated healthcare costs. Management strategies include adjusting heparin dosage, supplementing antithrombin levels, and considering alternative anticoagulants. Multidisciplinary management of HR involves collaboration among various specialities. Strategies include additional heparin doses, fresh frozen plasma (FFP) administration, and antithrombin concentrate supplementation. Emerging alternatives to heparin, such as direct thrombin inhibitors and nafamostat mesilate, are also being explored. Conclusion: Optimizing the management of HR is crucial for improving surgical outcomes and reducing complications in cardiac surgery patients. Multidisciplinary approaches and emerging anticoagulation strategies hold promise for addressing this challenge effectively. [ABSTRACT FROM AUTHOR]

Ambulatory thromboprophylaxis (AT) in patients with pancreatic adenocarcinoma (PAC) reduces venous thromboembolism (VTE) risk and is recommended for patients receiving systemic chemotherapy. We evaluated VTE rates, severity, timing, and risk factors in PAC patients as well as AT rates and initiation times. Patients diagnosed with PAC were included. Data collected included patient demographics, medical history, PAC diagnosis, development of VTE, AT, and bleeding episodes. VTE was defined as a DVT or a PE. Patients were classified as receiving AT for VTE prevention if they received a prescription for outpatient anticoagulation. The cohort included 243 PAC patients. VTE occurred in 24 %. Overall, 52 % developing VTE were hospitalized and 5 % died as a result of the VTE. Of those who developed VTE 50 % were diagnosed within the first 2 months of PAC diagnosis. Univariate predictors of elevated VTE risk included an elevated Onkotev score, metastasis at diagnosis, male gender and not receiving AT. Multivariate predictors of elevated VTE risk included male gender (P = 0.014) and not receiving AT (P = 0.001). Overall, 30 % of patients received AT. The median time from diagnosis to initiation of AT was 43 days. Major bleeding occurred in 5.8 %. Patients receiving AT were not at a significantly increased risk of major bleeding (p = 0.5). Patients with intestinal tumor invasion were at significantly increased risk of major bleeding (P = 0.021). VTE risk is significant and morbid in PAC patients. AT rates are low, and initiation is often delayed. Therapeutic endoscopists diagnosing PAC may be helpful in AT initiation. [ABSTRACT FROM AUTHOR]

Background: There has been growing interest in exploring combined interventions to achieve a more effective heparin-free treatment approach. Aim: to evaluate combination of interventions compared to standard practice (intermittent flushes) to prevent clotting and consequently reduce premature interruptions of hemodialysis. Methods: This open-label randomized controlled trial recruited chronic hemodialysis patients with contra-indication to systemic heparinization. Participants were randomized into one of five groups to receive different strategies of heparin-free hemodialysis treatment for up to three sessions. Primary endpoint: the successful completion of hemodialysis without clotting. Secondary outcomes: the clotting of the air traps assessed by a semi-quantitative scale, online KT/V, and safety of the interventions. Results: Forty participants were recruited and randomized between May and December 2020. Participants showed similar baseline biochemistry results and coagulation profiles. The highest success rates were observed in group 3 (heparin-coated dialyzers combined with intermittent flushes) (100%) and group 5 (hemodiafiltration with online predilution combined with heparin-coated dialyzers), with 91% vs. the control (intermittent flushes) (64%). Group 2 (heparin-coated dialyzers alone) had the poorest success rate, with 38% of the sessions being prematurely terminated due to clotting. KT/V and clotting scores were similar between groups. No adverse events related to the trial interventions were observed. Conclusions: The proposed combination of interventions may have had additive effects, leading to less frequent clotting and the premature termination of an HD/HDF session. Our study supports the feasibility of conducting a larger randomized controlled trial focusing on the efficacy of combined interventions for heparin-free HD in patients with a high risk of bleeding. [ABSTRACT FROM AUTHOR]

Superficial venous thrombosis (SVT) is a fairly common disorder, characterized by the formation of thrombi inside superficial veins, with or without an associated inflammatory reaction. Its evolution is frequently self-limited. However, serious complications may change this clinical course with extension to deep vein thrombosis (DVT) and pulmonary embolism (PE). SVT shares similar risk factors with DVT and is frequently associated with the presence of varicose veins. However, the occurrence of non-varicose veins could conceal risk factors such as malignancies, thrombophilia, or Buerger's disease. While the clinical diagnosis is generally straightforward, additional diagnostic evaluations are often necessary. Duplex ultrasound (DUS) is an invaluable tool that provides the location of SVT, the proximity to the sapheno–femoral junction, and the clot length, all of which influence the decision for optimal management. The treatment of SVT should be symptomatic, pathogenic (limiting the extension of thrombosis), and prognostic (to prevent complications). There are several guidelines that provide recommendations, and despite the need for more consensus and for further studies, the treatment of SVT should be mainly medical, including anticoagulation in specific clinical situations and symptom relief, with invasive treatment in a minority of cases. Initiation, intensity, and length of anticoagulant treatment should be based on the eventual risk of progression to DVT or PE, which can be high, intermediate, or low, based on the location of SVT and the clot length. Our review summarizes the evaluation and proper management of SVT and highlights the importance of a shared decision within the heart team regarding this condition in order to prevent further complications. [ABSTRACT FROM AUTHOR]

Abstract Background Bleeding complications following intramuscular (IM) injections are generally considered rare with reported incidence of 0.06%. However, evidence on safety of IM injections among anticoagulated hospitalized patients is lacking. The objective of the current study was to examine the incidence of injection site bleeding complications following IM injection among anticoagulated hospitalized patients. Methods A retrospective comparative study comprised of all hospitalized patients ≥ 18 years old that were treated with ≥ 1 IM injection between 2009 and 2019 in a large tertiary medical center. Bleeding complications were defined as focal hematoma, local bleeding, intramuscular bleeding or compartment syndrome. Each case with IM injection was searched for ICD9 codes (e.g., hematoma, hemorrhage or compartment syndrome) and for indirect evidence suggestive of potential bleeding: hemoglobin drop ≥ 2 g/dl, AST or CPK increase, packed red blood cell transfusion, or abrupt cessation of the anticoagulation. These case were then verified for true injection-site bleeding by natural language processing model and manual review of the electronic medical record. Results A total of 71,710 patients were treated with 236,406 IM injections. Mean age 53 (± 22) and 63% were females. Concomitant anticoagulation (Heparins: 90.3%, warfarin: 6.8% and DOACs: 4.7%) occurred in 40,819 IM injections (8189 patients). Suspected bleeding complications at the IM injection site were identified among 7,111 patients following 23,089 IM injections, the majority were unrelated to the IM injection-site (e.g., gastrointestinal bleeding, retroperitoneal, etc.). Two cases were verified as true injection site bleeding complication, both in the anticoagulated group (2/8189, 0.02%). Conclusion Bleeding complications at site of IM injections among anticoagulated hospitalized patients are rare, and their risk is probably not higher compared to patients without anticoagulation.

Abstract Background Atrial fibrillation is a growing epidemic in Africa. Anticoagulation, considered the backbone for non-valvular atrial fibrillation (NVAF) management, is limited to warfarin as the mainstay of available anticoagulation therapy in most low- and middle-income countries (LMIC). The optimal time in the therapeutic range (TTR) while on warfarin is essential to avoid bleeding and thromboembolic complications. This study assessed anticoagulation control in patients with NVAF on warfarin in Johannesburg, South Africa. Methods We conducted a cross-sectional retrospective study on patients with NVAF managed in the Division of Cardiology, at a tertiary-level academic centre in Johannesburg, South Africa, between 1 January 2015 and 31 December 2019. Anticoagulation control for patients with NVAF was assessed by calculating the TTR using the Rosendaal method. Results The study population comprised 177 patients diagnosed with NVAF. The mean age was 65.0 ± 13.1 years. The median TTR among patients with NVAF was 46% [interquartile range (IQR): 8.7–86.0], and 63 (35.6%) patients with NVAF had a TTR ≥ 70% (optimal anticoagulation control). Patients with poor anticoagulation control (TTR

Abstract Paroxysmal nocturnal hemoglobinuria (PNH) is a rare hematological disorder characterized by the absence of complement regulatory proteins on the surface of erythrocytes, leading to intravascular hemolysis and thrombosis. Managing PNH during pregnancy poses significant challenges due to increased risks of morbidity and mortality. This case report describes the detailed obstetric course of a 44‐year‐old woman with PNH and additional hereditary protein C deficiency who had previously experienced multiple thrombotic events and adverse pregnancy outcomes (two early miscarriages and one stillbirth at 25 weeks gestation [WG]), treated with eculizumab (terminal C5 inhibitor) and optimal anticoagulation management. Close monitoring of hemolysis and hemostasis parameters was conducted throughout the gestation period together with increased obstetrical surveillance. The pregnancy progressed without thrombotic complications or breakthrough hemolysis, and the patient delivered a healthy newborn at 36 WG after induction of labor due to restricted fetal growth. To the best of our knowledge, this is the first reported case of a positive pregnancy outcome despite PNH in conjunction with hereditary thrombophilia. This case report highlights the importance of a multidisciplinary approach involving hematologists and obstetricians in the management of pregnant women with PNH. Tailored therapy, close monitoring, and comprehensive care are crucial to minimize risks and optimize outcomes.

Abstract Background Inconsistent study results and contradictory recommendations from health authorities regarding the use of apixaban in patients on hemodialysis have generated considerable uncertainty among clinicians, making investigations of appropriate dosing an unmet need. Methods We analyzed pre-dialysis apixaban drug levels from a tertiary care dialysis unit, comparing 2.5 mg once versus twice daily dosing. We applied mixed-effects models including dialysis modality, adjusted standard Kt/V, ultrafiltration, and dialyzer characteristics. We included an exploratory analysis of bleeding events and compared the drug levels of our dialysis patients to those from non-CKD reference populations taking the standard dose of 5 mg twice daily. Results We analyzed 143 drug levels from 24 patients. Mean (SD) age at first drug level measurement was 64.7 (15.9) years (50 % female), median (IQR) follow-up was 12.5 (5.5 – 21) months. For the apixaban 2.5 mg once and twice daily groups, median (IQR) drug levels were 54.4 (< 40 – 72.1) and 71.3 (48.8 – 104.1) ng/mL respectively (P < 0.001). Levels were below the detection limit in 30 % (with 2.5 mg once daily) and 14 % (with 2.5 mg twice daily) respectively. Only dosing group (twice versus once daily) was independently associated with higher drug levels (P = 0.002). Follow-up did not suggest accumulation. The 95th percentile of drug levels did not exceed those of non-CKD populations taking 5 mg twice daily. Median (IQR) drug levels before a bleeding (8 episodes) were higher than those without a subsequent bleeding: 111.6 (83.1 – 129.3) versus 54.8 (< 40 – 77.1) ng/mL (P < 0.001). Concomitant antiplatelet therapy was used in 86% of those with bleeding events versus 6% without bleeding events (P < 0.001). Conclusions Drug monitoring may be a contributory tool to increase patient safety. Despite non-existing target ranges, drug levels on both edges of the spectrum (e.g. below detectability or beyond the 95th percentiles of reference populations) may improve decision-making in highly individualized risk-benefit analyses.

Eishan Beotra,1 Vincent JJ Ngian,1– 3 Fiona Tran,1– 3 Kelvin Hsu,1,4 Fintan O’Rourke,1,3 Bin S Ong1– 3 1South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia; 2Department of Ambulatory Medicine and Medical Assessment Unit, Bankstown-Lidcombe Hospital, South Western Sydney Local Health District, Sydney, NSW, Australia; 3Department of Aged Care, Bankstown-Lidcombe Hospital, South Western Sydney Local Health District, Sydney, NSW, Australia; 4Department of Respiratory Medicine, Bankstown-Lidcombe Hospital, South Western Sydney Local Health District, Sydney, NSW, AustraliaCorrespondence: Bin S Ong, Department of Ambulatory Care, Eldridge Road, Bankstown, NSW, 2200, Australia, Email bin.ong@health.nsw.gov.auBackground: Treatment for pulmonary embolism has expanded to include Direct Oral Anticoagulants (DOACs). The incidence of pulmonary-embolism (PE) in “oldest-old” age group (≥ 85 years) is rapidly increasing, but there is limited research on its management and clinical outcomes.Aim: To examine the differences in management and outcomes in those aged ≥ 85 years compared to other age groups.Methods: We performed a retrospective cohort-study of 373 consecutive patients with pulmonary embolism confirmed on imaging by Computed Tomography Pulmonary Angiogram (CTPA) or Ventilation Perfusion (VQ) Scan at a principal referral hospital in Sydney, Australia. Data collected include clinical and demographic data, Charlson comorbidity index, treatment type and outcomes including complications, recurrent venous thromboembolism, and mortality.Results: Across the age groups, DOACS were prescribed to 53.4% (n=199) of patients. In oldest-old patients with PE, LMWH bridging to warfarin was the most frequently prescribed treatment, used in 46.2% (n=18, 95% CI: 30.8%– 61.5%, p=0.003) of these patients. The mortality rate for patients on LMWH was 13.9% (n=5, 95% CI: 4.2%– 37.5%, p=0.553). Overall, major bleeding incidents were rare, occurring in just 1.7% (n=4, 95% CI: 0.4%– 3.3%) of patients, with no significant differences in outcomes across age groups.Conclusion: DOACs are increasingly used as the treatment modality of choice in atrial fibrillation but are less well studied in pulmonary embolism, particularly in oldest-old patients. We found that the safety and efficacy profile of DOACs in pulmonary embolism treatment is similar across the age groups. Our study does not support any change in treatment protocols of PE in the oldest old, but further studies are required to confirm our findings.Keywords: oldest-old, pulmonary embolism, anticoagulation, treatment, adverse outcomes

Adenomyosis is a chronic disease associated with abnormal uterine bleeding and debilitating pain with severely reduced quality of life in many affected women. Primary strategies for its management encompass surgical interventions, hormonal therapy, or a synergistic blend of these therapeutic modalities. Dienogest (DNG), a new progestin, is primarily utilized to treat adenomyosis due to its exceptional selectivity for the progesterone receptor. In this uncommon case report, we introduce a 42-year-old woman who experienced hemorrhagic shock as a result of uterine bleeding and pulmonary embolism that occurred while a patient was undergoing dienogest therapy for uterine adenomyosis. This situation necessitated blood transfusion and introduction of drugs then an emergency hysterectomy was scheduled followed by the initiation of anticoagulation. We hypothesize that the emergence of pulmonary embolism was intimately tied to adenomyosis, and the occurrence of hemorrhagic shock was likely due to the intake of dienogest.

Continuous renal replacement therapy (CRRT) in children is quite challenging to manage because of their increased propensity for circuit clotting. The anticoagulant strategies are paramount in reducing the downtime in pediatric CRRT. The most commonly used anticoagulants in pediatrics are unfractionated heparin and citrate anticoagulation. The other less explored options include regional heparin protamine anticoagulation, prostacyclin, low-molecular-weight heparin, and thrombin antagonists. The choice of anticoagulant primarily depends on the patient’s condition, availability and cost of the anticoagulant, potential side effects, and the local expertise for troubleshooting. This article aims to bring about the merits and demerits of the different anticoagulants available for CRRT and the available evidence for the use of each of these anticoagulants.

In patients with stroke caused by cardiac embolism, the responsible heart diseases include atrial fibrillation, acute myocardial infarction, sick sinus syndrome, valvular disease, and significant heart failure. When there is no clear source of the embolism, the condition is referred to as “embolic stroke with unknown source (ESUS).” Recent studies have shown that the most common cause of ESUS is a right-to-left cardiac shunt through a patent foramen ovale (PFO). However, considering that PFOs are found in up to 25% of the general population, their presence does not necessarily indicate causality. In patients with ESUS associated with a PFO, either anticoagulants or antiplatelets are used for the prevention of future strokes or transient ischemic attacks. However, it currently remains unclear which treatment is superior. Nevertheless, recent randomized clinical trials have shown that percutaneous closure of the PFO more effectively reduces the incidence of recurrent strokes compared to medical therapy alone in patients with PFO-related strokes. This benefit is especially significant when the PFO carries high-risk features, such as a large shunt or the presence of an atrial septal aneurysm. Furthermore, the effectiveness of PFO closure has been well documented in young patients (

Abstract Background Early neurological deterioration (END) occurs in many patients with acute ischemic stroke due to a variety of causes. Although pharmacologically induced hypertension (PIH) and anticoagulants have been investigated in several clinical trials for the treatment of END, the efficacy and safety of these treatments remain unclear. Here, we investigated whether PIH or anticoagulation is better as a rescue therapy for the progression of END in patients with lacunar stroke. Methods This study included patients with lacunar stroke who received rescue therapy with END within 3 days of symptom onset between April 2014 and August 2021. In the PIH group, phenylephrine was administered intravenously for 24 h and slowly tapered when symptoms improved or after 5 days of PIH. In the anticoagulation group, argatroban was administered continuously intravenously for 2 days and twice daily for next 5 days. We compared END recovery, defined as improvement in NIHSS from baseline, excellent outcomes (0 or 1 mRS at 3 months), and safety profile. Results Among the 4818 patients with the lacunar stroke, END occurred in 147 patients. Seventy-nine patients with END received PIH (46.9%) and 68 patients (46.3%) received anticoagulation therapy. There was no significant difference in age (P = 0.82) and sex (P = 0.87) between the two groups. Compared to the anticoagulation group, the PIH group had a higher incidence of END recovery (77.2% vs. 51.5%, P

BACKGROUND: An unmet need exists to reliably predict the risk of intracranial hemorrhage (ICH) in patients with atrial fibrillation (AF) treated with oral anticoagulants (OACs). HYPOTHESIS: An externally validated model improves ICH risk stratification. METHODS: Independent factors associated with ICH were identified by Cox proportional hazard modeling, using pooled data from the GARFIELD-AF (Global Anticoagulant Registry in the FIELD-Atrial Fibrillation) and ORBIT-AF (Outcomes Registry for Better Informed Treatment of Atrial Fibrillation) registries. A predictive model was developed and validated by bootstrap sampling and by independent data from the Danish National Patient Register. RESULTS: In the combined training data set, 284 of 53 878 anticoagulated patients had ICH over a 2-year period (0.31 per 100 person-years; 95% confidence interval [CI]: 0.28-0.35). Independent predictors of ICH included: older age, prior stroke or transient ischemic attack, concomitant antiplatelet (AP) use, and moderate-to-severe chronic kidney disease (CKD). Vitamin K antagonists (VKAs) were associated with a significantly higher risk of ICH compared with non-VKA oral anticoagulants (NOACs) (adjusted hazard ratio: 1.61; 95% CI: 1.25-2.08; p = .0002). The ability of the model to discriminate individuals in the training set with and without ICH was fair (optimism-corrected C-statistic: 0.68; 95% CI: 0.65-0.71) and outperformed three previously published methods. Calibration between predicted and observed ICH probabilities was good in both training and validation data sets. CONCLUSIONS: Age, prior ischemic events, concomitant AP therapy, and CKD were important risk factors for ICH in anticoagulated AF patients. Moreover, ICH was more frequent in patients receiving VKA compared to NOAC. The new validated model is a step toward mitigating this potentially lethal complication.

BACKGROUND: Patients hospitalized for COVID-19 are at high risk of thrombotic complications and organ failure, and often exhibit severe inflammation, which may contribute to hypercoagulability. OBJECTIVES: To determine whether patients hospitalized for COVID-19 experience differing frequencies of thrombotic and organ failure complications and derive variable benefits from therapeutic-dose heparin dependent on the extent of systemic inflammation and whether observed benefit from therapeutic-dose anticoagulation varies depending on the degree of systemic inflammation. METHODS: We analyzed data from 1346 patients hospitalized for COVID-19 enrolled in the ATTACC and ACTIV-4a platforms who were randomized to therapeutic-dose heparin or usual care for whom levels of C-reactive protein (CRP) were reported at baseline. RESULTS: Increased CRP was associated with worse patient outcomes, including a >98% posterior probability of increased organ support requirement, hospital length of stay, risk of 28-day mortality, and incidence of major thrombotic events or death (patients with CRP 40-100 mg/L or ≥100 mg/L compared to patients with CRP

The safe use of cardiopulmonary bypass (CPB) relies upon the ability to administer, monitor, and reverse anticoagulation. Although rare, the factor XII deficient patient creates a challenge for the perfusionist due to resultant complications in monitoring anticoagulation. There have been proposed strategies to aid in monitoring anticoagulation in factor XII deficient patients, however, documentation of successful monitoring during CPB is infrequent. With the use of the Hemochron Signature Elite and ACT + cartridges, CPB in a factor XII deficient 8-month-old was completed with predictable and reliable anticoagulation monitoring. This case report explores the current suggestions for factor XII deficiency management with CPB.

Antiphospholipid syndrome (APS) is characterized by hypercoagulability, manifesting as venous or arterial thrombosis, and pregnancy-related complications, such as fetal loss, pre-eclampsia, and eclampsia. These conditions occur in the presence of antiphospholipid antibodies (aPL), including anticardiolipin antibodies (aCL) and/or a positive lupus anticoagulant (LA) test.Antiphospholipid syndrome (APS) can manifest as a primary, isolated condition or be associated with connective tissue diseases, such as systemic lupus erythematosus (SLE). The cardiac system is one of the main target organs affected by APS.This report describes a rare clinical case involving a young woman with a history of recurrent miscarriages, who presented with cardiac complications, including severe mitral regurgitation and Spontaneous coronary artery dissection. Etiological assessment identified antiphospholipid antibody syndrome as the underlying cause.The multidisciplinary management plan included initiating therapeutic-dose anticoagulation, followed by referring the patient for potential mitral valve replacement surgery.

Severe left ventricular dysfunction and ventricular wall motion abnormalities predispose individuals to thrombosis and thromboembolism. Thromboembolism is one of the main causes of increased mortality in patients with heart failure and reduced ejection fraction (HFrEF). However, regarding thromboembolism due to HFrEF in sinus rhythm, most cases to date have reported ischemic strokes, and repeated embolization of peripheral arteries has been reported not uncommon. Herein, we report the case of a 48-year-old man with a definite diagnosis of sinus rhythm HFrEF and recurrent peripheral arterial embolization within a short period. The condition is caused by severe left ventricular systolic dysfunction and abnormal left ventricular wall motion, resulting in blood stasis and abnormal blood composition, with or without left ventricular thrombosis, and can lead to thromboembolism. Current guidelines state that patients with heart failure and clear indication(s) for anticoagulation (e.g., atrial fibrillation, heart valve replacement) should be administered appropriate anticoagulation therapy. However, controversy persists regarding whether patients with HFrEF in sinus rhythm can benefit from anticoagulation therapy. This case highlights the utility and necessity of anticoagulation for the prevention of intracardiac thrombosis and the treatment of peripheral arterial embolism in patients with HFrEF in sinus rhythm.

Background: American Association for Thoracic Surgery and The International Society for Heart and Lung Transplantation (AATS/ISHLT) guidelines recommend warfarin in patients with continuous-flow left ventricular assist devices (LVADs) to reduce the risk of device thrombosis and systemic embolization. Left ventricular assist device patients often undergo elective and emergent procedures that require interrupted anticoagulation. Data and experience vary on the optimal strategy to rapidly reverse warfarin in LVAD patients when an emergent procedure is planned. Objective: The purpose of this study was to describe the use of 4-factor prothrombin complex concentrate (PCC4) for warfarin reversal in patients with LVADs undergoing elective and emergent procedures. Methods: This retrospective, single-center, cohort review describes the use of PCC4 in patients with LVADs who require warfarin reversal for elective or emergent procedures. The primary outcome was a composite incidence of pump thrombosis, venous thromboembolism, and ischemic stroke within 30 days of PCC4 administration. Results: In total, 14 patients received 17 administrations of PCC4. One patient received 3 administrations, and 1 other patient received 2 administrations during separate encounters. The median dose was 500 units or 6.6 units/kg (range = 4.2-14.1 units/kg). Of the PCC4 administrations, 82% (14/17) were for low bleed risk procedures and 76% (13/17) were for elective procedures. There were no cases of pump thrombosis, venous thromboembolism, or stroke within 30 days of the procedure. Conclusions and Relevance: Low-dose PCC4 appears to be a safe and effective temporary reversal strategy for patients with LVADs undergoing low-bleed risk elective procedures. [ABSTRACT FROM AUTHOR]

Background and purpose: The impact of bridging thrombolysis prior to endovascular thrombectomy (EVT) compared to EVT alone on intracerebral haemorrhage (ICH), subarachnoid haemorrhage (SAH), and death in anticoagulated atrial fibrillation (AF) patients with acute ischaemic stroke (AIS) is not well defined. Methods: A retrospective study was conducted using data from a federated research network (TriNetX) including 114 health care organisations in the United States. Anticoagulated AF patients with AIS who received either bridging thrombolysis (BT) or EVT alone from September 2018 to November 2023 were included. Following propensity score matching, Cox regression analyses examined the risk of ICH, SAH, and death within 30 and 90 days, comparing anticoagulated AF patients receiving BT versus EVT only. Results: A total of 3156 patients with AIS were treated with BT or EVT alone. Following 1:1 propensity score matching, the cohort included 766 patients in each group. ICH occurred within 30 and 90 days in 6.9% and 8.0% in the BT group compared with 7.4% and 7.7% in the EVT‐only group (hazard ratios [HR] = 0.92, 95% confidence interval [CI] = 0.63–1.33 and HR = 1.01, 95% CI = 0.71–1.45, respectively). SAH occurred within 30 and 90 days in 4.2% and 4.4% of patients in the BT compared to 3.0% and 3.4% in the EVT‐only group (HR = 1.38, 95% CI = 0.81–2.38 and HR = 1.29, 95% CI = 0.77–2.14, respectively). Death occurred within 30 and 90 days in 17.8% and 19.8% of patients in the BT compared to 22.2% and 27.3% in the EVT‐only group (HR = 0.77, 95% CI = 0.62–0.97 and HR = 0.65, 95% CI = 0.56–0.86, respectively). Conclusions: In anticoagulated AF patients with AIS, BT was associated with a significantly lower risk of death, with no difference in ICH or SAH risk within 30 and 90 days compared to EVT only. [ABSTRACT FROM AUTHOR]

Background : Several studies have examined INR fluctuations using pharmacokinetic (PK) models or post-hoc INR values after completing nirmatrelvir/ritonavir, but further study of the effects of the drug interaction with warfarin during treatment is necessary. Case Summary : Nirmatrelvir/ritonavir is largely utilized in the outpatient setting so data regarding INR trends in hospitalized patients on warfarin is limited. However, many who receive nirmatrelvir/ritonavir outpatient experience difficulty with presenting to clinic for INR checks due to feeling acutely ill along with isolation precautions. We present the case of a patient receiving warfarin and utilizing home INR testing for monitoring. After diagnosis of coronavirus disease of 2019 (COVID-19), she was started on nirmatrelvir/ritonavir on day five after testing positive. Most recent INR prior to the start of therapy was 2.7 and had been stable on the same dose for months prior to infection. On day two of nirmatrelvir/ritonavir, her INR rose to 4.0 on home point of care INR testing. Despite reducing her dose of warfarin by 15%, her INR remained supratherapeutic the day after completing nirmatrelvir/ritonavir (4.0) and for several checks after. One month after completion of therapy, her INR returned to therapeutic levels. Practice Implications : While PK models and case series have hypothesized both potential increases or decreases in INR with the nirmatrelvir/ritonavir and warfarin interaction, COVID-19 infection itself can cause several pharmacodynamic changes which can increase INR, including decreased appetite and, in severe cases, organ dysfunction. This case provides real-world insight into the drug interaction between nirmatrelvir/ritonavir and the drug-disease state interaction between warfarin and COVID-19. [ABSTRACT FROM AUTHOR]

Abnormal conduction, structure, and function of the atrial myocardium predispose to atrial fibrillation (AF) and stroke. The usefulness of electrocardiographic indices in predicting stroke or systemic embolism (SSE) in patients undergoing cardioversion (CV) for AF remains unknown, especially in those at low estimated risk. We systematically evaluated the performance of various P-wave abnormalities (PWAs) in predicting SSE 30 days after CV (derivation cohort) and in the long term (validation cohort). Electrocardiograms (n = 1773) of AF patients undergoing an acute CV were manually reviewed. The 30-day post-CV data were used to derive a composite PWA variable. The electrocardiographic findings were validated by the long-term follow-up of patients with no anticoagulation. Electrocardiograms of 27 CAREBANK study patients with right atrial appendage biopsies were further analyzed for histopathologic validation. During data derivation, the best performance was found with a combination of prolonged P-wave (≥180 ms), deflected P-wave morphology in lead II, biphasic P-waves in inferior leads, or increased P-terminal force (≥80 mm·ms) as markers for extensive PWA. In the validation cohort, 219 of 874 (25.1%) had extensive PWA. During a median follow-up of 4.9 years, there were 51 patients (5.8%) with SSE in total. In a competing risk model, PWA predicted SSE (adjusted hazard ratio, 2.1 per category; 95% CI, 1.4–3.1; P <.001). Areas under the curve for SSE at 3 years were 0.77, 0.79, and 0.86 for PWA, CHA 2 DS 2 -VASc, score, and their combination, respectively. On histologic evaluation, extensive PWA was associated with interstitial fibrosis (P =.033). Novel electrocardiographic PWA classification provided additional prognostic insight in AF patients. [Display omitted] [ABSTRACT FROM AUTHOR]

The administration of intravenous thrombolysis (IVT) for patients with acute ischemic stroke who have recently ingested direct oral anticoagulants (DOACs) presents a clinical challenge due to the perceived increased risk of intracranial hemorrhage (ICH). Traditional guidelines from the US and European authorities advise against IVT within 48 h of last DOAC ingestion, unless specific coagulation tests indicate safety. However, emerging observational studies suggest that IVT might be safe in selected patients. A US stroke registry study and a global multicenter cohort study both reported no significant increase in symptomatic ICH among patients on DOACs compared to those not on anticoagulants. A systematic review of all published observational studies further supported these findings, showing comparable bleeding rates and functional outcomes in DOAC-treated patients. Reversal agents like idarucizumab for dabigatran have demonstrated potential in facilitating safer IVT administration, though logistical and cost-related barriers limit their widespread use. The variability in global guidelines reflects differing approaches to risk assessment and resource availability, highlighting the need for individualized treatment decisions. In India, the increasing prevalence of atrial fibrillation and stroke as well as prescription of DOACs necessitate adapted guidelines that consider local health-care infrastructure. Despite the promising observational data, the lack of randomized controlled trials underscores the need for further research to establish robust evidence for IVT use in this context. Collaborative international efforts and inclusion of diverse patient populations in future studies will be crucial to refine treatment protocols and improve outcomes for stroke patients on DOACs.

Abstract Regional citrate anticoagulation use in intermittent hemodialysis is limited by the increased risk of metabolic complications due to faster solute exchanges than with continuous renal replacement therapies. Several simplifications have been proposed. The objective of this study was to validate a mathematical model of hemodialysis anticoagulated with citrate that was then used to evaluate different prescription scenarios on anticoagulant effectiveness (free calcium concentration in dialysis filter) and calcium balance. A study was conducted in hemodialyzed patients with a citrate infusion into the arterial line and a 1.25 mmol/L calcium dialysate. Calcium and citrate concentrations were measured upstream and downstream of the citrate infusion site and in the venous line. The values measured in the venous lines were compared with those predicted by the model using Bland and Altman diagrams. The model was then used with 22 patients to make simulations. The model can predict the concentration of free calcium, bound to citrate or albumin, accurately. Irrespective of the prescription scenario a decrease in free calcium below 0.4 mmol/L was obtained only in a fraction of the dialysis filter. A zero or slightly negative calcium balance was observed, and should be taken into account in case of prolonged use.

Abstract Background In critically ill cases, CRRT is a renal replacement intervention. The most common reason why CRRT terminates prematurely (non-electively) is clotting in the extracorporeal circuit, more especially in the filter. Aim of work To determine the frequency of thrombotic and hemorrhage complications throughout CRRT, the role of antithrombin III level monitoring, the type of anticoagulation, and the dose and laboratory tests utilized to monitor it. Method The study was carried out on 58 children who were undergoing CRRT. The children underwent a comprehensive history-taking, assessment, CRRT prescription parameters and alterations, vascular access data, anticoagulation type, dose, and adjustment, as well as monitoring of antithrombin III levels. Furthermore, any extracorporeal circuit clotting or bleeding was documented. Results Of the 58 sessions that were examined, 25 (43.1%) resulted in filter clotting. The indication was cured in 16 cases (27.6%), 8 cases (13.8%) resulted in the patient’s mortality, and 9 cases (15.5%) had life-threatening bleeding. The remaining 33 cases (56.9%) were not terminated with filter clotting. Forty-one (70.7%) of studied sessions used unfractionated heparin as anticoagulation, 22.4% used heparin-protamine, 5.2% was not anticoagulated, and one circuit (1.7%) was anticoagulated using regional citrate. Filter clotting incidence was significantly related to activated partial thromboplastin time (a PTT) value at the end of sessions (P value = 0.000), and platelets count after 4 h of session initiation (P value = 0.048). Antithrombin III levels pre-heparin infusion less than 80 were found in patients who received higher doses of a heparin bolus dose, median dose 35 (IQR 20–35), this relation is statistically significant (P value = 0.042). Conclusion In the 58 cases that were examined, the incidence of bleeding was 32.8%; however, 19% of the cases were not severe. The incidence of filter clotting was 43.1% in the study group. a PTT value at the end of sessions, and platelets count after 4 h could be predictors of thrombotic complications during CRRT, antithrombin III deficiency before sessions is a predictor of filter clotting.

ABSTRACT Introduction and objectives: Most patients with acute pulmonary embolism (PE) receive anticoagulation only. Reperfusion is required in high-risk and a minority of intermediate-risk PE patients. Systemic thrombolysis (ST) is the first-line reperfusion therapy, but due to contraindications and major bleeding concerns, the use of catheter-directed therapies (CDT) is increasing as a suitable alternative. The objective of the present study was to detect predictors of the use of CDT compared with other therapies in patients with acute PE. Methods: This registry included consecutive intermediate- and high-risk PE patients in 2 tertiary centers with a 24/7 PE response team from 2014 to 2022. The patients were grouped according to the primary treatment: anticoagulation only, CDT, or ST. We evaluated predictors of treatment assignment and safety endpoints. Results: A total of 274 patients were included. Of them, 112 received anticoagulation only, 96 received ST as the primary treatment, and 66 underwent CDT first. Comorbidities were higher in the CDT group than in the other 2 groups. Patients undergoing ST/CDT had higher PE severity parameters at hospital admission. On multivariable analysis, independent predictors for the use of CDT were Charlson Comorbidity Index (OR, 1.29; 95%CI, 1.05-1.59), recent surgery (OR, 11.07; 95%CI, 3.07-39.87), and bilateral central PE (OR, 2.42; 95%CI, 1.10-5.32). Analysis of early safety outcomes showed that intracranial bleeding occurred only in the ST group (1.8% of patients). Conclusions: This contemporary registry used CDT as the primary treatment in 24% of intermediate- and high-risk patients, mainly in comorbid and postsurgical patients. CDT was a safe and effective alternative to medical therapy in selected patients.

Objective: Pediatric patients on ventricular assist devices (VAD) are at risk of thromboembolic (TE) complications. Our objective was to identify factors associated with TE events, including the role of initial anticoagulation strategy and device type in the pediatric VAD population. Methods: This was a retrospective, single-center review (2005-2022) of children who were implanted with paracorporeal pulsatile (PP), paracorporeal continuous (PC), or a combination of devices. Patient- and device-related factors were collected. Kaplan-Meier survival analysis was performed to determine freedom from TE. Cox proportional hazard analysis was conducted to look for factors associated with TE events. Results: Ninety-five patients included with a median age of 0.9 years (interquartile range, 0.3, 5.4); median weight of 8.4 kg (interquartile range, 4.5, 17.8), and 63.2% with noncongenital heart disease. Device breakdown included 47.4% PC, 24.2% PP, and 23.2% combination of devices. Initial anticoagulation was either heparin (61.5%) or bivalirudin (38.5%). In Kaplan-Meier analysis, unadjusted freedom from a TE event was significantly greater in those who received bivalirudin as their initial anticoagulation strategy (P = .02) and PP VADs (P = .02). In multivariate analysis, initial anticoagulation strategy with bivalirudin (hazard ratio, 0.30; 95% confidence interval, 0.12-0.75, P = .01) was associated with a reduced hazard of TE events, whereas PC device strategy was found to be associated with an increased hazard (hazard ratio, 2.78; 95% confidence interval, 1.12-6.88, P = .03). Conclusions: This study suggests that PC device strategy and heparin as an initial anticoagulation strategy are associated with increased hazard of TE events. Further research is required to understand the interaction between device type and initial anticoagulation strategy.

Introduction: Abdominal pain is the most common presenting complaint in any Emergency Department. Superior Mesenteric Vein Thrombosis (SMVT) is a very rare condition, a surgical emergency seen in the elderly population with a high mortality rate. Aim: To assess the clinical profile, risk factors, radiological findings, management and outcome of patients presenting with SMVT. Materials and Methods: A retrospective descriptive study was conducted in the Department of General Surgery, Father Muller Medical College, Mangaluru, Karnataka, India, from January 2018 to December 2022. Hospital data and case files were analysed and parameters such as age group, sex distribution, presenting features, management and outcomes were recorded. Statistical analysis of the data was done using Excel 2021 (Microsoft 365), and the data was described in numbers and percentages. Results: A total of 10 patients were included, with a predominance of male patients, of which 6 (60%) were males and 4 (40%) were females. Eight patients had associated co-morbidities. Among the 10 patients, 4 (40%) were diagnosed with malignancies (three pancreatic, one liver secondary), 2 (20%) patients were on oral contraceptive pills. Two (20%) patients developed SMVT after intra-abdominal surgery following trauma, two had a history of Distal Venous Thrombosis (DVT) and pre-existing portal hypertension were identified as causative factors. The majority, 6 (60%) of patients, presented within 48 hours of the onset of pain and vomiting. Computed Tomography (CT) angiography was the diagnostic test used in all patients (100%). Anticoagulation was initiated in all patients, and three patients underwent surgery for complications associated with the condition. Out of the 10 patients, 3 (30%) died during treatment, while 7 out of 10 (70%) had a good recovery. Within one year of follow-up, four patients out of the seven deceased. Conclusion: Acute mesenteric venous thrombosis is observed in the elderly population with multiple co-morbidities. Early presentation to the hospital with appropriate clinical and radiological investigations helps in reducing mortality.

Effective pain management is vital for critically ill patients, particularly post-surgery or trauma, as it can mitigate the stress response and positively influence morbidity and mortality rates. The suboptimal treatment of pain in Intensive Care Unit (ICU) patients is often due to a lack of education, apprehensions about side effects, and improper use of medications. Hence, the engagement of pain management and anesthesiology experts is often necessary.

Ana Marco-Rico,1– 3 Alix Juliette Mantilla Pinilla,2,4 Javier Corral,5 Pascual Marco-Vera2,3 1Thrombosis and Hemostasis Department, Hematology Service, University General Hospital Dr. Balmis, Alicante, Spain; 2Biomedical Health Research Institute (ISABIAL), Alicante, Spain; 3Department of Clinical Medicine, Miguel Hernández University, Alicante, Spain; 4Vascular and Interventional Radiology Department, University General Hospital Dr. Balmis, Alicante, Spain; 5Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, IMIB, CIBERER-ISCIII, Universidad de Murcia, Murcia, SpainCorrespondence: Ana Marco-Rico, Thrombosis and Hemostasis Department, Hematology Service, University General Hospital Dr. Balmis, Pintor Baeza avenue, 12, Alicante, 03010, Spain, Tel +34 965913863, Fax +34 965913869, Email marco_anaric@gva.esAbstract: Combined thrombophilia represents 7.8– 8.3% of the patients with thrombophilia and confers a higher risk for thrombosis development and recurrence. Here, we present a 17-year-old boy carrier of three congenital thrombophilias, two severe (type I antithrombin deficiency and type I protein S deficiency) and one prothrombotic polymorphism (prothrombin G20210A), all in heterozygosis. He developed an extensive deep venous thrombosis in lower left limb, reaching proximal inferior vena cava and contralateral iliac vein, in the setting of prolonged rest. Endovascular therapy with local thrombolytic agent infusion followed by mechanical thrombectomy was performed, achieving a favorable clinical and radiological evolution. Antithrombin replacement to achieve levels between 80% and 120% with heparin administration was used during the endovascular procedure. The patient is currently asymptomatic and maintains indefinite anticoagulation with warfarin, keeping an appropriate anticoagulation range (international normalized range between 2.5 and 3.5).Keywords: combined thrombophilia, deep venous thrombosis, inferior vena cava, endovascular therapy, anticoagulation

Abstract Background The percentage of elderly trauma patients under anticoagulation and antiplatelet agents has been rising lately. As newer agents are introduced, each comes with its own advantages and precautions. Our study covered elderly patients admitted to the ED with maxillofacial trauma while on anticoagulation (AC) or antiplatelet therapy (APT). We aimed to investigate the demographic characteristics, causes, and types of maxillofacial trauma, along with concomitant injuries, duration of hospitalisation, haemorrhagic complications, and the overall costs of care in the emergency department (ED). Methods Data were gathered from the ED of Bern University Hospital. In this retrospective analysis, patients over 65 of age were included, who presented at our ED with maxillofacial trauma between 2013 and 2019 while undergoing treatment with therapeutic AC/APT. Results The study involved 188 patients with a median age of 81 years (IQR: 81 [74; 87]), of whom 55.3% (n=104) were male. More than half (54.8%, n=103) were aged 80 years or older. Cardiovascular diseases were present in 69.7% (n=131) of the patients, with the most common indications for AC/APT use being previous thromboembolic events (41.5%, n=78) and atrial fibrillation (25.5%, n=48). The predominant cause of facial injury was falls, accounting for 83.5% (n=157) of cases, followed by bicycle accidents (6.9%, n=13) and road-traffic accidents (5.3%, n=10). The most common primary injuries were fractures of the orbital floor and/or medial/lateral wall (60.1%, n=113), zygomatic bone (30.3%, n=57), followed by isolated orbital floor fractures (23.4%, n=44) and nasal bone fractures (19.1%, n=36). Fractures of the mandible occurred in 14.9% (n=28). Facial hematomas occurred in 68.6% of patients (129 cases), primarily in the midface area. Relevant facial bleeding complications were intracerebral haemorrhage being the most frequent (28.2%, n=53), followed by epistaxis (12.2%, n=23) and retrobulbar/intraorbital hematoma (9%, n=17). Sixteen patients (8.5%) experienced heavy bleeding that required emergency treatment. The in-hospital mortality rate was 2.1% (4 cases). Conclusions This study indicates that falls are the leading cause of maxillofacial trauma in the elderly, with the most common diagnoses being orbital, zygomatic, and nasal fractures. Haemorrhagic complications primarily involve facial hematomas, especially in the middle third of the face, with intracerebral haemorrhage being the second most frequent. Surgical intervention for bleeding was required in 8.5% of cases. Given the aging population, it is essential to improve prevention strategies and update safety protocols, particularly for patients on anticoagulant/antiplatelet therapy (AC/APT). This can ensure rapid diagnostic imaging and prompt treatment in emergencies.

Abstract Background Pulmonary vein thrombosis is a rare condition with a non-specific presentation with multiple underlying etiologies such as malignancy or lung surgery. In rare instances, no etiology could be encountered. Instead, it has a broad spectrum of clinical manifestations, from dyspnea to lung infarction with a compromise to hemodynamics. Case presentation A 71 years old male with a history of shortness of breath. The patient tested positive for COVID-19; the prolonged exertional fatigue led to undergoing CTPA (CT pulmonary angiography), which revealed pulmonary vein thrombosis. This case emphasizes the importance of maintaining a high index of clinical suspicion in the absence of other possible diagnoses. Furthermore, diagnostic work-up and treatment strategies depend highly on the patient’s presentation and risk factors. Conclusions Pulmonary vein thrombosis is an infrequent entity reported in the medical literature and underdiagnosed because of its ambiguous presentation. Early diagnosis is paramount to prevent complications.

Abstract Background Portal vein thrombosis (PVT) is a common complication of liver cirrhosis, yet there are fewer studies about predictors of PVT recanalization. We aimed to further explore the predictors of recanalization in cirrhotic PVT to facilitate accurate prediction of patients’ clinical status and timely initiation of appropriate treatment and interventions. To further investigate the benefits and risks of anticoagulant therapy in cirrhotic PVT patients. Methods A retrospective cohort study of patients with cirrhotic PVT in our hospital between January 2016 and December 2022, The primary endpoint was to analyze predictors of PVT recanalization by COX regression. Others included bleeding rate, liver function, and mortality. Results This study included a total of 82 patients, with 30 in the recanalization group and 52 in the non-recanalization group. Anticoagulation therapy was the only independent protective factor for portal vein thrombosis recanalization and the independent risk factors included massive ascites, history of splenectomy, Child-Pugh B/C class, and main trunk width of the portal vein. Anticoagulation therapy was associated with a significantly higher rate of PVT recanalization (75.9% vs. 20%, log-rank P

Objective To investigate the correlation and consistency between the parameters of thromboelastography(TEG) and routine coagulation tests, and to evaluate the application value of the two methods in heparin anticoagulation monitoring and coagulation function monitoring in patients receiving extracorporeal membrane oxygenation(ECMO) therapy. Methods A total of 138 patients who recieved ECMO in the Department of Critical Care Medicine of the People′s Hospital of Guangxi Zhuang Autonomous Region from October 2021 to December 2022 were selected. A total of 317 pairs of ordinary TEG and heparinase-modified TEG(hmTEG) parameters measured simultaneously were analyzed for correlation and consistency with activated partial thromboplastin time(APTT), fibrinogen(Fib), and platelet count(Plt), and the parameters tested when ECMO was established and 24 hours after ECMO operation were compared. Results The correlation coefficient between R values and APTT of hmTEG(r=0.441, P0.05), while as for hmTEG, the correlation was 0.359(P0.05). Conclusion The parameters of hmTEG can better reflect the real level of coagulation factors in patients receiving ECMO. The results of hmTEG and APTT are complementary to assess whether heparin in ECMO patients is overdosed, and hmTEG has unique advantages. Routine coagulation tests and TEG cannot replace each other, and the combination of them can achieve better anticoagulation and coagulation management.

A 43-year-old male diagnosed with end-stage renal disease on hemodialysis with extensive thrombosis in the inferior vena cava and bilateral iliofemoral vein underwent renal transplantation at our institute. Thrombosis in the major vein can have serious consequences for the success of the transplantation. The common anastomosing vein during renal transplantation is the right external iliac vein, but due to extensive thrombosis, left native nephrectomy with the orthotopic placement of the donor kidney was done. During surgery, the donor renal vein was anastomosed with the left renal vein, and the donor renal artery was anastomosed with the aorta. Postsurgery, the creatinine level showed a progressive decline over time and the patient was discharged home.

Abstract Background Warfarin is considered the primary oral anticoagulant for patients with atrial fibrillation and end‐stage renal disease (ESRD) requiring dialysis. Although warfarin can offer significant stroke prevention in this population, the accompanying major bleeding risks make warfarin nearly prohibitive. Apixaban was shown to be superior to warfarin in preventing stroke or systemic embolism, with a lower risk of bleeding and mortality in a large, randomized trial of individuals with mostly normal renal function but none with ESRD. Methods We systematically reviewed evidence comparing apixaban versus warfarin for atrial fibrillation in this population, and evaluated outcomes of stroke or systemic embolism, and major bleeding using random‐effects models. The main safety outcome was major bleeding, and the main effectiveness outcome was stroke or systemic embolism. Results We found five observational studies of 10 036 patients (2638 receiving apixaban, and 7398 receiving warfarin) meeting inclusion criteria. Pooled analysis demonstrated a significant reduction in major bleeding with apixaban as compared to warfarin (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.42–0.61; p

Abstract Background Atrial tachycardia poses challenges in patient management due to the associated risks of stroke and systemic embolism. While anticoagulation is recommended in atrial fibrillation (AF), its role in atrial tachycardia remains less defined. This prospective study aimed to evaluate the efficacy and safety of apixaban, a direct oral anticoagulant, in individuals diagnosed with left-sided atrial tachycardias. Methods Patients diagnosed with left-sided atrial tachycardia (n = 439) were observed over 3 years. Baseline characteristics, medication regimens, and clinical outcomes were assessed. Apixaban-treated individuals (n = 213) received standard or reduced dosages, while the control group (n = 226) received standard care. Primary outcomes included stroke, systemic embolism, bleeding, and mortality rates. Results Baseline characteristics were comparable between groups. The apixaban cohort showed a lower incidence of stroke (7.0% vs. 9.3%, p = 0.027) and decreased all-cause mortality (11.7% vs. 12.8%, p = 0.012) compared to controls. No significant differences were found in major bleeding or systemic embolization between groups. Conclusion Apixaban demonstrated a potential benefit in reducing stroke and mortality rates in patients with left-sided atrial tachycardia. While requiring further validation, these findings suggest a potential role for apixaban in anticoagulation strategies for atrial tachycardia management.

Chun Wang,1,&ast; Xiaohong Fan,1,&ast; Li Nie,2 Qing Wang,1 Shanshan Li,1 Wen Zheng,1 Wei Zhang,1 Wangshu Dai,1 Minmin Chen1 1Department of Geriatric Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing, Jiangsu, People’s Republic of China; 2Department of Pharmacy, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing, Jiangsu, People’s Republic of China&ast;These authors contributed equally to this workCorrespondence: Wangshu Dai; Minmin Chen, Department of Geriatric Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing, Jiangsu, 210008, People’s Republic of China, Email daysue1213@163.com; minminchen_2006@126.comBackground: Rivaroxaban, a non-vitamin K antagonist oral anticoagulant, has become widely used for the management of venous thromboembolism (VTE) in adult patients. However, few trials have explored the efficacy and safety of rivaroxaban in VTE patients over 80 years of age. This necessitates further real-world studies of rivaroxaban across elderly populations.Methods: We performed a retrospective single center study involving extremely aged VTE sufferers treated with rivaroxaban. The sample comprised 121 patients newly initiated on rivaroxaban diagnosed between January 2018 and January 2020. Patients were followed up for no less than 2 years. The effectiveness outcome was the disappearance of thromboembolism. The safety outcome was the incidence of major bleeding events. Comorbidities and complications were recorded throughout the entire study.Results: The efficacy outcome occurred in 114 of 121 patients (94.21%) and the safety outcome occurred in 12 of 121 patients (9.91%). Increased hemorrhages were observed in patients with infection (15.15% vs 7.80%), but no significant difference was observed due to limited sample size (P=0.3053). Patients with an age-adjusted Charlson comorbidity index score higher than 6 points exhibited higher bleeding rates (14.08% vs 4.00%; P=0.0676) and lower thrombus cure rates (88.73% vs 100%; P=0.0203).Key conclusions: Patients with infection should be more careful of bleeding events during rivaroxaban therapy. An age-adjusted Charlson comorbidity index score higher than 6, which predicted poor survival, indicated inferior safety and efficacy of rivaroxaban.Aim: To investigate the efficacy and safety of Rivaroxaban in an aged venous thromboembolism patient population under real-world conditions.Keywords: rivaroxaban, anticoagulation, venous thromboembolism, retrospective trial, extremely old