-
The Western Journal of Emergency... May 2024Alteplase (tPA) is the initial treatment for acute ischemic stroke. Current tPA guidelines exclude patients who took direct oral anticoagulants (DOAC) within the prior...
BACKGROUND
Alteplase (tPA) is the initial treatment for acute ischemic stroke. Current tPA guidelines exclude patients who took direct oral anticoagulants (DOAC) within the prior 48 hours. In this propensity-matched retrospective study we compared acute ischemic stroke patients treated with tPA who had received DOACs within 48 hours of thrombolysis to those not previously treated with DOACs, regarding three outcomes: mortality; intracranial hemorrhage (ICH); and need for acute blood transfusions (as a marker of significant blood loss).
METHODS
Using the United States cohort of 54 healthcare organizations in the TriNetx database, we identified 8,582 stroke patients treated with tPA on DOACs within 48 hours of thrombolysis and 46,703 stroke patients treated with tPA not on DOACs since January 1, 2012. We performed propensity score matching on demographic information and seven prior clinical diagnostic groups, resulting in a total of 17,164 acute stroke patients evenly matched between groups. We recorded mortality rates, frequency of ICH, and need for blood transfusions for each group over the ensuing 7- and 30-day periods.
RESULTS
Patients treated with tPA on DOACs had reduced mortality (3.3% vs 7.3%; risk ratio [RR] 0.456; < 0.001), fewer ICHs (6.8% vs 10.1%; RR 0.678; < 0.001), and less risk of major bleeding as measured by frequency of blood transfusions (0.5% vs 1.5%; RR 0.317; < 0.001) at 7 days post thrombolytic, than the tPA patients not on DOACS. Findings for 30 days post-thrombolytics were similar/statistically significant with lower mortality rate (7.2% vs 13.1%; RR 0.550; < 0.001), fewer ICHs (7.6% vs 10.8%; RR 0.705; < 0.001), and fewer blood transfusions (0.9% vs 2.0%; RR 0.448; < 0.001).
CONCLUSION
Acute ischemic stroke patients treated with tPA who received DOACs within 48 hours of thrombolysis had lower mortality rates, reduced incidence of ICH, and less blood loss than those not on DOACs. Our study suggests that prior use of DOACs should not be a contraindication to thrombolysis for ischemic stroke.
Topics: Humans; Retrospective Studies; Female; Male; Aged; Thrombolytic Therapy; Tissue Plasminogen Activator; Fibrinolytic Agents; Anticoagulants; United States; Propensity Score; Administration, Oral; Ischemic Stroke; Middle Aged; Intracranial Hemorrhages; Stroke; Aged, 80 and over; Blood Transfusion
PubMed: 38801047
DOI: 10.5811/westjem.18063 -
Scientific Reports May 2024Spontaneous intracerebral hemorrhage (SICH) remains a devastating form of stroke. Prior use of antiplatelets or warfarin before SICH is associated with poor outcomes,...
Spontaneous intracerebral hemorrhage (SICH) remains a devastating form of stroke. Prior use of antiplatelets or warfarin before SICH is associated with poor outcomes, but the effects of direct oral anticoagulants (DOACs) remain unclear. This study aimed to clarify trends in prior antithrombotic use and to assess the associations between prior use of antithrombotics and in-hospital mortality using a multicenter prospective registry in Japan. In total, 1085 patients were analyzed. Prior antithrombotic medication included antiplatelets in 14.2%, oral anticoagulants in 8.1%, and both in 1.8%. Prior warfarin use was significantly associated with in-hospital mortality (odds ratio [OR] 5.50, 95% confidence interval [CI] 1.30-23.26, P < 0.05) compared to no prior antithrombotic use. No such association was evident between prior DOAC use and no prior antithrombotic use (OR 1.34, 95% CI 0.44-4.05, P = 0.606). Concomitant use of antiplatelets and warfarin further increased the in-hospital mortality rate (37.5%) compared to warfarin alone (17.2%), but no such association was found for antiplatelets plus DOACs (8.3%) compared to DOACs alone (11.9%). Prior use of warfarin remains an independent risk factor for in-hospital mortality after SICH in the era of DOACs. Further strategies are warranted to reduce SICH among patients receiving oral anticoagulants and to prevent serious outcomes.
Topics: Humans; Hospital Mortality; Aged; Female; Male; Registries; Cerebral Hemorrhage; Warfarin; Japan; Aged, 80 and over; Anticoagulants; Fibrinolytic Agents; Middle Aged; Risk Factors; Platelet Aggregation Inhibitors; Prospective Studies
PubMed: 38796624
DOI: 10.1038/s41598-024-62717-5 -
JACC. Cardiovascular Interventions Jun 2024Left atrial appendage occlusion (LAAO) provides mechanical cardioembolic protection for atrial fibrillation (AF) patients who cannot use oral anticoagulation therapy... (Comparative Study)
Comparative Study Observational Study
BACKGROUND
Left atrial appendage occlusion (LAAO) provides mechanical cardioembolic protection for atrial fibrillation (AF) patients who cannot use oral anticoagulation therapy (OAT). Patients with a thrombotic event despite OAT are at high risk for recurrence and may also benefit from LAAO.
OBJECTIVES
This study sought to investigate the efficacy of LAAO in AF patients with a thrombotic event on OAT compared to: 1) LAAO in AF patients with a contraindication for OAT; and 2) historical data.
METHODS
The international LAAO after stroke despite oral anticoagulation (STR-OAC LAAO) collaboration included patients who underwent LAAO because of thrombotic events on OAT. This cohort underwent propensity score matching and was compared to the EWOLUTION (Evaluating Real-Life Clinical Outcomes in Atrial Fibrillation Patients Receiving the WATCHMAN Left Atrial Appendage Closure Technology) registry, which represents patients who underwent LAAO because of OAT contraindications. The primary outcome was ischemic stroke. Event rates were compared between cohorts and with historical data without OAT, yielding relative risk reductions based on risk scores.
RESULTS
Analysis of 438 matched pairs revealed no significant difference in the ischemic stroke rate between the STR-OAC LAAO and EWOLUTION cohorts (2.5% vs 1.9%; HR: 1.37; 95% CI: 0.72-2.61). STR-OAC LAAO patients exhibited a higher thromboembolic risk (HR: 1.71; 95% CI: 1.04-2.83) but lower bleeding risk (HR: 0.39; 95% CI: 0.18-0.88) compared to EWOLUTION patients. The mortality rate was slightly higher in EWOLUTION (4.3% vs 6.9%; log-rank P = 0.028). Relative risk reductions for ischemic stroke were 70% and 78% in STR-OAC LAAO and EWOLUTION, respectively, compared to historical data without OAT.
CONCLUSIONS
LAAO in patients with a thrombotic event on OAT demonstrated comparable stroke rates to the OAT contraindicated population in EWOLUTION. The thromboembolic event rate was higher and the bleeding rate lower, reflecting the intrinsically different risk profile of both populations. Until randomized trials are available, LAAO may be considered in patients with an ischemic event on OAT.
Topics: Humans; Atrial Appendage; Atrial Fibrillation; Female; Male; Anticoagulants; Aged; Contraindications, Drug; Risk Factors; Registries; Risk Assessment; Aged, 80 and over; Time Factors; Administration, Oral; Ischemic Stroke; Cardiac Catheterization; Treatment Failure; Hemorrhage; Recurrence; Middle Aged; Retrospective Studies; Europe
PubMed: 38795093
DOI: 10.1016/j.jcin.2024.04.012 -
JACC. Cardiovascular Interventions Jun 2024
Topics: Humans; Anticoagulants; Stroke; Risk Factors; Atrial Fibrillation; Treatment Outcome; Risk Assessment; Hemorrhage; Administration, Oral; Clinical Decision-Making
PubMed: 38795090
DOI: 10.1016/j.jcin.2024.04.036 -
International Journal of Molecular... May 2024Periodontal diseases, including gingivitis and periodontitis, are among the most prevalent diseases in humans. Gingivitis is the mildest form of periodontal disease,...
Periodontal diseases, including gingivitis and periodontitis, are among the most prevalent diseases in humans. Gingivitis is the mildest form of periodontal disease, characterized by inflammation of the gingiva caused by the accumulation of dental plaque. Salivary diagnostics are becoming increasingly popular due to the variation in saliva composition in response to pathological processes. We used a metabolomics approach to investigate whether a specific saliva metabolic composition could indicate preclinical stage of gingivitis. H-NMR spectroscopy was used to obtain the salivary metabolite profiles of 20 healthy subjects. Univariate/multivariate statistical analysis evaluated the whole saliva metabolite composition, and the Full-Mouth Bleeding Score (FMBS) was employed as a classification parameter. Identifying a signature of specific salivary metabolites could distinguish the subjects with high FMBS scores but still within the normal range. This set of metabolites may be due to the enzymatic activities of oral bacteria and be associated with the early stages of gingival inflammation. Although this analysis is to be considered exploratory, it seems feasible to establish an FMBS threshold that distinguishes between the absence and presence of early inflammatory alterations at the salivary level.
Topics: Humans; Saliva; Female; Male; Pilot Projects; Adult; Gingivitis; Healthy Volunteers; Metabolomics; Gingival Hemorrhage; Metabolome; Young Adult; Middle Aged; Biomarkers
PubMed: 38791486
DOI: 10.3390/ijms25105448 -
La Revue de Medecine Interne Jun 2024Although all patients with cancer-associated thrombosis (CAT) have a high morbidity and mortality risk, certain groups of patients are particularly vulnerable. This may... (Review)
Review
Although all patients with cancer-associated thrombosis (CAT) have a high morbidity and mortality risk, certain groups of patients are particularly vulnerable. This may expose the patient to an increased risk of thrombotic recurrence or bleeding (or both), as the benefit-risk ratio of anticoagulant treatment may be modified. Treatment thus needs to be chosen with care. Such vulnerable groups include older patients, patients with renal impairment or thrombocytopenia, and underweight and obese patients. However, these patient groups are poorly represented in clinical trials, limiting the available data on which treatment decisions can be based. Meta-analysis of data from randomised clinical trials suggests that the relative treatment effect of direct oral factor Xa inhibitors (DXIs) and low molecular weight heparin (LMWH) with respect to major bleeding could be affected by advanced age. No evidence was obtained for a change in the relative risk-benefit profile of DXIs compared to LMWH in patients with renal impairment or of low body weight. The available, albeit limited, data do not support restricting the use of DXIs in patients with TAC on the basis of renal impairment or low body weight. In older patients, age is not itself a critical factor for choice of treatment, but frailty is such a factor. Patients over 70 years of age with CAT should undergo a systematic frailty evaluation before choosing treatment and modifiable bleeding risk factors should be addressed. In patients with renal impairment, creatine clearance should be assessed and monitored regularly thereafter. In patients with an eGFR less than 30mL/min/1.72m, the anticoagulant treatment may need to be adapted. Similarly, platelet count should be assessed prior to treatment and monitored regularly. In patients with grade 3-4, thrombocytopenia (less than 50,000platelets/μL) treatment with a LMWH at a reduced dose should be considered. For patients with CAT and low body weight, standard anticoagulant treatment recommendations are appropriate, whereas in obese patients, apixaban may be preferred.
Topics: Humans; Neoplasms; Vulnerable Populations; Thromboembolism; Anticoagulants; France; Aged; Risk Factors; Language; Heparin, Low-Molecular-Weight; Hemorrhage
PubMed: 38789323
DOI: 10.1016/j.revmed.2024.05.019 -
Medicine May 2024Acquired hemophilia-A (AHA) is a rare but potentially life-threatening impaired coagulation disorder characterized by the development of autoantibodies against clotting...
INTRODUCTION
Acquired hemophilia-A (AHA) is a rare but potentially life-threatening impaired coagulation disorder characterized by the development of autoantibodies against clotting factor VIII. Only a few case reports have been experienced with influenza vaccine-triggered AHA. Here, we report a case of severe hemorrhagic disorder due to AHA following influenza vaccine, which was successfully treated.
PATIENT CONCERNS
The patient presented to the emergency department because of several severe, progressively worsening bruises after receiving the influenza vaccination. Consequently, the patient required intubation due to nasal-oral bleeding, which compromised the airway, and retroperitoneal hemorrhage with shock also developed.
DIAGNOSIS
AHA was confirmed through a coagulation factor assay, including coagulation activity and antibody testing, which is possibly triggered by influenza vaccination.
INTERVENTION
Low-dose cyclophosphamide and hydrocortisone were prescribed until activated partial thromboplastin time showed normal levels. Coagulation factor VIIa was administered, and aggressive blood transfusion was carried out concurrently to address the blood loss.
OUTCOMES
The upper airway bleeding subsided and bleeding tendencies had been corrected to normal. The patient was smoothly weaned from the ventilator and recovered from critical illness. She was then discharged on the 19th day.
LESSONS
The activated partial thromboplastin time mixing test can be performed immediately to establish the initial differential diagnosis and treatment plan for severe coagulopathy. AHA may be triggered by vaccination, with the hypothesis of activation of autoantibodies and molecular mimicry; this mechanism should be further studied.
Topics: Humans; Hemophilia A; Female; Ecchymosis; Hemorrhage; Retroperitoneal Space; Influenza Vaccines; Middle Aged
PubMed: 38787989
DOI: 10.1097/MD.0000000000038300 -
Cureus Apr 2024Scurvy is a rare condition characterized by a deficiency in dietary vitamin C. Historically a disease taught in the context of long ocean voyages with limited vitamin...
Scurvy is a rare condition characterized by a deficiency in dietary vitamin C. Historically a disease taught in the context of long ocean voyages with limited vitamin intake, it is now rare in developed nations. The classical physical exam findings include gingival bleeding, perifollicular hemorrhages, and corkscrew hairs. We discuss the case of a 15-year-old female with scurvy whose initial presentation suggested more common diagnoses seen in the emergency department setting. Her course was complicated by a prior history of anorexia nervosa and a restrictive diet that lacked necessary vitamins. Once the patient's dietary habits were identified, a detailed physical exam revealed the characteristic findings. She was subsequently discharged with oral vitamin C supplements and was scheduled for outpatient follow-up to monitor symptoms.
PubMed: 38784361
DOI: 10.7759/cureus.58782 -
Thrombosis Research Jul 2024Approximately 10 % of all diagnosed pulmonary embolism are isolated to the subsegmental vessels. The risk of recurrent venous thromboembolism (VTE) in patients with an... (Observational Study)
Observational Study
INTRODUCTION
Approximately 10 % of all diagnosed pulmonary embolism are isolated to the subsegmental vessels. The risk of recurrent venous thromboembolism (VTE) in patients with an acute subsegmental pulmonary embolism (SSPE) managed with or without anticoagulant therapy remains poorly understood.
METHODS
This is an observational cohort study including consecutive adult patients diagnosed with acute isolated SSPE between June 01, 2019, and August 31, 2022. We excluded patients with a concomitant diagnosis of deep vein thrombosis and those who had an indication for long-term anticoagulation. The primary outcome was objectively confirmed recurrent VTE.
RESULTS
Overall, 118 patients with acute SSPE were included in the analysis. The mean (± standard deviation [SD]) age of the participants was 59 ± 17 years and 44 % of them had active cancer. Mean (±SD) duration of follow-up was 438 ± 426 days. Seventy-seven patients (65 %) were initially treated with anticoagulation, whereas 41 patients (35 %) were not. Of the 77 patients receiving anticoagulant therapy, 23 (30 %) received extended-duration anticoagulation (beyond 3 months) for secondary prevention. Overall, recurrent VTE events occurred in 6/118 (5 %, 95 % CI 2.4 to 10.7) patients. Four events (4/77 = 5.2 %, 95 % CI 2.0 to 12.6) occurred in initially treated patients. Two recurrent VTE occurred in patients initially left untreated (2/41 = 4.9 %, 95 % CI 1.4 to 16.1). Half of the recurrent VTE occurred in patients with active cancer.
CONCLUSIONS
Most patients diagnosed with an acute SSPE received anticoagulation. The incidence of recurrent VTE detected over time was relatively high, especially in patients with cancer.
Topics: Humans; Pulmonary Embolism; Middle Aged; Male; Female; Venous Thromboembolism; Recurrence; Hemorrhage; Risk Factors; Aged; Anticoagulants; Cohort Studies; Adult; Acute Disease
PubMed: 38781706
DOI: 10.1016/j.thromres.2024.109037 -
Risk Management and Healthcare Policy 2024The objective of this investigation is to delineate the distributional attributes of factors correlated with post-tooth extraction bleeding and to scrutinize...
OBJECTIVE
The objective of this investigation is to delineate the distributional attributes of factors correlated with post-tooth extraction bleeding and to scrutinize corresponding strategies for emergency prevention and intervention.
METHODS
The chi-squared test and rank sum test were deployed to evaluate fluctuations in blood loss. Univariate and multivariate binary logistic regression methodologies were employed to compute the odds ratio (OR) and its associated 95% confidence interval (95% CI). Furthermore, we delved into the relationship between each contributing factor and blood loss. Concurrently, univariate and multivariate logistic regression techniques were utilized to probe the nexus between blood loss and treatment modalities.
RESULTS
Following adjustments for pertinent factors, the outcomes of multivariate analyses unveiled an escalated susceptibility to bleeding among male patients and individuals aged 60 years or older. The adjusted OR values and their corresponding 95% CI were determined as follows: OR = 1.54 (95% CI: 1.34-1.77, P < 0.001), OR = 0.74 (95% CI: 0.59-0.91, P = 0.005), OR = 0.58 (95% CI: 0.42-0.80, P = 0.001). Additionally, the results of multivariate logistic regression analysis indicated that, in contrast to individuals experiencing minimal blood loss, the OR values associated with treatment modalities for patients encountering substantial blood loss, namely iodoform gauze strips, sutures, collagen, and compression, were noted as follows: OR = 220.80 (95% CI: 151.43-321.95, P < 0.001), OR = 69.40 (95% CI: 46.11-104.44, P < 0.001), OR = 52.78 (95% CI: 34.66-80.38, P < 0.001), OR = 12.85 (95% CI: 9.46-17.45, P < 0.001).
CONCLUSION
It is imperative to prioritize the scrutiny of risk factors associated with post-tooth extraction hemorrhage, with the aim of preemptively averting incidences of bleeding subsequent to tooth extraction. Moreover, it is paramount to offer expert and tailored emergency interventions designed to address diverse case scenarios.
PubMed: 38778922
DOI: 10.2147/RMHP.S458260