Search Results (248)

Oral anticoagulation (OAC) is essential for preventing ischemic stroke events in patients with atrial fibrillation (AF), and leads to a significant ischemic prophylaxis, when appropriately used. However, there is still a risk of experiencing stroke events, despite being under anticoagulation. Stroke despite OAC is an increasingly common diagnosis, and pathophysiologically, it can be associated with several etiologies, ranging from AF competing mechanisms to true anticoagulation failure. While the cardioembolic origin of stroke is the most frequently identified etiology, other factors also have to be considered, as there is a significance risk of coexistence. This highlights the need for thorough diagnostic testing, evaluating each stroke etiology independently, with the use of imaging, biomarker and blood tests. Treating such patients, however, is more complex, as there is still uncertainty regarding the selection of OAC post-stroke, with data showing a superiority of direct OAC (DOAC), compared to vitamin K antagonists, in recurrent ischemic stroke prevention and conflicting results regarding OAC switch. Finally, the additive value of cardiac interventions, such as left atrial appendage occlusion (LAAO), in secondary prevention of stroke, is being explored, as it could potentially lead to significant stroke risk reduction. This review, therefore, provides an updated summary of the pathophysiology, diagnostics and therapeutics of stroke under OAC, while also discussing the future direction on the Achilles heel of AF management. Full article

Direct oral anticoagulants (DOACs) have emerged as a preferred alternative to vitamin K antagonists (VKAs) for the prevention and treatment of thromboembolic disorders, offering improved safety, predictable pharmacokinetics, and ease of administration. Despite these advantages, their use in complex clinical scenarios presents significant challenges that necessitate individualized therapeutic strategies. This comprehensive review explores the efficacy, safety, and limitations of DOAC therapy in special populations, including patients with renal or hepatic impairment, obesity, cancer-associated thrombosis, and antiphospholipid syndrome. Additionally, we examine their role in uncommon thrombotic conditions such as superficial venous thrombosis, embolic stroke of undetermined source, upper extremity vein thrombosis, inferior vena cava thrombosis, pelvic vein thrombosis, and cerebral vein thrombosis. The pharmacokinetic variability of DOACs in renal and hepatic dysfunction requires caution to balance the bleeding and thrombotic risks. In obesity, altered drug distribution and metabolism raise concerns regarding appropriate dosing and therapeutic efficacy. Cancer-associated thrombosis presents a complex interplay of prothrombotic mechanisms, necessitating careful selection of anticoagulant therapy. Furthermore, the use of DOACs in antiphospholipid syndrome remains controversial due to concerns about recurrent thrombotic events. Finally, in some unusual scenarios like inferior vena cava, pelvic vein, and cerebral vein thrombosis, the use of DOACs has scarce evidence. This review aims to guide clinicians in optimizing anticoagulation management in challenging patient populations by synthesizing current evidence and providing practical recommendations. Full article

Introduction: Cancer patients are at a heightened risk of veous thromboembolism (VTE) and bleeding complications. Direct oral anticoagulants (DOACs) are increasingly used due to their oral administration and lack of routine monitoring. However, factors such as drug interactions, chemotherapy, tumor location, and renal function may influence their safety and efficacy. This study evaluates clinical predictors of VTE recurrence and bleeding outcomes in cancer patients on DOAC therapy. Methods: A multicenter retrospective cohort study included 160 adult cancer patients treated with DOACs for VTE. Data on demographics, clinical characteristics, and outcomes—including VTE recurrence, major bleeding, minor bleeding, and clinically relevant non-major bleeding (CRNMB)—were analyzed. Logistic regression identified predictors of outcomes, with significance set at p < 0.05. Results: At six months, VTE recurrence occurred in 7.5% of patients, while major bleeding and CRNMB were observed in 6.3% and minor bleeding in 8.8%. Decreased creatinine clearance (OR = 0.957, p = 0.024) and dexamethasone use (OR = 18.03, p = 0.031) were significant predictors of major bleeding. NSAID use (OR = 12.37, p = 0.009) increased CRNMB risk. Major bleeding at 12 months was significantly associated with recurrent VTE (χ²(1, N = 160) = 10.03, p = 0.002). Conclusions: DOACs are effective for VTE in cancer patients, but careful monitoring of renal function and dexamethasone use is essential due to increased bleeding risk. Caution is advised with NSAIDs in this population. Full article

Background/Objectives: Oral anticoagulant (OA) therapy (OAT) may be prescribed to patients for a variety of reasons, with several agent classes currently available as well as emerging. The classical oral anticoagulants are represented by vitamin K antagonists (VKAs), including warfarin, and the more modern alternatives comprise the direct oral anticoagulants (DOACs). We aimed to assess usage of OAs over time in Australia, especially focusing on the period of the coronavirus disease 2019 (COVID-19) pandemic and its transition to an endemic phase, to assess for any trends. Methods: Using data from the pharmaceutical benefits scheme (PBS), Medicare and other online sites, we specifically assessed for changes in OA prescription and cost patterns over the period 1992–2024, but focusing especially on the period 2020–2024 inclusive. Results: Apixaban is now the most prescribed OA in Australia. Costs of OAT prescriptions have steadily increased over the data capture period, reaching half a billion dollars in 2023. Interestingly, costs have started to fall, seemingly driven by the release of DOAC generics and PBS pricing adjustments. We could identify no clear signals related to COVID-19-related changes in prescription trends, contrary to previous reports in other locations. Conclusions: We provide Australian data on both OA usage as well as costs. Despite an ongoing trend to increasing use of DOACs over VKAs, we could not identify any specific COVID-19-related changes. Full article

Background: Atrial fibrillation (AF) is prevalent in patients undergoing transcatheter aortic valve replacement (TAVR). However, the optimal antithrombotic strategy tailored to individual patient profiles remains unclear. This study aims to evaluate the outcomes of personalized antithrombotic regimens in patients with AF after TAVR. Methods: We enrolled 121 AF patients who underwent TAVR from 2009 to 2023. Patients were grouped into seven groups based on individualized post-procedural antithrombotic regimens. The regimens included the following: single antiplatelet therapy (SAPT) + direct oral anticoagulant (DOAC) (n = 44, 36.3%); DOACs only (n = 25, 20.6%), SAPT + warfarin (n = 17, 14%); dual antiplatelet therapy (DAPT) (n = 13, 10.7%); warfarin only (n = 8, 6.6%); DAPT + warfarin (n = 7, 5.8%); and DAPT + DOACs (n = 7, 5.8%). The study outcomes included incidences of strokes or transient ischemic attacks (TIAs), major bleeding, and survival. Results: The median follow-up was 27 months. The incidence of stroke, TIA, or major bleeding was similar among the seven treatment groups. However, a trend toward a higher rate of stroke was observed in the triple regimen containing warfarin (28.6%); also, the highest rate of major bleeding was observed in the warfarin-only group (25%). Survival for patients discharged and placed under various antithrombotic regimens did not differ significantly despite some numerical variations being present across the groups, with the lowest mortality reported with SAPT + warfarin (7%) and the highest with DAPT + warfarin (57%). Conclusions: This study highlights the outcomes related to stroke, major bleeding, and mortality across personalized antithrombotic regimens in patients with AF after TAVR. While no statistically significant differences were observed, findings emphasize the need for further large-scale studies to define optimal personalized antithrombotic strategies based on individual patient characteristics. Full article

Background: The one-year mortality risk for elderly patients undergoing proximal femur fracture repair surgery is three to four times higher compared to the general population. Other than time to surgery, risk factors for postoperative morbidity and mortality following surgery are poorly understood in the elderly. We sought to identify risk factors associated with morbidity and mortality in geriatric patients by anticoagulation status undergoing hip fracture repair. Methods: Patients aged ≥65 years undergoing surgery for hip fracture repair were included (2009–2019) from a US-based hip fracture registry. Factors associated with 90-day mortality were determined using multivariable logistic regression and stratified by antithrombotic agent medication use prior to surgery. Direct oral anticoagulation (DOAC) medications were the largest group, and all antithrombotic agents were included in the delineation. Results: A total of 35,463 patients were identified, and 87.1% (N = 30,902) were DOAC-naïve. Risk factors for 90-day mortality in DOAC-naïve patients were an American Society of Anesthesiologist’s (ASA) classification ≥3 (odds ratio [OR] = 2.56, 95% confidence interval [CI] = 2.24–2.93), preoperative myocardial infarction (OR = 1.87, 95% CI = 1.33–2.64), male gender (OR = 1.73, 95% CI = 1.59–1.88), congestive heart failure (CHF) (OR = 1.64, 95% CI = 1.50–1.80), psychoses (OR = 1.27, 95% CI = 1.15–1.42), renal failure (OR = 1.29, 95% CI = 1.19–1.40), smoking history (OR = 1.19, 95% CI = 1.09–1.29), chronic pulmonary disease (OR = 1.14, 95% CI = 1.05–1.25), increasing age (OR = 1.07, 95% CI = 1.06–1.07), and decreasing body mass index (BMI) (OR = 1.06, 95% CI = 1.05–1.08). Identified factors for mortality in the DOAC group also included ASA classification ≥3 (OR = 2.15, 95% CI = 1.44–3.20), male gender (OR = 1.68, 95% CI = 1.41–2.01), CHF (OR = 1.45, 95% CI = 1.22–1.73), chronic pulmonary disease (OR = 1.34, 95% CI = 1.12–1.61), decreasing BMI (OR = 1.04, 95% CI = 1.02–1.06), and increasing age (OR = 1.02, 95% CI = 1.01–1.03). Conclusions: Regardless of preoperative DOAC status, ASA classification, gender, CHF, chronic pulmonary disease, lower BMI, and higher age are associated with an increased risk of mortality. Some of these comorbidities can be utilized for risk stratification prior to surgery. Full article

Background/Objectives: This study aimed to research the potential association between brain atrophy and hematoma expansion (HE) in intracerebral hemorrhage (ICH). Methods: A retrospective analysis was conducted using data from patients with primary ICH in our stroke database. ICH volumes from initial and follow-up CT scans were manually segmented. Total brain and intracranial volumes were quantified using an automated head CT segmentation method. Normalized brain volume (NBV) was calculated by dividing the total brain volume by the total intracranial volume to account for individual head size differences. The relationship between the NBV and hematoma expansion was assessed using linear regression, adjusting for other variables influencing hematoma expansion. Results: Our final analysis included 420 patients. Brain atrophy (lower NBV) was associated with hematoma growth (>0 mL) in patients not on oral anticoagulants (β = −0.159, p = 0.032). A strong association was observed in patients using vitamin K antagonists (β = −0.667, p = 0.006) but not in those on direct oral anticoagulants (DOACs; (β = −0.159, p = 0.436)). Results remained significant in patients not on oral anticoagulants and in those on VKAs when hematoma expansion was defined as a volume increase >6 mL or >33%. Conclusions: This research provides initial evidence that brain atrophy is a risk factor for hematoma expansion, depending on the patient’s coagulation status. These findings could enhance risk stratification for acute clinical management and deepen understanding of the biological mechanisms behind hematoma expansion. Full article

Background and Aim: Left ventricular thrombus (LVT) is a common complication of myocardial infarction (MI) and heart failure with reduced ejection fraction (HFrEF), typically managed with vitamin K antagonists (VKAs) for up to six months. However, data on direct oral anticoagulants (DOACs) for LVT treatment remain limited and conflicting. This study evaluates the effectiveness and safety of DOACs compared to warfarin for LVT resolution. Methods: We conducted a single-center retrospective cohort study of consecutive patients diagnosed with LVT from January 2010 to May 2024. The primary outcome was LVT resolution at 24 months. Safety outcomes included major bleeding and thromboembolic events. Diagnosis and follow-up were performed via echocardiography, with cardiac magnetic resonance and computed tomography as needed. Anticoagulant type, dose, duration, and concurrent antiplatelet therapy were at the treating physician’s discretion. Results: Among 171 patients (82.5% male, mean age 59.8 ± 14.7 years), 99 received DOACs and 72 received warfarin. LVT resolution was higher with DOACs (66.7% vs. 50%, HR 2.0, 95% CI 1.07–3.73, p = 0.029), with a trend toward faster thrombus resolution (185 vs. 220 days, p = 0.214) though statistically not significant. DOAC use remained an independent predictor of LVT resolution, regardless of antiplatelet use. Major bleeding (2.9%), thromboembolic events (5.3%), and mortality (5.3%) were similar between groups. Conclusions: DOAC therapy was associated with higher LVT resolution rates and a comparable safety profile to warfarin. Further randomized clinical trials are warranted to validate these findings. Full article

Background/Objectives: Venous thromboembolism (VTE) is a major risk for cancer patients undergoing surgery due to hypercoagulability and surgical stress. Traditional low-molecular-weight heparins (LMWHs) are used as the standard of care for VTE prophylaxis, but subcutaneous administration often leads to suboptimal patient adherence. Direct oral anticoagulants (DOACs) are being explored as more convenient and effective alternatives. This study employed a network meta-analysis approach to comparatively assess the safety and efficacy of DOACS and LMWH in preventing VTE among cancer patients undergoing oncologic surgery. Methods: A systematic review and network meta-analysis were conducted. The search strategy included randomized controlled trials (RCTs) retrieved from databases such as CLINICALTRIAL.GOV, MEDLINE, and EMBASE. The search encompassed studies published up to October 2023 and compared the efficacy and safety of DOACs with LMWHs in patients undergoing cancer surgery. The primary outcome was the incidence of VTE, and the secondary outcomes included the incidences of major bleeding events (MB) and clinically relevant non-major bleeding (CRNMB). Results: A network meta-analysis of four randomized controlled trials (RCTs) involving 1600 cancer surgery patients was conducted. No statistically significant differences in VTE rates were observed between DOACs and LMWHs. While rivaroxaban 10 mg once daily for 30 days significantly reduced VTE risk compared to placebo (RR: 0.27, 95% CI: 0.08–0.95), no significant differences were found in major or clinically relevant non-major bleeding risks between DOACs and LMWH or placebo. Conclusions: This network meta-analysis provides evidence supporting the use of DOACs, specifically apixaban and rivaroxaban, as safe and efficacious alternatives to LMWHs for VTE prophylaxis in cancer patients undergoing surgery. The oral administration and reduced monitoring requirements associated with DOACs address the limitations inherent to LMWHs, potentially improving patient adherence. These findings emphasize the need for additional head-to-head trials and long-term studies further to solidify their role in this high-risk patient population. Full article

Direct oral anticoagulants (DOACs) have emerged as the preferred oral anticoagulant therapy for patients with deep vein thrombosis of the lower extremities and pulmonary embolism. DOACs offer several advantages over vitamin K antagonists, including fixed dosage, fewer drug interactions, faster onset of action, and a lower risk of major bleeding, especially intracranial. Although evidence on the use of DOACs in unusual-site venous thrombosis (USVT) is limited, their use in such cases is becoming increasingly common. This narrative review examines the evidence derived from randomized controlled trials, and large observational studies focused on the use of the DOACs in USVT, including cerebral, splanchnic, upper extremity, ovarian, renal, and retinal vein thrombosis. In addition, it also provides practical advice for their use in these clinical settings according to the updated scientific literature. Full article

Background/Objectives: Direct oral anticoagulants (DOACs), when compared to the Vitamin K antagonist (VKA) warfarin, exhibit greater safety and effectiveness. However, DOACs may still have potential drug–drug interactions that result in major bleeding events. There is a paucity of studies on medications that have pharmacodynamic interactions with DOACs, such as selective serotonin reuptake inhibitors (SSRIs). This study evaluates the potential major bleeding risk associated with the concomitant use of SSRIs among nonvalvular atrial fibrillation (NVAF) patients who were receiving DOACs. Methods: Adult patients receiving DOACs with consecutive NVAF diagnoses were identified from the Penn State Health Electronic Health Records from 2013 to 2023. These patients were then checked for exposure (i.e., concomitant use of SSRIs). The outcome was time to the first occurrence of a major bleeding event, with a follow-up from the first DOAC prescription until a major bleeding event, death, or end of follow-up. This retrospective cohort study used a Cox cause-specific proportional hazard model to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) with inverse probability of treatment weighting to adjust for measurable confounding factors (e.g., demographics, comorbidities, comedications). Results: A total of 8657 NVAF patients who were receiving DOACs were identified. The mean age was 70.3 ± 11.95 years, and females comprised 39.8% of the study population. The baseline CHA2DS2-VASc score was 3.77 ± 1.76, and the HAS-BLED score was 2.98 ± 1.27. Among these patients, 2649 (30.6%) were co-prescribed with SSRIs. The unadjusted hazard ratio for SSRIs was 0.87 (95% CI: 0.76–0.99) and the adjusted hazard ratio was 0.68 (95% CI: 0.59–0.78). Conclusions: In patients with NVAF receiving DOACs, concomitant use of SSRIs was not associated with a higher risk of major bleeding. Full article

Blood transports nutrients and oxygen to the cells while removing the waste. It also possesses a hemostasis function to prevent excessive bleeding. However, abnormal clot formation (thrombosis) within healthy blood vessels can lead to life-threatening conditions like heart attacks, strokes, and pulmonary embolism. This review explores anticoagulants, their historical aspects, current clinical applications, and future trends. Anticoagulants play a critical role in preventing and treating thrombosis by interfering with different stages of blood clotting. The journey began with heparin, a rapidly acting injectable medication discovered in 1916. The introduction of warfarin in the 1950s revolutionized anticoagulation by offering long-term oral regimens. Today, anticoagulants are crucial for managing conditions like deep vein thrombosis and pulmonary embolism, especially in an aging population with a rising prevalence of thrombotic complications. Three main types of anticoagulants are used today: vitamin K antagonists (VKAs), injectable heparins, and direct oral anticoagulants (DOACs). Despite advancements, managing anticoagulant therapy remains complex due to individual patient variability, the need for regular monitoring, and the delicate balance between preventing thrombosis and bleeding risks. Emerging trends include the development of factor XIa inhibitors, which promise more targeted thrombosis prevention with potentially lower bleeding risks. This review highlights the ongoing innovation in anticoagulant development, the need for precise management, and potential future avenues like factor XIa inhibitors. Additionally, artificial intelligence holds promise for improving patient outcomes and addressing the complexities of thrombotic disease management by personalizing therapy and reducing bleeding risks. Full article

Left ventricular thrombosis (LVT) is one of the most feared complications of both ischemic and non-ischemic cardiopathy, and despite its incidence having decreased over the years (mostly due to novel reperfusion therapies in acute coronary syndromes), it is still not negligible. If transthoracic echocardiography, possibly with the adjunction of echo contrast, represents the cornerstone in LVT diagnosis, sometimes it is found to be nonconclusive and advanced cardiovascular imaging, namely cardiac magnetic resonance, needs to be performed to fully exclude intraventricular masses or to better characterize them. Vitamin K antagonists always represented the anticoagulant of choice for the treatment of LVT; however, the recent spread of direct oral anticoagulants (DOACs) pushed clinicians to adopt them also in this setting despite the absence of robust evidence in their favor. If the optimal duration of anticoagulation for the treatment of LVT in non-ischemic cardiopathy is still a matter of debate, an initial treatment of 3–6 months seems to be reasonable in the setting of ischemic cardiopathy, with possible extension according to the follow-up findings. High-quality randomized studies are strongly needed to evaluate the potential role of prophylactic anticoagulation in high-risk patients and provide conclusive evidence for the use of DOACs in LVT treatment. Full article

Background: Selecting the optimal oral anticoagulation (OAC) therapy for elderly patients with atrial fibrillation (AF) remains challenging. Our real-world study investigates clinical factors guiding OAC prescription patterns and compares outcomes between full- and reduced-dose direct-acting oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) in this demographic. Methods: This post hoc analysis of the MISOAC-AF trial focused on hospitalized AF patients aged ≥ 75 years prescribed OAC at discharge. Predictors of VKA and reduced DOAC dosing were identified using adjusted odds ratios (aORs). Cox regression models calculated adjusted hazard ratios (aHRs) for primary (all-cause mortality) and secondary outcomes (stroke, bleeding, AF or heart failure hospitalization, cardiovascular death). Results: Among 450 elderly patients, 63.6% received DOACs and 36.4% received VKAs. Higher CHA2DS2-VASc and HAS-BLED scores and antiplatelet use predicted VKA prescription. Hypertension, prior stroke, and bleeding history favored DOAC use. Advanced age and chronic kidney disease correlated with reduced DOAC dosing. Over a 3.7-year follow-up period, there was no significant difference in all-cause mortality between the DOAC and VKA groups (aHR 0.79, 95% CI 0.58–1.06) or between the full-dose and reduced-dose DOAC groups (aHR 0.96, 95% CI 0.60–1.53). Secondary analyses also did not yield statistically significant results in either comparison. Conclusions: Clinical profile parameters in elderly AF patients predict VKA or DOAC use. Clinical outcomes were similar between different OAC therapies. Full article

Background/Objectives: People affected by COVID-19 are exposed to abnormal clotting and endothelial dysfunction, which may trigger thromboembolic events. This study aimed at retrospectively investigating whether oral anticoagulant therapy (OAT), encompassing either direct oral anticoagulants (DOACs), mainly apixaban, or the vitamin K antagonist (VKA) warfarin, could have impacted medium-term mortality in a cohort of SARS-CoV-2 patients. Methods: Among 1238 COVID-19 patients, hospitalized from 17 March 2020 to 15 June 2021, 247 survivors and 247 deceased within 90 days from hospitalization were matched 1:1 based on age, sex, and intensive care unit (ICU) admission within three days. Conditional logistic regression was used to estimate associations by means of odds ratio (OR) with a 95% confidence interval (CI). Results: A univariate regression analysis suggested that OAT, no differently from subcutaneous low-molecular-weight heparins (LMWHs) during hospitalization, has no significant impact (p value > 0.05) on medium-term mortality. A multivariate analysis, limited to baseline variables (i.e., comorbidities and pharmacotherapies at hospital admission) showing significant association (p < 0.05) to mortality in a univariate analysis, revealed that, compared to patients living at 90 days from hospitalization, deceased patients had cancer histories (OR 1.75, CI 1.06–2.90, p = 0.029) or suffered from asthma (OR 2.25, CI 1.13–4.47, p = 0.021). In contrast, heart failure (HF), atrial fibrillation (AF), arteriopathy, chronic obstructive pulmonary disease (COPD), and kidney failure (KF), which, in a univariate analysis, were found to be associated with the endpoint (p < 0.05), lost significance in a multivariate analysis. Therapy at admission with aldosterone antagonists also appeared to be associated with medium-term mortality (OR 2.49, CI 1.52–4.08, p < 0.001); whereas, vitamin D supplementation during hospitalization appeared to be beneficial. Although not conclusive, a search into the Eudravigilance database, combined with consulting a digital predictive platform (PLATO, polypharmacology platform prediction), suggested potential off-target activities, which might contribute to increasing the severity of SARS-CoV-2 infection. Conclusions: This retrospective clinical study furnished evidences of the impact of OAT, comorbidities and other pharmacological treatments on COVID-19 clinical course. Full article