TCT-712 Evaluating Antithrombotic Therapy Variations Post-Left Atrial Appendage Occlusion: A Retrospective TriNetX Study

Introduction: The incidence of ischemic stroke in young adults (defined by several studies as the population aged 1850) accounts for approximately 15% - 18% of the total number of ischemic stroke cases. Many studies have highlighted the significant impact of traditional vascular risk factors in the etiology of ischemic stroke among the young adult population. Purpose: To assess the risk factors and causes of ischemic stroke among young adults in an institutional cohort. Materials and Methods: A retrospective cohort study was conducted using the electronic data registry of the Institute of Neurology and Neurosurgery, by analyzing medical records of patients hospitalized with a diagnosis of ischemic stroke between October 2017 and February 2022. Predominantly traditional risk factors were analyzed in young adults with ischemic stroke. Results: From 2056 medical records analyzed, 79 patients (3.8%) were identified as young adults, 55 males and 24 females, with an average age of 43.24 ± 7.35 [min 21; max 50]. 65 patients (82.3% of cases) were diagnosed with primary ischemic stroke, and 14 patients (17.7% of cases) with recurrent ischemic stroke. The most frequent traditional risk factors found among young adults were hypertension (75.9% - 60 patients), dyslipidemia (36.7% - 29 patients), the presence of atherosclerotic plaques (34.2% - 27 patients, of which 10 had occlusions), smoking (30.4% - 24 patients), obesity (29.1% - 23 patients), and type II diabetes (21.5% - 17 patients). 27 individuals had high total cholesterol levels, and 16 individuals had high triglyceride levels. For prevention, antihypertensive treatment was administered by only 33 patients (41.8%), antithrombotic therapy -- by 22 patients (27.85%), and lipid-lowering drugs by 8 patients (10.1%). Conclusions: Like other studies, ours shows a high prevalence of traditional, potentially modifiable risk factors for ischemic stroke in young adults, so it highlights the need of implementation of more rigorous national prevention measures and control of risk factors, particularly for young individuals.

In this retrospective study, the use of chronic antithrombotic therapy (ATT) did not increase the risk of hemorrhagic complications after trabecular bypass microstent surgery and phacoemulsification. Stent type and female sex were associated with hyphema. To report the incidence of hemorrhagic complications after trabecular bypass microstent surgery and phacoemulsification with and without (ATT). Retrospective case series on glaucoma patients on chronic ATT who underwent trabecular bypass microstent surgery (iStent, iStent inject, and Hydrus) combined with phacoemulsification between 2013 and 2019 with ≥3-month follow-up. The primary outcome measure was the incidence of hemorrhagic complications within a 3-month postoperative period. Generalized estimating equations were created to account for inter-eye correlation and logistic regression analysis was performed to identify factors predictive of hemorrhagic complications. Of 333 patients (435 eyes), 161 patients (211 eyes) were on ATT and 172 patients (224 eyes) were not on ATT; both groups were similar in age and baseline ocular characteristics. The only hemorrhagic complication was hyphema, which occurred in 84 (19.3%) eyes (41 ATT, 43 non-ATT eyes; P = 1.00). Onset was at postoperative day 1 in 98.8% of eyes, with a duration of 1 week in 73.8% of eyes, without difference between ATT and non-ATT groups. Hyphema was most common with Hydrus microstent (36.4%) versus iStent (19.9%) and iStent inject (8.5%) ( P = 0.003). In the multivariate model, the female sex was a predictor of hyphema [hazard ratio (HR) = 2.062; P = 0.009], iStent inject was protective against hyphema (HR = 0.379; P = 0.033), whereas Hydrus did not reach statistical significance (HR = 2.007; P = 0.081). Age, systemic comorbidities, ATT use, and baseline ocular characteristics were not significant predictors. Hemorrhagic complications after trabecular bypass microstent surgery were limited to transient hyphema and were not associated with chronic ATT use. Stent type and female sex were associated with hyphema.

Background Although numerous studies have demonstrated a strong association between blood pressure (BP) and hemorrhagic complications of antithrombotic therapy, there is still a paucity of information regarding the status of BP control in hypertensive patients on antithrombotic therapy. Methods This cross-sectional, retrospective study was conducted at an outpatient clinic to examine BP control and its associated factors in hypertensive patients receiving or not receiving antithrombotic therapy. Results Of 26,803 outpatients who had scheduled visits in 2018, 7,800 hypertensive patients met the inclusion criteria, of whom 1,727 cases were on oral antithrombotic drugs. Then, target BP values were defined according to the Japanese Society of Hypertension Guidelines for the Management of Hypertension 2019. While BP values <140/90 mmHg were observed in 63.0% and 61.6% of patients with and without antithrombotic therapy, respectively, only 31.1% and 23.4% of them displayed BP values <130/80 mmHg. Multivariable logistic analysis indicated that comorbidity with obesity was a significant correlate of insufficient BP control (target BP <130/80 mmHg) in hypertensive patients, irrespective of antithrombotic therapy (patients with antithrombotic therapy, odds ratio (OR) = 1.690, 95% confidence interval (CI) = 1.351–2.113; patients without antithrombotic therapy, OR = 1.475, 95% CI = 1.290–1.687). Conclusion The majority of patients exhibited BP values <140/90 mmHg, whereas BP values <130/80 mmHg were achieved only in a small proportion of the patients. Furthermore, obesity appeared to be one of the factors contributing to insufficient BP control in a real-world setting.

The European Society of Cardiology recommends a risk-based antithrombotic strategy for patients with atrial fibrillation (AF) who undergo percutaneous coronary intervention (PCI) based on CHA2DS2-VASc and HAS-BLED scores. However, because it is unclear if that strategy can be generalized to Asians, we aimed to describe antithrombotic therapies among Japanese patients. Using a nationwide claims database in Japan, this retrospective cohort study identified AF patients who underwent PCI from April 1, 2014 to March 31, 2015. The primary outcome was utilization of anticoagulant and antiplatelet agents before PCI, at discharge, and 6, 9, and 12 months after PCI. The secondary outcome was incidence of stroke after PCI. We identified 10,862 patients and 87.5% of them had high CHA2DS2-VASc and HAS-BLED scores. There were no significant differences in antithrombotic therapies across the risk strata. More than 30% of patients at high risk of thrombosis did not receive oral anticoagulant prescriptions at discharge. The hazard ratio of incidence of stroke in patients with prior stroke compared with patients without prior stroke was 9.09 (95% confidence interval 7.86-10.50, P<0.01). Among Japanese AF patients who underwent PCI, prescriptions for antiplatelet agents were more common than those for anticoagulant agents. The majority of study participants were classified as high risk, suggesting a need for a new risk classification that reflects the risk profiles of Japanese patients.

The optimal perioperative management of antithrombotic therapy (ATT) in patients requiring urgent neurosurgical intervention for subdural hematoma (SDH) is poorly understood. The delicate equilibrium of effective hemostasis while preventing thrombosis is complex and relies on numerous factors such as indication for and type of ATT, medical comorbidities, and extent of neurological injury. This study aimed to analyze the impact of ATT and reversal strategies on surgical outcomes to highlight current challenges in the management of these high-risk patients. The authors performed a retrospective surgical cohort analysis of 100 patients undergoing urgent SDH evacuation at a level I trauma center between March 2020 and May 2021. The patients were first stratified into two cohorts based on preoperative ATT use and then further segregated by receipt of reversal agents. Statistical analysis included the chi-square test, Welch two-sample t-test, and multivariate logistic regression. The primary outcome was mortality. Secondary endpoints included radiographic SDH reexpansion, revision surgery, improvement in preoperative neurological deficits, and incidence of thromboembolism. A crossover cohort was secondarily analyzed in patients for whom ATT was interrupted for a minimum duration equal to effective drug metabolism. Finally, ATT reinitiation patterns were examined. Of 100 patients, 48% received ATT, 54.2% of whom were given reversal agents. ATT use was significantly associated with decreased rates of postoperative neurological improvement (p = 0.023) with trends toward increased mortality (p = 0.078), SDH reexpansion (p = 0.12), and need for revision surgery (p = 0.10). Patient crossover revealed a 4 times greater likelihood of death in patients without ATT interruption prior to surgery (p = 0.040) without an observable impact on secondary outcomes. ATT reversal contributed no improvement in outcomes other than a decreased intensive care unit length of stay when adjusted for in-hospital mortality (p = 0.014). The rate of postoperative thromboembolism following ATT reversal was 11.5%. ATT reinitiation was highly variable, occurring in 59.5% of patients, with median times of 17 and 15 days for antiplatelets and anticoagulants, respectively. Use of preoperative ATT portends poor clinical outcomes following nonelective SDH evacuation regardless of attempts to reverse these medications with replacement blood products. This study further reinforces the critical need for judicious use of ATT and optimization of reversal strategies in high-risk patient populations as best guided by multidisciplinary teams and evolving clinical practice guidelines.

Background: Dialysis pts sustain high mortality rates from acute myocardial infarction (AMI) but were excluded from trials evaluating therapeutic strategies in AMI. Aims: To compare the utilization of anti-thrombotic (AT) and anti-platelet (AP) therapies during AMI in dialysis vs. non-dialysis pts and the relation between outcomes of dialysis pts and the use of AT and AP therapies. Methods: Retrospective cohort study using cross-matched data from the US Renal Data System database and 3rd National Registry of Myocardial Infarction for AMI hospitalizations between 04/01/1998 and 06/30/2000. A cohort of 3049 matching dialysis pts in both databases were identified; pts transferred in or out of the index hospital were excluded, leaving 2390 dialysis and 304096 non-dialysis pts for analysis. Results: Table 1 describes utilization of AT and AP therapies in dialysis pts with AMI. Table 2 details likelihood of adverse outcomes relative to the use of AT and AP agents. Conclusions: AT and AP therapies are underutilized in dialysis pts with AMI. Aspirin use is associated with marked reduction in mortality and major cardiac events in both dialysis and non-dialysis pts. In contrast to non-dialysis patients, GP IIb/IIIa antagonist use is associated with a 3 fold increase in major bleeding in dialysis pts without any reduction in risk of cardiac events; and UF and LMW heparin use are also not associated with any reduction in mortality and cardiac events. Optimal AT and AP strategies in dialysis pts need to be further examined in prospective studies.

Antithrombotic therapy is a well-known independent risk factor for bleeding after endoscopic submucosal dissection (ESD) of early gastric cancer (EGC). A novel method of ulcer base closure using an endoloop and endoclips has been reported. This study aimed to evaluate the effectiveness of endoscopic closure using an endoloop and endoclips in preventing post-ESD bleeding in patients undergoing gastric ESD on antithrombotic therapy. This was a single center, retrospective study. Patients on antithrombotic therapy who underwent gastric ESD were divided into two groups, the closure group and the non-closure group. We analyzed procedural outcomes, post-ESD bleeding rate and factors associated with post-ESD bleeding. Among 400 ESDs with EGCs in 311 patients, 131 ESDs in 110 patients were in the closure group, and 269 ESDs in 217 patients were in the non-closure group (16 patients were overlapped in both groups). Post-ESD bleeding rate was 11.5% (15/131) in the closure group, and 11.9% (32/269) in the non-closure group (p = 0.89). Total sustained closure rate during second look endoscopy was 47.8% (33/69). Post-ESD bleeding rate tended to be lower in the closure group than in the non-closure group for lesions located in the greater curvature (3.6% vs. 11.1%, p = 0.11). In addition, sustained closure rate was significantly higher in the greater curvature than in the lesser curvature (72.0% vs. 34.1%, p < 0.01). Multivariate analysis revealed resection size > 40mm and heparin bridge were the independent risk factor for post-ESD bleeding. Ulcer base closure using endoloop and endoclips did not prevent post-ESD bleeding in patients on antithrombotic therapy.

Patients with intracerebral hemorrhage (ICH) who require antithrombotic therapy (AT) face competing risks of recurrent bleeding and ischemic events. Optimal timing of AT resumption during hospitalization remains uncertain. We evaluated whether restarting AT in hospitalized patients with acute spontaneous ICH reduces ischemic complications without increasing hemorrhagic risk. We conducted a retrospective cohort study at Peking Union Medical College Hospital (2014-2022) including adults (≥ 18 years) admitted with spontaneous ICH within 6 months of onset. Patients were categorized as: Group 1, no AT indication; Group 2, AT indicated but not treated; Group 3, AT indicated and treated. Primary endpoints were ischemic events (ischemic stroke, transient ischemic attack, myocardial infarction, pulmonary embolism, deep venous thrombosis) and hemorrhagic events (new ICH or hematoma expansion ≥ 12.5 mL or ≥ 33%). Outcomes were assessed from onset to discharge. Among 601 patients (median age 58 years; 40.3% female), 256 (42.6%) were in Group 1, 247 (41.1%) in Group 2, and 98 (16.3%) in Group 3. Median time to AT resumption was 19 days (IQR 8-36). Restarting AT (Group 3) significantly reduced ischemic events (14.3% vs. 28.7%; adjusted HR 0.34, 95% CI 0.18-0.65) without increasing hemorrhagic events (5.1% vs. 6.3%; adjusted HR 0.67, 95% CI 0.20-2.19). Competing-risk models and sensitivity analysis confirmed these findings. In-hospital resumption of AT after acute spontaneous ICH significantly decreased ischemic events without excess hemorrhagic risk, supporting its potential benefit in carefully selected patients.

PurposeThe necessity of a specialized ophthalmological assessment following fractures of the zygomaticoorbital (ZMO) complex in an emergency setting is still debated in resource-limited health systems. The primary aim of this study was to determine the incidence and types of ocular and periocular injuries (OPIs) associated with different fracture patterns of the ZMO complex. The secondary aim was to investigate the association between patient- and trauma-specific variables with the different types of OPI and identify high-risk patients for severe OPI.MethodsA retrospective cohort study was conducted on patients with ZMO complex fractures over a seven-year period. All patients underwent a specialized ophthalmic assessment in the ophthalmology clinic within 24 h of initial admission. Visual acuity, extraocular eye movements, and pupillary reaction were examined to determine the type of OPI that occurred. Demographic and medical history data, clinical and radiological findings and specific OPIs were recorded. Demographics, fracture patterns and ophthalmological findings were presented using descriptive statistical analysis. A multivariable analysis was performed to identify associations between predictor factors (etiology of injury, fracture pattern, pre-traumatic ophthalmological conditions, antithrombotic therapy) and OPI severity.Results489 patients with a mean age of 50.88 years and a total of 540 examined eyes met the inclusion criteria. Ground-level fall was the most common etiology of injury. Periocular hematomas (28.99%), subconjunctival hemorrhage (18.65%) and periorbital swelling (15.13%) were the most common ophthalmologic findings. Eye motility disorders (p = 0.0003) and diplopia (p = 0.0019) were significantly more common in isolated orbital wall fractures than in other midface fracture patterns. Chemosis was significantly more common in fractures of the zygomaticoorbital complex (p = 0.0199), while lid tears (p = 0.0470) and open globe injuries (p = 0.0002) were more common in Le Fort fractures. Optic disc hemorrhage occurred significantly more frequently in patients under single antithrombotic therapy (p = 0.0171). Blow from blunt objects and Le Fort fractures were associated with higher rates of severe OPI, while pre-traumatic ophthalmologic conditions and antithrombotic therapy were not.ConclusionsWithin the limitations of the study, patients who experienced blows from blunt objects and those with Le Fort fractures are at a higher risk for severe OPIs. Early specialized ophthalmological consultation is recommended for patients with zygomatic fractures and orbital involvement, especially for those with visual alterations such as motility disorders and diplopia as well as those taking antithrombotic medication.

BackgroundOptimised antithrombotic therapy requires clinical experience and an understanding of the current guidelines. This retrospective study aimed to evaluate whether pharmacist interviews and interventions with patients taking oral antithrombotic drugs in the pharmaceutical outpatient cardiology clinic had favourable clinical outcomes including decreased bleeding.MethodsThe participants included patients visiting the outpatient clinic of cardiovascular internal medicine at the Kobe University Hospital from January–December 2017, and were taking oral antithrombotic medication. The observation period was from the first visit to the outpatient clinic to October 2021 or death. Patients who received pharmacist intervention more than twice were defined as the pharmacist intervention group. Two control patients per one pharmacist intervention group individual were selected from the non-intervention pool matched for age, gender and antithrombotic medication type.ResultsOf the 895 eligible patients, 132 were in the pharmacist intervention group and 264 were selected for the matched non-intervention group. Bleeding events according to the Bleeding Academic Research Consortium criteria over type 2 were significantly lower in the pharmacist intervention group compared with the non-intervention group (17.4% versus 28.4%, P = 0.019). There were no significant differences in mortality and heart failure hospitalisation frequency, stroke, or cardiovascular events between the groups. Multivariate analysis identified age (≥ 65 years) and pharmacist intervention as factors associated with bleeding (odds ratio = 2.29 and 0.51, respectively).ConclusionPharmacist intervention in the outpatient clinic of cardiovascular internal medicine was effective in reducing the risk of bleeding in patients undergoing antithrombotic therapy.

Objectives: Patients with peripheral arterial occlusive disease (PAOD) are at risk of worsening limb symptoms, major adverse cardiovascular events and exhibit an impaired life expectancy. There is a lack of evidence on the extent of pharmacological secondary prevention in PAOD patients. This study assesses treatment patterns of antithrombotic agents in symptomatic PAOD patients. Methods: This is a retrospective cohort study using data from the second largest insurance fund in Germany, BARMER. We included symptomatic PAOD patients undergoing in-hospital treatment with an index admission between 1 January 2010 and 31 December 2017. Outcomes were proportions of single antiplatelets (SAPT), dual antiplatelets (DAPT), vitamin-K antagonists (VKA), or direct oral anticoagulants (DOAC) in the 12 months prior and 6 months after the index hospitalization. Non-parametric cumulative incidence for competing risks was estimated to account for censoring and death after discharge from hospital stay. Patient flows were visualised by alluvial diagrams. All analyses were stratified by intermittent claudication (IC) and chronic limb-threatening ischaemia (CLTI). The protocol was registered to ClinicalTrials.gov (NCT03909022). Results: A total of 80,426 unique patient encounters were identified. Mean age was 72.7 (46.3% female). Amongst all patients, 25.6% were on SAPT, 4.1% on DAPT, 9.1% on VKA, 3.9% on DOAC, 3.9% on both antiplatelets and oral anticoagulation, and 53.3% without any antithrombotic therapy during the 12 months before index stay. The estimated cumulative incidence was 37.9% SAPT, 14.8% DAPT, 7.5% VKA, 4.3% DOAC, 7.4% both, and 28.1% without any antithrombotic therapy during the 6 months after index stay. The considerable increases in antiplatelet therapy were mainly driven by the group of patients without antithrombotics before index stay. As compared with IC, patients who suffered from CLTI received less often antiplatelets but more often anticoagulants both before and after index stay. Conclusions: Utilisation rates of antithrombotic therapy increased considerably after in-hospital treatment for PAOD. Yet, remarkably high rates of symptomatic patients without any blood-thinning therapy constitute a major concern with respect to adequate secondary prevention of PAOD patients.

Efficacy of Traditional Chinese Medicine in patients with acute myocardial infarction suffering from diabetes mellitus

To evaluate current clinical evidence for management of oral anticoagulation therapy after gastrointestinal bleeding (GIB) with an emphasis on whether to, when to, and how to resume an anticoagulation therapy. Relevant articles from MEDLINE, Cochrane Library, and EMBASE databases were identified from 1946 through May 20, 2017, using the keywords: gastrointestinal hemorrhage or gastrointestinal bleeding and antithrombotic therapy or anticoagulation therapy or warfarin or dabigatran or rivaroxaban or apixaban or edoxaban. All English-language studies assessing management of oral anticoagulation therapy after GIB were evaluated. A total of 9 studies were identified. Four retrospective cohort studies showed that resuming anticoagulation therapy was associated with significantly lower rate of thromboembolism (TE) in the general population. Meta-analyses and prospective cohort studies also supported this finding. Two retrospective cohort studies indicated an increase in GIB when anticoagulation reinitiation occurred in less than 7 days without a decrease in TE. Resuming therapy between 7 and 15 days did not demonstrate a significant increase in GIB or TE. A large retrospective study showed that apixaban was associated with the significantly lowest risk of GIB compared with both rivaroxaban and dabigatran. Anticoagulation therapy resumption is recommended, with resumption being considered between 7 and 14 days following GIB regardless of the therapy chosen. Data for warfarin management after GIB should be applied with caution to direct oral anticoagulants (DOACs) because of the quicker onset and experimental nature of reversal agents. Apixaban may be a preferred option when restarting a DOAC therapy.

IntroductionIncomplete endothelialization (IDE) of left atrial appendage closure (LAAC) devices increases the risk of device-related thrombosis (DRT) and stroke. Insulin resistance (IR) may contribute to IDE by impairing endothelial function, but its role remains unclear. This study aimed to investigate the association between IR markers and IDE and develop a predictive model for identifying high-risk patients.MethodsThis retrospective observational study included 168 patients with nonvalvular atrial fibrillation (AF) who underwent successful LAAC at Shanghai Ninth People’s Hospital between January 2022 and December 2023. IDE was assessed using transesophageal echocardiography (TEE) and cardiac computed tomography angiography (CCTA) at 6 months post-procedure. IR was evaluated using the triglyceride-glucose (TyG) index, triglyceride-to-high-density lipoprotein cholesterol (TG/HDL-c) ratio, and metabolic score for insulin resistance (METs-IR). Logistic regression analysis was performed to identify independent predictors of IDE, and a predictive model was constructed.ResultsAmong the 168 patients included in the analysis, 43 (25.5%) exhibited IDE, as determined by TEE or CCTA at 6 months post-procedure. Patients with IDE had a significantly higher body mass index, triglyceride (TG) levels, total TG/high-density lipoprotein ratio, TyG index, METs-IR index, and D-dimer levels, as well as a larger maximum LAA orifice diameter (p < 0.05). Multivariate logistic regression identified D-dimer, METs-IR, and maximum LAA orifice diameter as independent predictors of IDE. The predictive probability model incorporating these factors demonstrated high discriminatory ability (area under the curve 0.800, 95% confidence interval 0.71–0.89, p < 0.0001). The optimal predicted probability cut-off value was 0.284, achieving a sensitivity of 76.2% and a specificity of 85.2%.ConclusionIR markers, D-dimer levels, and LAA orifice size are significant predictors of IDE following LAAC. The logistic regression model proposed here provides an effective risk stratification tool for identifying patients at higher risk for IDE, enabling personalized anticoagulation strategies and optimizing post-procedural management. Future research should explore whether metabolic interventions can enhance endothelialization and improve long-term outcomes in patients undergoing LAAC.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40119-025-00418-4.

Background:Despite use of arterial closure devices (APCDs) and thrombin injection , surgery is needed at times to repair femoral pseudoaneurysms (FPA) in patients undergoing endovascular interventions. We analysed the indications and results of surgical repair in a tertiary referral center performing more than 6.000 angiographies and/or interventions annually.Objectives:The aim of this retrospective observational study was to identify local and clinical factors related to the need of surgical repair.Patients and Methods:In this retrospective study, 122 (0.06%) FPAs treated among 21060 patients over a period of five years were assessed. Patient characteristics and therapeutic procedures were analyzed through hospital records.Results:There were 15.163 (72%) coronary and 5.897 (27%) peripheral interventions, respectively. In 89 (73%) patients, FPA was successfully treated by ultrasound guided compression (USGC) alone.Thirty-three (28%) patients underwent open surgical repair. Indication for operative treatment was hemodynamic instability in 9 (7%) patients, rapidly expanding haematoma unsuitable for USGC or after unsuccessful USGC in 23 (19%). One (0.8%) patient had an arterio-venous fistula. Intraoperative findings suggest that atypical endovascular access (e.g. deep femoral artery, lateral or medial puncture) and multiple puncture sites and/or laceration of the vessel wall were related to the need for surgery in 22 (67%) cases. Most patients had active antithrombotic therapy. Gender or the nature of procedure (diagnostic vs. intervention) did not increase risk for open repair. One (0.8%) patient died. No amputations were performed. Mean hospital stay of patients undergoing open surgical repair was 11 (range 4-36) days.Conclusions:Technical puncture problems were identified in 2/3 of patients requiring open surgery.