Search Results for: Associazione FANS e Warfarin

Circulation, Volume 150, Issue Suppl_1, Page A4141024-A4141024, November 12, 2024. Background:Atrial fibrillation (AF) is increasingly prevalent in patients with liver cirrhosis, which is associated with both bleeding and thromboembolism. Patients with cirrhosis have been excluded from randomized controlled trials on the efficacy and safety of anticoagulants in AF. We performed a systematic review to compare direct oral anticoagulants (DOACs) with warfarin in patients with AF and concomitant cirrhosis.Methods:We systematically searched Pubmed and Embase from inception to the present. The primary outcome of interest was the hazard ratio of major bleeding. Secondary outcomes included gastrointestinal bleeding, all-cause bleeding, and ischemic stroke/systemic embolism[AN1] . Random effects models were used to calculate the weighted pooled hazard ratios for the outcomes. A two-tailed p

Circulation, Volume 150, Issue Suppl_1, Page A4117646-A4117646, November 12, 2024. Introduction:The HeartMate 3 (HM3) LVAD, was shown to have a higher survival free of hemocompatibility related adverse events (HRAE) compared to its predecessors (HM2, HVAD). Superior HM3 outcomes are attributed to wide blood flow pathways coupled with frictionless movement and intrinsic pulsatility, reducing shear stress and blood stasis. It is unknown if improved hemocompatibility can withstand pump restart after prolonged shutdown. We herein report a case of HM3 pump stoppage without subsequent HRAE.Case Presentation:A 41-year-old male underwent HVAD implant in 2019 for advanced non-ischemic cardiomyopathy. This was exchanged to HM3 for recurrent neurological events despite therapeutic anticoagulation. Ten months after exchange, he awakened one morning to find his LVAD had been off for an unknown period but had not heard any device alarms (85dB if on battery power, 165dB if on wall power). Since he felt well he changed to battery power resulting in immediate pump restart. Log file analysis showed pump stoppage 2 am – 10 am, without preceding low flow alarms or power elevations.Management and Outcomes:In the ER INR was 1.5 (2.8 one week prior) and systemic heparin was started. Evaluation included: 1) CT brain without acute infarcts 2) echocardiogram without intracardiac thrombus 3) CT Angiography with patency of the inflow cannula and outflow graft 4) stable serial LDH measurements. The controller was exchanged, and analysis noted normal function. 1-year later the patient is maintained on warfarin and aspirin 325mg without further HRAE. Given the patient’s neurologic history and pump stoppage event, we did not invoke ARIES trial guidance and thus continued aspirin.Conclusion:Pump stoppage occurs when there is complete battery depletion, disconnection of both power leads, or the percutaneous lead from system controller. Our case is unique in that the duration of pump shutdown was 8 hours and INR subtherapeutic, without HRAE in the background of neurologic events on HVAD support. It has been previously reported that complete outflow graft thrombosis can occur shortly after LVAD decommissioning. The HM3 User Manual recommends restarting the pump immediately if off for a few minutes and using clinical judgment for longer durations due to increased risk for thromboembolic events. Our case adds to the paucity of existing data on improved hemocompatibility of the HM3 during rare circumstances of the ultimate test in hemocompatibility: complete pump shut down.

Circulation, Volume 150, Issue Suppl_1, Page A4141927-A4141927, November 12, 2024. Background:Prior data suggest the MI risk may be higher with paroxysmal AF (PAF) vs. non-paroxysmal AF (non-PAF). Proposed mechanisms include tachycardia-induced oxidative stress (via LOX-1) with microvascular flow abnormalities, ischemia downstream of a fixed coronary obstruction, and plaque rupture.Methods:We compared MI rates in pts with PAF vs. non-PAF in COMBINE AF, a patient-level metanalysis of 4 RCTS of DOACs vs warfarin (ARISTOTLE, ENGAGE AF-TIMI 48, RE-LY,ROCKET AF). Secondary endpoints were ischemic stroke and CV death. Cox proportional-hazards models stratified by trial and adjusted for elements of the CHADS-VASc score were constructed. Sensitivity analyses were performed across subgroups, omitting pts on lower-dose DOAC regimens, and accounting for competing risk of death.Results:Of 71,466 pts, 16,609 (23%) had PAF at enrollment. Pts with PAF vs non-PAF were similar age (median 72 vs 72. P=0.15), but more likely women (43 vs 36%), with prior CAD (35 vs 31%), and on aspirin (41 vs 32%); but less likely Asian race (12 vs 15%) or with CHADS-VASc score >4 (59 vs 60%), p160,000 pt-yrs of follow-up, 1033 MIs occurred: 277 (1.67%) in pts with PAF vs 766 (1.40%) in pts with non-PAF, corresponding to rates of 0.81% and 0.70% per pt-year. The HRadjfor MI with PAF vs non–paroxysmal AF was 1.17 [1.02-1.35], p=0.028 (Fig). Ischemic stroke occurred in 364 (2.19%) vs 1425 (2.60%) pts with PAF vs non–paroxysmal AF (HRadj0.81 [0.72-0.91], p

Circulation, Volume 150, Issue Suppl_1, Page A4141243-A4141243, November 12, 2024. Description of Case:A 36-year-old male with a history of non-ischemic cardiomyopathy status post HeartMate 3 left ventricular assist device (LVAD) presented with a 2-day history of dizziness, lightheadedness, chest pain, and an increase in low flow alarm frequency from his LVAD. On admission, his temperature was 37.2, return to flow was 86, oxygen saturation was 100% on room air, heart rate was 99, and respiratory rate was 23. His lungs were clear to auscultation, and his abdomen was distended, tense, and non-tender. His extremities were warm, with moderate edema in his legs bilaterally. He had mild increased work of breathing without accessory muscle uses. Laboratory evaluation revealed a prothrombin time of 2.6 seconds, a B-type natriuretic peptide level of 176 pg/mL, and a hemoglobin of 13.7 g/dL. Imaging revealed a chest CT demonstrating a complete obstruction of the distal outflow cannula near its attachment to the aorta. Patient hemodynamics worsened after admission, necessitating transfer to the cardiac intensive care unit. After an unsuccessful attempt at warfarin reversal and tissue plasminogen activator administration, the patient was eventually taken for surgical intervention with cardiothoracic surgery. During the procedure, there were no signs of outflow graft thrombus; instead, a sizeable peri-graft fluid collection was observed and drained, which relieved the outflow graft obstruction. The patient’s post-operative course was uneventful, and he was eventually discharged home with a resolution of his symptoms.Discussion:This patient’s presentation presents a few key features that suggest an alternative cause of an outflow obstruction other than an acute thrombus. The most important feature is that the patient had been diligent with his anticoagulation to indicate his being a therapeutic prothrombin time on admission, consistent with the patient’s reported anticoagulation adherence. We believe that cases such as this one provide clinical support for the reevaluation of the way we approach outflow tract obstructions in LVADs; especially as we continue to develop devices that have lower thrombus risk that their predecessors. We hope that this patient’s clinical presentation and course will be helpful in the future differentiation of intrinsic vs extrinsic compression of LVAD cannulas and the management of such obstructions.

Circulation, Volume 150, Issue Suppl_1, Page A4142289-A4142289, November 12, 2024. Description of Case:This case presents a 32-year-old woman with history of rheumatoid arthritis who presented with symptoms of worsening dyspnea on exertion, fatigue, and stable angina five weeks after starting abatacept.Methods:Performed a comprehensive retrospective analysis of one patient’s medical history, clinical presentation, diagnostic assessment, therapeutic intervention, and clinical outcome.Results:Physical exam was remarkable for signs of volume overload. Electrocardiogram showed sinus tachycardia and diffuse nonspecific T-wave inversions. Laboratory studies revealed a complete blood count significant for eosinophilia of 26,000, representing 79.5% of the differential. Troponins were negative. A brain natriuretic peptide was 903 pg/ml. Echocardiogram findings included mild reduction in biventricular systolic function with wall motion abnormality seen at the apex. Cardiac MRI (CMR) demonstrated mild biventricular systolic dysfunction, left ventricular intracavitary filling defect consistent with thrombi, and diffuse biventricular subendocardial late gadolinium enhancement (LGE) consistent with fibrosis. Abatacept was stopped with resolution of eosinophilia. Patient was treated with a short course of steroids and initiated on warfarin for left ventricular thrombi. Repeat CMR four months later showed resolution of left ventricular thrombi and biventricular dysfunction, with persistence of diffuse subendocardial fibrosis in both left and right ventricles.Discussion:CMR demonstrates findings consistent with Loeffler Endocarditis as evident by ventricular intracavitary filling defects and diffuse biventricular subendocardial late gadolinium enhancement. Initial management of involves prompt discontinuation of the suspected offending drug. Corticosteroids may be employed to mitigate eosinophilic infiltrate and myocardial inflammation. Diagnostic modalities such as cardiac imaging, endomyocardial biopsy, and laboratory testing play crucial roles in confirming the diagnosis and assessing severity. Follow-up CMR can help follow the response to cessation of the offending agent and rule-out confounding disease processes, as seen in this case. In conclusion, abatacept-induced eosinophilic endocarditis is a rare phenomenon that is poorly understood. Drug-induced eosinophilic endocarditis should be considered as a differential in patients that develop heart failure symptoms and eosinophilia after initiating abatacept.

Circulation, Volume 150, Issue Suppl_1, Page A4124430-A4124430, November 12, 2024. Introduction:Heart failure can be a manifestation of underlying immune mediated myopathies like dermatomyositis/polymyositis which can present in broad range of clinical manifestations and sometimes dermatologic lesions can be the only manifestation of these underlying pathologies without typically involving the muscle weakness. Calcinosis cutis is the deposition of calcium salts in the skin and subcutaneous tissue. There are five subtypes of calcinosis cutis, dystrophic, metastatic, idiopathic, iatrogenic and calciphylaxis.Case summary:70-year-old female was evaluated for bilateral lower extremity swelling. Past medical history was significant for Graves’ disease, atrial fibrillation, mechanical aortic valve on warfarin, hypertension, hyperlipidemia, ascending aortic aneurysm. Work up showed BNP of 4700 pg/ml with normal cardiac enzymes. Transthoracic echocardiogram revealed newly reduced ejection fraction of 25—30% with severely dilated left ventricle. Patient refused cardiac catheterization. Nuclear stress test showed no evidence of ischemia. Patient was started on guideline directed medical therapy and biventricular Implantable cardioverter defibrillator device was placed as per cardiology recommendation. Six months later patient developed multiple calcinosis cutis lesions on abdominal wall requiring surgical excisions. Endocrine work up including PTH, serum Ca level was normal, however creatin kinase level was high normal (150 U/L). Serum aldolase was ordered which was found to be elevated(25U/L). Muscle biopsy was performed as per recommendations of rheumatology which was diagnostic of dermatomyositis. Patient was started on high dose steroids and methotrexate and eventually IV immunoglobulins as per rheumatology recommendation. Follow up echocardiogram revealed improved ejection fraction to 40–45% with resolution of any further lesion of calcinosis cutis afterwards.Conclusion:Cardiac involvement such as congestive heart failure can be a part of presentation of underlying untreated myopathies. Calcinosis cutis can be the only clinical manifestation of dermatomyositis affecting heart. Etiology of calcinosis cutis in patients with heart failure should be worked up properly. Dystrophic calcinosis cutis is the subtype associated with underlying autoimmune connective tissue diseases.

Circulation, Volume 150, Issue Suppl_1, Page A4144096-A4144096, November 12, 2024. Background:The patient population undergoing left atrial appendage occlusion (LAAO) in the US is older and at a higher bleeding and thromboembolic risk than that enrolled in the initial trials that led to FDA approval. Real world outcomes in this population have implications for the use of LAAO.Goals:We sought to compare clinical outcomes of LAAO in patients with atrial fibrillation (AF) with prior major gastrointestinal (GI) bleeding to continued oral anticoagulation (OAC).Methods:Using data from a large US hospital system, patients with AF who underwent LAAO from 01/2016 to 11/2022 with a history of at least one major (requiring admission or transfusion) GI bleed event (LAAO group) were identified and compared to a control group with prior GI bleed with continued OAC. Controls were selected in a 1:2 fashion using propensity score matching based on 17 variables. Hospital admissions for major bleeding, ischemic stroke or transient ischemic attack (TIA) as well as survival were tracked during follow-up.Results:Patients in the LAAO group (n=642, age 76.5±8.2 years, 47.8% female) had higher CHA2D2-VASc (4.3±1.7 vs. 4.1±1.6, p=0.003) and lower HAS-BLED (3±0.9 vs. 3.3±0.9, p

Circulation, Volume 150, Issue Suppl_1, Page A4145487-A4145487, November 12, 2024. Background:Pulmonary vein thrombi (PVTs) are common, and their prevalence is underestimated. Neutrophil extracellular traps (NETs) may initiate the formation of PVTs, and NETs are associated with many diseases, such as type 2 diabetes mellitus (T2DM), atherosclerosis and heart diseases. A study of the retrieved thrombi revealed that they had calcification, indicating that they were old. PVTs can release several types of particles, potentially ranging from microclots including NETs to large clots. We reported that standard-dose heparin-warfarin treatment ameliorated mild to moderate T2DM. Heparin might improve blood flow in the microvessels of most organs by destroying histones in NETs. Other NET-associated diseases might be ameliorated, so it is important to understand the traits of PVTs.We reported several cases in which right lower pulmonary vein (RLPV) thrombi extended into the left atrium (LA). The reported shape of these extended thrombi is rod-like in many cases, as estimated using transesophageal echocardiography (TEE). Most of these thrombi cannot be detected using enhanced computed tomography (ECT). Whether LA thrombi extending from the right upper pulmonary vein (RUPV) are rod-like remains unclear.Methods:We examined thrombi in the RUPV in thirty-one patients with and type 2 diabetes mellitus (24 men and 7 women; age = 73.5 (+/- 8.9)-year-old; range: 50- to 88-year-old) using TEE and ECT.Results:None of the patients had rod-like LA thrombi extending from the RUPV in the LA. When we checked using TEE, six patients clearly had PVTs in the RUPV, in which thrombi were attached to the vessel wall and could not be detected using ECT. Thrombi extended into the LA, contacting the wall of the RUPV and the wall of the LA. Thrombi are difficult to visualize directly and are recognized as lacking in pulmonary vein blood flow. This study had two limitations. First, only thirty-one patients were included. If we check more patients, rod-like extending LA thrombi might exceptionally exist. The second was that there were several small white spot-like areas around the RUPV; however, we diagnosed them as having no thrombi. These spot-like areas might be thrombi.Conclusions:PVTs in the RUPV did not have rod-like extending thrombi in the LA. Attachments to the vessel wall were not rare, and they were detectable when using TEE but not ECT. The thrombi depicted by TEE were different from the thrombi depicted by ECT in some cases.

Circulation, Volume 150, Issue Suppl_1, Page A4135975-A4135975, November 12, 2024. Introduction:Coronary artery ectasia (CAE) is a rare but well-recognized anatomical abnormality of the coronary arteries with a prevalence of up to 9% in patients presenting with acute coronary syndrome (ACS). While anticoagulants have been suggested to reduce recurrent events, the optimal antithrombotic therapy in CAE and ACS remains unclear.Research Question:What is the comparative effect of anticoagulation therapy versus no anticoagulation in patients with CAE and ACS receiving background antiplatelet therapy?Goals:To perform a systematic review and meta-analysis evaluating the efficacy of anticoagulation in preventing major adverse cardiovascular events (MACE) among patients with CAE and ACS.Methods:We searched PubMed, Embase, and Cochrane to identify studies comparing the use of anticoagulants versus no use of anticoagulants as part of the antithrombotic therapy in patients presenting CAE and ACS, and reported MACE. Statistical analysis was performed using R version 4.2.2 adopting the Mantel-Haenszel random-effects model. Heterogeneity was assessed using Cochrane’s Q statistic and Higgins and Thompson’s I2 statistics. Pooled risk ratios were used to evaluate the effectiveness of anticoagulant therapy in CAE and ACS.Results:We included 3 studies, including 1 randomized controlled trial and 2 observational studies, comprising a total of 441 patients, of whom 162 (36.7%) received anticoagulants, including vitamin K antagonists (warfarin and acenocoumarol) or direct oral anticoagulants (rivaroxaban, apixaban, and dabigatran). Time of follow-up ranged from 12 to 52 months, mean age was 57.9 ± 11.4 years, and 388 (87.9%) were male. We found no significant difference in MACE between patients who received anticoagulation and patients who did not (RR 0.64; 95% CI 0.31, 1.32; p=0.22; I2 = 0%). Additionally, there was no difference in the risk of re-infarction (RR 0.71; 95% CI 0.43, 1.18; p=0.19; I2 = 0%). Finally, there was no significant difference in risk of bleeding between both groups (RR 1.41; 95% CI 0.70, 1.85; p=0.19; I2 = 0.59%).Conclusion:Our findings suggest that, among patients with CAE and ACS, anticoagulation does not reduce the risk of MACE or re-infarction as compared with no anticoagulation.

Circulation, Volume 150, Issue Suppl_1, Page A4135327-A4135327, November 12, 2024. Background:With the aging population, the prevalence of malignancies in patients undergoing percutaneous coronary intervention (PCI) is increasing. Active malignancy is increasingly recognized as a significant contributor to high bleeding risks. In cases where anticoagulant (AC) therapy is required, it becomes crucial to determine which is the optimal choice for cancer patients, direct oral anticoagulants (DOACs) or warfarin. The aim of this study was to investigate long-term bleeding events in patients with malignancy undergoing PCI.Methods:CLIDAS (Clinical Deep Data Accumulation System) is a multicenter database with 7 tertiary medical hospitals in Japan. This retrospective analysis using CLIDAS database included 6838 patients who underwent PCI during April 2014 and March 2020 and also who have completed 3-year follow-up were divided into two groups; No malignancy group (n=6155) and malignancy group (n=683). Malignancy was defined as patients with treatment history of malignancy. Furthermore, these patients were categorized into six groups based on the presence of malignancy and the type of AC therapy;1)No malignancy without AC (n=5369),2)No malignancy with DOAC (n=294),3)No malignancy with warfarin (n=492),4)Malignancy without AC (n=586),5)Malignancy with DOAC (n=44), and6)Malignancy with warfarin (n=53). The primary outcome was the incidence of bleeding events, defined according to the Global Use of Streptokinase and t-PA for Occluded Coronary Arteries classification of moderate and severe bleeding.Results:During the 3-year follow-up period, 260 (3.8%) patients experienced major bleeding events after PCI. Among these patients, 180 (3.4%) were in group 1, 9 (3.1%) in group 2, 33 (6.7%) in group 3, 27 (4.6%) in group 4, 2 (4.5%) in group 5, and 9 (17.0%) in group 6. Multivariate Cox regression analysis showed that patients in the malignancy group had a significantly higher rate of bleeding events (HR, 1.50; 95% CI, 1.03-2.18). Furthermore, only the malignancy with warfarin group showed a significantly higher rate of bleeding events compared to the no malignancy without AC group (HR, 4.03; 95% CI, 1.94-8.37).Conclusions:Patients with malignancies receiving warfarin were associated with a higher risk of bleeding events. DOACs may be a safer alternative to warfarin in reducing bleeding risk in this population.

Circulation, Volume 150, Issue Suppl_1, Page A4140488-A4140488, November 12, 2024. Background:Central venous catheters (CVC) are common in cancer pts but provide a nidus for right atrial thrombus (RA-Th). CMR can identify presence and risk factors for RA-Th.Objectives:To evaluate predisposing factors and embolic risk conferred by RA-Th.Methods:The population comprised adult (≥18yo) cancer pts with CVC who underwent CMR at two sites; RA-Th was defined by avascularity on LGE-CMR. Registry data included clinical and CVC indices and chart review for pulmonary embolism (PE) 1 month pre- or 6 months post-CMR.Results:211 pts with CVC (52±17yo; 45% M) were studied, inclusive of RA-Th and controls matched for cancer etiology/stage (heme 28%| GI 27%| sarcoma 22%). CVC type varied (Mediport 81% |PICC 9%| pheresis 6%| HD 4%), as did time between RA-Th and catheter insertion (6.5[2.4-15.8] mo). Pts with and w/o RA-Th were of similar age, sex, CVC type/duration, and cardiac function on CMR (p=NS). CVC depth was greater in pts with RA-Th (2.8±1.6cm vs. 1.5±1.6cm, p

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