Rescue therapy of early neurological deterioration in lacunar stroke.

BACKGROUND: Early neurological deterioration (END) occurs in many patients with acute ischemic stroke due to a variety of causes. Although pharmacologically induced hypertension (PIH) and anticoagulants have been investigated in several clinical trials for the treatment of END, the efficacy and safety of these treatments remain unclear. Here, we investigated whether PIH or anticoagulation is better as a rescue therapy for the progression of END in patients with lacunar stroke. METHODS: This study included patients with lacunar stroke who received rescue therapy with END within 3 days of symptom onset between April 2014 and August 2021. In the PIH group, phenylephrine was administered intravenously for 24 h and slowly tapered when symptoms improved or after 5 days of PIH. In the anticoagulation group, argatroban was administered continuously intravenously for 2 days and twice daily for next 5 days. We compared END recovery, defined as improvement in NIHSS from baseline, excellent outcomes (0 or 1 mRS at 3 months), and safety profile. RESULTS: Among the 4818 patients with the lacunar stroke, END occurred in 147 patients. Seventy-nine patients with END received PIH (46.9%) and 68 patients (46.3%) received anticoagulation therapy. There was no significant difference in age (P = 0.82) and sex (P = 0.87) between the two groups. Compared to the anticoagulation group, the PIH group had a higher incidence of END recovery (77.2% vs. 51.5%, P < 0.01) and excellent outcomes (34.2% vs. 16.2%, P = 0.04). PIH was associated with END (HR 2.49; 95% CI 1.06-5.81, P = 0.04). PIH remained associated with END recovery (adjusted HR 3.91; 95% CI 1.19-12.90, P = 0.02). Safety outcomes, like hemorrhagic conversion and mortality, were not significantly different between the two groups. CONCLUSIONS: As a rescue therapy for the progression of END in lacunar stroke patients, PIH with phenylephrine was more effective with similar safety compared to anticoagulation with argatroban.

The anticoagulation one year after ablation of atrial fibrillation in patients with atrial fibrillation (ALONE-AF) trial: Study protocol.

Background: The ideal long-term antithrombotic strategy for patients after successful catheter-based atrial fibrillation (AF) ablation is still uncertain. Presently, practices vary, and the advantages of oral anticoagulation (OAC) for the post-ablation population are not clearly established. To date, no randomized trials have addressed this therapeutic question. This study aimed to evaluate whether no OAC therapy is superior to apixaban in reducing the risk of stroke, systemic embolism, or major bleeding among patients without apparent recurrent atrial arrhythmias for at least 1 year after their AF ablation procedure. Methods: The ALONE-AF trial is a prospective, multicenter, open-label, randomized study with blinded outcome assessment. Patients with AF who have at least one non-gender stroke risk factor (as determined by the CHA2DS2-VASc score) and no documented recurrences of atrial arrhythmia for at least 12 months post-ablation will be randomly assigned to apixaban 5 mg b.i.d. or no OAC therapy. The primary endpoint is a composite outcome of stroke, systemic embolism, and major bleeding. Key secondary outcomes include clinically relevant non-major bleeding, all-cause mortality, myocardial infarction, transient ischemic attack, quality of life, and frailty analysis. Participants will be followed for a period of 2 years. The estimated total sample size is 840 subjects, with 420 subjects in each arm. Conclusion: The ALONE-AF trial aims to provide robust evidence for the optimal anticoagulation strategy for patients with stroke risk factors following successful AF ablation.

Atrial Fibrillation in Hypertrophic Cardiomyopathy.

Atrial fibrillation (AF) is common among patients with hypertrophic cardiomyopathy (HCM) with a prevalence greater than 25%. AF in HCM is associated with a high risk of stroke and can be a marker of more advanced cardiomyopathy. Although, it frequently results in cardiac hemodynamic changes which are poorly tolerated, it can be subclinical. Thus, prompt diagnosis and adequate management of AF are essential to minimizing AF-related adverse outcomes in HCM. All HCM patients should be screened for AF regularly, and those with high-risk features should be screened more frequently preferably with extended ambulatory monitoring. Once AF is detected, oral anticoagulation should be initiated. Both general and HCM-specific modifiable risk factors should be addressed and assessment for cardiomyopathy progression should be performed. Although no randomized controlled studies have compared rate versus rhythm control in HCM, early rhythm control could be considered to prevent further LA remodeling.

Benefits and limitations of implantable loop recorders in the very elderly.

BACKGROUND: Implantable loop recorder (ILR) allows rhythm-monitoring up to 3 years. They are recommended in patients with recurrent syncope and for the detection of atrial fibrillation (AF) in patients with cryptogenic thromboembolic events. AF and syncope occur more often in elderly patients. However, data in this cohort is limited. METHODS AND RESULTS: All patients ≥ 80 years undergoing ILR-implantation between 2011 and 2022 in our center were included. Permanent pacemaker implantation (PPI) and oral anticoagulation due AF were defined as primary endpoints. Forty-five patients ≥ 80 years were included, 33 because of recurrent syncope and 12 because of suspected AF. The average follow up (FU) was 17.6 months. Overall in 22 patients, ILR-implantation led to a therapeutic consequence (48.9%). In the 12 patients who underwent ILR-implantation for detection of AF, AF was detected in nine patients (75%). In the 33 elderly patients who received ILR-implantation after syncope, 11 underwent PPI during FU (33.3%). One patient accidentally removed the ILR himself via the implantation-wound, and no other ILR-related complications were observed. CONCLUSION: ILR are effective and safe in elderly patients. AF was often found in patients with suspected AF, especially in patients after catheter ablation of only documented atrial flutter (AFlu). PPI-rate was high in patients with recurrent syncope and ILR-implantation. Further investigations are necessary to determine whether PPI may be considered in elderly patients with syncope even in the absence of a bifascicular block.

Effect of Screening for Undiagnosed Atrial Fibrillation on Stroke Prevention.

BACKGROUND: Atrial fibrillation (AF) often remains undiagnosed, and it independently raises the risk of ischemic stroke, which is largely reversible by oral anticoagulation. Although randomized trials using longer term screening approaches increase identification of AF, no studies have established that AF screening lowers stroke rates. OBJECTIVES: To address this knowledge gap, the GUARD-AF (Reducing Stroke by Screening for Undiagnosed Atrial Fibrillation in Elderly Individuals) trial screened participants in primary care practices using a 14-day continuous electrocardiographic monitor to determine whether screening for AF coupled with physician/patient decision-making to use oral anticoagulation reduces stroke and provides a net clinical benefit compared with usual care. METHODS: GUARD-AF was a prospective, parallel-group, randomized controlled trial designed to test whether screening for AF in people aged ≥70 years using a 14-day single-lead continuous electrocardiographic patch monitor could identify patients with undiagnosed AF and reduce stroke. Participants were randomized 1:1 to screening or usual care. The primary efficacy and safety outcomes were hospitalization due to all-cause stroke and bleeding, respectively. Analyses used the intention-to-treat population. RESULTS: Enrollment began on December 17, 2019, and involved 149 primary care sites across the United States. The COVID-19 pandemic led to premature termination of enrollment, with 11,905 participants in the intention-to-treat population. Median follow-up was 15.3 months (Q1-Q3: 13.8-17.6 months). Median age was 75 years (Q1-Q3: 72-79 years), and 56.6% were female. The risk of stroke in the screening group was 0.7% vs 0.6% in the usual care group (HR: 1.10; 95% CI: 0.69-1.75). The risk of bleeding was 1.0% in the screening group vs 1.1% in the usual care group (HR: 0.87; 95% CI: 0.60-1.26). Diagnosis of AF was 5% in the screening group and 3.3% in the usual care group, and initiation of oral anticoagulation after randomization was 4.2% and 2.8%, respectively. CONCLUSIONS: In this trial, there was no evidence that screening for AF using a 14-day continuous electrocardiographic monitor in people ≥70 years of age seen in primary care practice reduces stroke hospitalizations. Event rates were low, however, and the trial did not enroll the planned sample size.(Reducing Stroke by Screening for Undiagnosed Atrial Fibrillation in Elderly Individuals [GUARD-AF]; NCT04126486).

Exploring the use of electroconvulsive therapy in the anticoagulated population: A systematic review.

BACKGROUND: Electroconvulsive therapy is an effective treatment for several psychiatric conditions. There are theoretical risks associated with electroconvulsive therapy in patients who are anticoagulated. However, there is no review investigating these adverse effects. AIM: This systematic review explored the literature on using electroconvulsive therapy in anticoagulated patients, including adverse effects associated with continuation or cessation of anticoagulation during electroconvulsive therapy. METHODS: The study was registered on PROSPERO (registration CRD42023432178). A search was conducted across CENTRAL, Embase, Medline and PsychINFO databases, with title and abstract screening, full-text review and data extraction by two independent reviewers. Patients planned for electroconvulsive therapy and on anticoagulation prior to electroconvulsive therapy were included. Papers not related to electroconvulsive therapy or anticoagulation were excluded. Data were recorded in Microsoft Excel, presented in tables. RESULTS: The studies comprised 108 patients and over 700 sessions of electroconvulsive therapy. 64.81% patients were on warfarin, 22.22% on a direct-acting oral anticoagulant, 5.55% on heparin and the rest on enoxaparin, dalteparin, acenocoumarol or bemiparin. There were two reports of both nonfatal non-central nervous system bleeding and pulmonary embolism in patients with anticoagulation. There were no intracranial haemorrhages or deaths. Bridging or substitution with an anticoagulant with a shorter half-life had no additional benefit. CONCLUSION: This review showed tolerability of anticoagulants continued throughout electroconvulsive therapy, with most patients reporting no adverse effects. Given limitations including few studies and medical comorbidities influencing patient risk profile, further studies are required to guide practice recommendations and review long-term outcomes.

Actioning atrial fibrillation identified by ambulance services in England: a qualitative exploration.

OBJECTIVES: To explore the acceptability and feasibility of detection of atrial fibrillation (AF) by emergency medical services (EMS) and identify potential barriers and facilitators to implementing a formal pathway to facilitate follow-up in primary care, which could reduce the risk of AF-related stroke. DESIGN: Qualitative study using focus groups and one-to-one interviews guided by a semistructured topic guide. SETTING: North East England. PARTICIPANTS: Focus groups with 18 members of the public and one-to-one online interviews with 11 healthcare and service providers (six paramedics and five experts representing cardiology, general practice (GP), public health, research, policy and commissioning). RESULTS: All participant groups were supportive of a role of EMS in identifying AF as part of routine assessment and formalising the response to AF detection. However, this should not create delays for EMS since rate-controlled AF is non-urgent and alternative community mechanisms exist to manage it. Public participants were concerned about communication of the AF diagnosis and whether this should be 'on scene' or in a subsequent GP appointment. Paramedics reported frequent incidental identification of AF, but it is not always clear 'on scene' that this is a new diagnosis, and there is variation in practice regarding whether (and how) this is communicated to the GP. Paramedics also focused on ensuring the safety of non-conveyed patients and a perceived need for an 'active' reporting process, so that a finding of AF was actioned. Field experts felt that a formal pathway would be useful and favoured a simple intervention without adding to time pressures unnecessarily. CONCLUSIONS: There is support for the development of a formal pathway to ensure follow-up for people with AF that is incidentally detected by EMS. This has the potential to improve anticoagulation rates and reduce the risk of stroke.

Automated regional citrate anticoagulation system based on individualized dosing models in nonliver failure patients undergoing PIRRT therapy.

INTRODUCTION: Regional citrate anticoagulation is a preferred option for renal replacement therapy in critically ill patients. However, current implementations ignore individual differences that may exist in the fluctuation of patients' ionized calcium levels. To address this problem, individualized citrate and calcium supplementation models were established based on the pharmacokinetic and clearance characteristics of citrate, and an automated regional citrate anticoagulation system was built with these models as its core to facilitate the treatment of clinical patients. This study was designed to preliminarily evaluate the safety and efficacy of this system, the SuperbMed® RCA-SP100 automated regional citrate anticoagulation system, in prolonged intermittent renal replacement therapy. METHODS: Seven patients undergoing prolonged intermittent renal replacement therapy completed treatment with the SuperbMed® RCA-SP100 system. In vivo and in vitro ionized calcium levels were measured every hour before and after the start of dialysis. The accuracy and alarm sensitivity of the pumps were also monitored. RESULTS: During seven treatments, the average extracorporeal ionized calcium level was 0.34 ± 0.02 mmol/L, and the mean ionized calcium level in vivo was 1.09 ± 0.07 mmol/L. No patient required intervention, and there was no filter coagulation. The pumps all had an absolute accuracy less than 5%, and alarms could be triggered precisely. CONCLUSIONS: We reported on an automated system that allows for individualized citrate and calcium supplementation in prolonged intermittent renal replacement therapy and enables the precise and secure implementation of regional citrate anticoagulation.

Application Value and Safety Analysis of Warfarin, Rivaroxaban, and Dabigatran Ester in Elderly Patients With Atrial Fibrillation.

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

Catheter and Non-Catheter-Related Venous Thromboembolism in Cancer Patients: Survival, Anticoagulation Efficacy, and Safety.

PURPOSE: To investigate the differences in survival after venous thromboembolism (VTE) and anticoagulation efficacy and safety between catheter (CRVTE) and non-catheter-related VTE (NCRVTE) in cancer patients. METHODS: A retrospective research was conducted, and consecutive cancer (digestive, respiratory, genitourinary, blood and lymphatic, and the other cancers) patients with VTE were enrolled. The anticoagulation therapies included low-molecular-weight heparin (LMWH), warfarin, new type of direct oral anticoagulants (NDOACs), LMWH combined with warfarin, and LMWH combined with NDOACs. Data were collected from the electronic medical record database of our hospital and were analyzed accordingly by Kruskal-Wallis H Test, Chi-square test, Fisher's exact test, Logistic regressions, Kaplan-Meier analysis, and Cox regressions. RESULTS: 263 patients were included, median age in years (interquartile range) was 64(56-71) and 60.5% were male. VTE recurrence rate was 16.7% in CRVTE group which was significantly lower than 34.8% in NCRVTE group (P = .032). Heart diseases were independently associated with VTE recurrence (P = .025). Kaplan-Meier survival estimates at 1, 2, and 3 years for CRVTE group were 62.5%, 60.0%, and 47.5%, respectively, compared with 47.9% (P = .130), 38.7% (P = .028), and 30.1% (P = .046), respectively, for NCRVTE group. Cox regression showed surgery (P = .003), anticoagulation therapy types (P = .009), VTE types (P = .006) and cancer types (P = .039) were independent prognostic factors for 3-year survival after VTE. Nonmajor and major bleeding were not significantly different (P = .417). Anticoagulation therapy types were independently associated with the bleeding events (P = .030). CONCLUSIONS: Cancer patients with CRVTE potentially have a better anticoagulation efficacy and survival compared to NCRVTE, and the anticoagulation safety seems no significant difference.

Exploring stakeholder perceptions of implementing a pharmacist-led anticoagulation clinic in primary care settings: a cross-sectional study.

Background: Anticoagulation therapy is crucial for managing various cardiovascular and thrombotic conditions; however, optimal delivery remains challenging in primary care. Pharmacist-led anticoagulation services have emerged as a potential strategy for enhancing patient care and outcomes in such settings. Understanding the perspectives of key stakeholders is critical for successful implementation. Objectives: This study aimed to explore the perceptions of key stakeholders involved in the implementation of pharmacist-led anticoagulation clinics in primary care settings. Methods: A cross-sectional study was conducted using structured, pilot-tested questionnaires between August and October 2023. Patients receiving warfarin, pharmacists, and physicians working across various primary healthcare centres were invited to complete an online survey. Each group of stakeholders had individualised questionnaires to assess their perceptions and expectations with regard to developing pharmacist-led anticoagulation clinics in primary care. Descriptive statistics were used to analyze the data. Results: The response rates for the survey were 29.4% for physicians, 10.4% for patients, and 48.6% for pharmacists. Participants expressed positive perceptions toward pharmacist-led anticoagulation clinics, acknowledging benefits such as improved access to care, enhanced medication management, and increased patient education. The respondents expressed confidence in the expertise and skills of pharmacists in this role. However, healthcare providers strongly agree that pharmacists should receive additional training specific to anticoagulation management. Establishing standardised protocols and fostering interprofessional collaboration were identified as the main facilitators for practical implementation. Conclusions: Broad support exists for pharmacist-led anticoagulation clinics in primary care, though additional pharmacist training and accountability concerns need to be addressed for successful implementation.

Bridging With Low-Molecular-Weight Heparin Versus Antiplatelet Therapy in Patients Undergoing Noncardiac Surgery After Percutaneous Coronary Intervention: A Comprehensive Review.

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

A Tool Integrated into the Electronic Health Record to Guide Proper Decision-Making Regarding Peri-Endoscopic Anticoagulant Management: A Retrospective Cohort Study.

Background-Anticoagulants, such as vitamin-K antagonists (VKA) and direct oral anticoagulants (DOAC), are widely used among patients who undergo endoscopic procedures. To balance between bleeding and thromboembolic risks, careful decisions must be made about whether and for how long anticoagulants have to be stopped peri-endoscopically and if bridging is necessary. We created a tool in the electronic health records system (EHR) HIX (Microsoft) for invasive procedures to aid this decision-making. By selecting the anticoagulant indication or thrombo-embolic risk and the bleeding risk of the procedure, the tool automatically generates advice for periprocedural anticoagulant management. Objectives-This study assesses whether the tool is used properly peri-endoscopically. Secondly, it examines how many bleeding and thromboembolic events have occurred since the implementation of the tool. Methods-This retrospective study included all orders placed for endoscopies for patients using VKA or DOAC between 2018 and 2021. Results-In total, 986 endoscopies were included for analysis. In 89%, the tool was used correctly; the main error was selecting the wrong bleeding risk (7.5%). The cumulative incidence for moderate or severe bleeding events for DOAC and VKA was 2 (0.5%) and 0, respectively. The cumulative incidence of thromboembolic events for DOAC and VKA was 1 (0.2%) for each. Conclusions-This study evaluates the use of an EHR-integrated decision-making tool to aid peri-endoscopic anticoagulant management. By analysing the usage of the tool, we formulated several suggestions to improve the tool. Although this study is not a comparative one, we can conclude that the thromboembolic and major bleeding risks were low.

Left Atrial Appendage Thrombus as a Marker of Disease Severity in 500 Patients with Atrial Fibrillation on Oral Anticoagulation: A 13-Year Follow-Up Study.

Background/Objective: Whether left atrial appendage thrombus (LAAT) in patients with atrial fibrillation (AF) on chronic anticoagulation significantly increases cardiovascular risk is unknown. This study aimed to assess LAAT prevalence and its predictive role in cardiovascular events among consecutive anticoagulated patients with AF admitted for electrical cardioversion. Methods: This prospective study included 500 patients. The primary outcome was LAAT on transesophageal echocardiography. Patients were followed up for a median of 1927.5 (interquartile range 1004-2643) days to assess cardiovascular events. Results: LAAT was detected in 65 (13%) patients. No significant differences in stroke, transient ischemic attack, systemic thromboembolic events, or myocardial infarction prevalence were observed between patients with AF with and without LAAT. Hospitalization for heart failure (HF) was more frequent in patients with LAAT than in those without LAAT; however, the effect of LAAT on HF hospitalization was not statistically significant. Patients with LAAT had a significantly higher risk of cardiovascular death than those without LAAT. LAAT and greater left atrial (LA) diameter were associated with higher rates of cardiovascular death. The independent HF hospitalization predictors were greater LA diameter, lower left ventricular ejection fraction (LVEF), and estimated glomerular filtration rate (eGFR). Conclusions: Patients with AF who received anticoagulation therapy showed a high prevalence of LAAT. LAAT and greater LA diameter were associated with significantly higher rates of cardiovascular death. LAAT, greater LA diameter, lower LVEF, and lower eGFR were associated with poor prognosis in anticoagulated patients with AF and were predictors of disease severity.

Health-Related Quality of Life and Satisfaction in Atrial Fibrillation Patients on Anticoagulant Therapy: Differences between Vitamin K Antagonists and Direct Oral Anticoagulants; Results from the Multicentre REGUEIFA Registry.

Background: Oral anticoagulation (OAC) is pivotal in the clinical management of atrial fibrillation (AF) patients. Vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) prevent thromboembolic events, but information about the quality of life (QoL) and patient satisfaction in relation with the anticoagulant treatment is limited. Methods: REGUEIFA is a prospective, observational, and multicentre study that included patients with AF treated by cardiologists. We included patients treated with VKAs or DOACs. The EuroQol-5D (EQ-5D) questionnaire evaluated QoL, and the Anti-Clot Treatment Scale (ACTS) questionnaire investigated patient satisfaction with OAC. Results: A total of 904 patients were included (532 on VKA and 372 on DOACs). A total of 846 patients completed the EQ-5D questionnaire, with results significantly worse in patients on VKAs than on DOACs: more mobility limitations (37.6% vs. 24.2%, p < 0.001), more restriction in usual activities (24.7% vs. 18.3%, p = 0.026), more pain/discomfort (31.8% vs. 24.2%, p = 0.015), a lower visual analogue scale (VAS) score (66.4 ± 16.21 vs. 70.8 ± 15.6), and a lower EQ-D5 index (0.79 ± 0.21 vs. 0.85 ± 0.2, p < 0.001). After adjusting for baseline characteristics, VKA treatment was not an independent factor towards worse EQ-5D results. Also, 738 patients completed the ACTS questionnaire, and burden and profit scores were lower in patients on VKAs than for DOACs (52.1 ± 8.4 vs. 55.5 ± 6.8, p < 0.001 and 11.1 ± 2.4 vs. 11.8 ± 2.6, p < 0.001, respectively). The negative impact score was higher for VKAs than for DOACs (1.8 ± 1.02 vs. 1.6 ± 0.99, p < 0.001), with a general positive impact score lower for VKAs than for DOACs (3.6 ± 0.96 vs. 3.8 ± 1.02, p < 0.001). Conclusions: Patients on VKA have more comorbidity and worse EQ-5D and VAS scores than those on DOACs. VKA has a greater burden and higher negative impact on the patient's life than DOACs.

Classification and Management of Portal Vein Thrombosis in Cirrhotic Patients: A Narrative Review.

Portal vein thrombosis (PVT) poses significant therapeutic challenges due to its complex pathophysiology and diverse clinical presentations. Recent advancements have spurred the development of new therapeutic approaches to enhance treatment efficacy and safety. This review synthesized emerging therapies for PVT based on a comprehensive literature search across major databases such as PubMed, EMBASE, and Web of Science, among others, focusing on studies published in the last decade. Anticoagulation therapy, particularly with novel oral anticoagulants (NOACs), emerged as beneficial in personalized treatment regimens. Innovative surgical techniques and improved risk stratification methods were identified as crucial in the perioperative management of PVT. Additionally, advances in cell therapy and medical treatments for hepatocellular carcinoma in the context of PVT were explored. Promising outcomes were observed with modalities such as Yttrium 90 and liver transplantation combined with thrombectomy, particularly in complex PVT cases associated with hepatocellular carcinoma, albeit on a limited scale. The reviewed literature indicates a shift towards individualized treatment approaches for PVT, integrating novel anticoagulants, refined risk assessment tools, and tailored interventional strategies. While these emerging therapies show potential for enhanced efficacy and safety, further research is essential to validate findings across broader patient populations and establish standardized treatment protocols.

Vascular Consequences: A Case Report on Posterior Circulation Infarction as a Sequela of COVID-19.

This case report presents a posterior circulation infarction in a previously healthy 39-year-old male, three months post-severe COVID-19. He presented with right-sided homonymous hemianopia and elevated inflammatory markers and D-dimer levels. Imaging revealed an acute left occipital infarct. Such post-COVID-19 posterior circulation strokes are rare. This report discusses the pathophysiology, optimal anticoagulation therapy for COVID-19-related thrombotic complications, and early predictor models. This case underscores the need to recognize thromboembolic events as potential late sequelae in severe COVID-19 cases.

Management of perioperative anticoagulation in patients with mechanical heart valve replacement undergoing laparoscopic cholecystectomy: a case report of postoperative cerebral embolism.

Patients with mechanical heart valve replacement require lifelong anticoagulation therapy, and additional surgeries can pose a risk of bleeding and thromboembolic events due to the need for perioperative anticoagulation management. Here, we present a case report of a patient who underwent laparoscopic cholecystectomy (LC) and endoscopic retrograde cholangiopancreatography (ERCP) after mechanical heart valve replacement and experienced postoperative cerebral embolism. The management of perioperative anticoagulation in these patients is discussed, including strategies for minimizing the risks of bleeding and thromboembolic events during and after surgery.

Effects of atrial fibrillation screening according to thyroid function: Post-hoc analysis of the randomized LOOP study.

PURPOSE: Subclinical thyroid dysfunction is a marker for atrial fibrillation (AF) and stroke risk. This study explored the effects of AF screening according to thyroid-stimulating hormone (TSH) levels. METHODS: An AF screening trial (the LOOP study) was analyzed post-hoc according to baseline TSH. The primary outcome was stroke or systemic embolism (SE). Secondary outcomes included major bleeding, all-cause death, and the combination of stroke, SE, and cardiovascular death. RESULTS: TSH measurement was available in 6003 of 6004 trial participants, 1500 randomized to implantable loop recorder (ILR) screening for AF and anticoagulation upon detection vs. 4503 to usual care; mean age was 74.7±4.1 years and 2836 (47%) were women. AF detection was approximately triple for ILR vs usual care across TSH tertiles (adjusted p-interaction=0.44). In the first tertile, screening was associated with decreased risk of the primary outcome (hazard ratio 0.52 [0.30-0.90]; p=0.02) and stroke, SE, or cardiovascular death (hazard ratio 0.54 [0.34-0.84]; p=0.006) compared to usual care, while no effect was observed among participants with higher TSH (adjusted p-interaction 0.03 and 0.01, respectively). There was no effect on other outcomes. Analyses of continuous TSH or excluding those with abnormal TSH or thyroid medication showed similar results. CONCLUSION: AF screening and subsequent treatment was associated with decreased stroke risk among participants with low TSH, though the yield of screening was similar across TSH levels. TSH may be useful as a marker to indicate benefit from AF screening vs. overdiagnosis and overtreatment. These findings should be considered exploratory and warrant further study. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT0203645.

Elderly Patients with Venous Thromboembolism: Insights from the RIETE Registry.

Venous thromboembolism (VTE) presents a notable healthcare burden, particularly among the elderly, who experience increased risks and more severe complications. This review aims to use the extensive data from the RIETE registry, a comprehensive database on consecutive patients with VTE. We examine the clinical features, therapeutic approaches, and patient outcomes of VTE in elderly patients, compared to younger patients, offering a comprehensive understanding of management challenges and emphasizing the need for strategies that accommodate the unique challenges of this population.