Deferring diagnostic evaluation of suspected deep vein thrombosis using direct oral anticoagulant or low-molecular-weight heparin as a single dose anticoagulant: A prospective real-world study in a regionwide care pathway.

BACKGROUND: Patients with suspected deep vein thrombosis (DVT) are typically referred to the emergency department for immediate evaluation. To enhance efficiency, our hospital implemented a regional, general practitioner (GP)-driven DVT care pathway, deferring diagnostic evaluation to a scheduled outpatient DVT clinic appointment the following day. Patients receive a single dose anticoagulant from their GP to prevent thrombosis progression while awaiting diagnostic workup. This prospective study aimed to evaluate the safety and patient preferences regarding the DVT care pathway and the type of single dose anticoagulant (low-molecular-weight heparin (LMWH) vs. direct oral anticoagulant (DOAC)). METHODS: Patients enrolled in the DVT care pathway between June 2021 and July 2023 were eligible. Until July 2022, LMWH was administered, and thereafter, the protocol recommended DOAC as the single dose anticoagulant. Patients completed questionnaires, incorporating patient-reported outcome and experience measures (PROMs/PREMs), during their DVT clinic visit and after five days. The primary endpoint was bleeding events within 72 h of receiving the single dose anticoagulant. RESULTS: Of 460 included patients, 229 received LMWH and 231 received DOAC as the single dose anticoagulant. DVT was confirmed in 24.8 % of patients. No major or clinically relevant non-major bleeding were reported. LMWH was associated with more minor bleedings (22.3 % vs. DOAC 13.4 %), primarily attributed to injection site hematomas. Patients reported high satisfaction with the DVT care pathway (96.5 %) and generally preferred DOAC over LMWH. CONCLUSION: Deferring diagnostic evaluation for DVT using a single dose of either LMWH or DOAC in a real-world population is deemed safe. Considering practical advantages, patient preferences, and fewer skin hematomas, we favor DOACs as the single dose anticoagulant in this care pathway.

Deferring diagnostic evaluation for suspected deep venous thrombosis using a single dose of anticoagulant: Real-world data from a regionwide care pathway.

BACKGROUND: Patients with suspected deep venous thrombosis (DVT) are typically referred to the emergency department (ED) for immediate evaluation. However, this often contributes to ED overcrowding and necessitates round-the-clock sonographic examinations. Therefore, we implemented a regionwide care pathway for deferring diagnostic workup of suspected DVT until the following day. Patients receive a single anticoagulant dose from their general practitioner (GP) to prevent progression of DVT in the interval between referral and diagnostic evaluation. The next day, patients undergo comprehensive evaluation at our outpatient DVT clinic, including venous ultrasound. This retrospective study aims to provide real-world data on the safety of this care pathway regarding the occurrence of bleeding complications and pulmonary embolism (PE). METHODS: We included all GP-referred patients with suspected DVT in 2018 and 2019. Patients with absolute contraindications to deferred evaluation or anticoagulation were excluded. The primary endpoint was the occurrence of bleeding complications. Secondary endpoints included PE events and all-cause mortality within seven days following DVT evaluation. RESULTS: Among 1,024 included patients, DVT was confirmed in 238 patients (23.2%) and superficial thrombophlebitis in 98 patients (9.6%). No bleeding events were recorded in patients in whom DVT was ruled out. PE was confirmed in eight patients on the same day as DVT evaluation (0.8%, 95%CI 0.4-1.6) and in six patients within seven days following DVT evaluation (0.6%, 0.2-1.3%). No deaths occurred during this timeframe. CONCLUSION: This real-world study observed a very low incidence of bleeding complications and PE events, indicating that this care pathway of deferred DVT workup is safe and may offer a more streamlined diagnostic approach for patients with suspected DVT.

Preoperative hemoglobin level as a predictor of mortality after aortic valve replacement.

OBJECTIVES: The predictive value of preoperative hemoglobin (HB) level on the outcome of patients undergoing valve surgery is not well established. This study evaluated the predictive value of preoperative HB level on survival after aortic valve replacement (AVR). DESIGN: This was a retrospective analysis of prospectively collected data. SETTING: A single-center study performed in an educational hospital. PARTICIPANTS: All consecutive patients (n = 1,808) who underwent AVR between January 1998 and December 2010. INTERVENTIONS AVR MEASUREMENTS AND MAIN RESULTS: Patients were classified into 4 groups according to the preoperative HB level: very low (HB of <12 g/dL in men and <11 g/dL in women), low (HB of 12-13 g/dL in men and 11-12 g/dL in women), normal (HB of 13-14.5 g/dL in men and 12-13.5 g/dL in women), and high normal (HB of ≥14.5 g/dL in men and ≥13.5 g/dL in women). The mean follow-up duration was 5.58±3.5 years, and the median follow-up duration was 5.38 years. The mean preoperative HB was 14±1.6 g/dL for men and 13.0±2.1 g/dL for women. Early mortality (≤30 days) was 6.1% in the very-low-HB group, 5.4% in the low-HB group, 3.2% in the normal HB group, and 2.3% in the high-normal-HB group (p = 0.37). Late mortality (>30 days) was 26.1% in the very-low-HB group, 23.7% in the low-HB group, 17.1% in the normal-HB group, and 12.6% in the high-normal-HB group (p<0.0001). The multivariate logistic regression model did not identify low HB as an independent predictor for early mortality. Cox regression multivariate analysis revealed both HB level, as a continuous variable, (p = 0.006), and very-low-HB level (p<0.0001), as independent predictors of late mortality. Cox regression analyses, corrected for confounders, demonstrated that low-HB level is an independent predictor for higher overall mortality (hazard ratio = 2.00, CI 1.41-2.85, p≤0.0001). CONCLUSIONS: In patients undergoing AVR, preoperative low-HB level is an independent risk factor for late mortality, but not for early mortality.

Patency of the internal mammary arteries after removal of the Nuss bar: an initial report.

OBJECTIVES: Surgical correction of pectus excavatum (PE) has shifted to the modern minimally invasive Nuss procedure, which proved to be safe and effective. In order to restore the dented deformity, custom-curved metal bars provide continuous retrosternal pressure but cross the habitat of the internal mammary arteries (IMAs) directly affecting their patency. In this initial report, we sought to assess the patency of the IMAs in the first 6 patients who underwent Nuss bar removal in our department. METHODS: In 2010, we started to perform correction of PE using the Nuss bar technique. In 2013, observational analysis was performed on the first 6 patients who underwent removal of the Nuss bar. Computed tomography angiography (CTA) was performed in order to assess the patency of both IMAs directly after removal. RESULTS: In 4 (67%) patients, IMA patency was affected unilaterally (total obstruction or highly decreased flow pattern) corresponding with the lowest retrosternal side. CONCLUSIONS: According to our preliminary results, the oppressive force of Nuss bars interferes with IMA patency and thereby compromises future usability in coronary artery bypass grafting (CABG). We recommend that patients undergoing CABG following the Nuss procedure undergo preoperative evaluation of IMA patency. This study will be continued to include a larger number of patients including follow-up CTA one year after removal of the bar.