The 2023 Belgian clinical guidance on anticoagulation management in hospitalized and ambulatory COVID-19 patients.

COVID-19 is associated with an increased risk for thrombotic complications. The trials investigating the optimal thromboprophylactic dose are performed in challenging times and seemingly produce conflicting evidence. The burdensome circumstances, divergent endpoints, and different analytical approaches hamper comparison and extrapolation of available evidence. Most importantly, clinicians should provide thromboprophylaxis in hospitalized COVID-19 patients while (re)assessing bleeding and thrombotic risk frequently. The COVID-19 Thromboprophylaxis Working Group of the BSTH updated its guidance document. It aims to summarize the available evidence critically and to guide clinicians in providing the best possible thromboprophylaxis.

Belgian clinical guidance on anticoagulation management in hospitalised and ambulatory patients with COVID-19.

OBJECTIVES: COVID-19 predisposes patients to thrombotic disease. The aim of this guidance document is to provide Belgian health-care workers with recommendations on anticoagulation management in COVID-19 positive patients. METHODS: These recommendations were based on current knowledge and a limited level of evidence. RESULTS: We formulated recommendations for the prophylaxis and treatment of COVID-related venous thromboembolism in ambulatory and hospitalised patients, as well as recommendations for the use of antithrombotic drugs in patients with prior indication for anticoagulation who develop COVID-19. CONCLUSIONS: These recommendations represent an easy-to-use practical guidance that can be implemented in every Belgian hospital and be used by primary care physicians and gynaecologists. Of note, they are likely to evolve with increased knowledge of the disease and availability of data from ongoing clinical trials.

Delayed Thrombotic Complications in a Thrombotic Thrombocytopenic Purpura Patient Treated With Caplacizumab.

Thrombotic thrombocytopenic purpura (TTP) is a rare and unpredictable disease with a high mortality rate (90%) if untreated. It results from systemic microvascular thrombosis and leads to profound thrombocytopenia, hemolytic anemia and organ failure of varying severity. However, macrovascular thrombosis has been described in very rare cases. Caplacizumab has emerged as a promising new drug for the management of TTP. We report the case of a patient with idiopathic refractory TTP treated with caplacizumab who developed thrombotic complications upon discontinuation of treatment.

Higher Intensity Thromboprophylaxis Regimens and Pulmonary Embolism in Critically Ill Coronavirus Disease 2019 Patients.

OBJECTIVES: To assess the role of thromboprophylaxis regimens on the occurrence of pulmonary embolism in coronavirus disease 2019 patients. DESIGN: Retrospective analysis of prospectively collected data on coronavirus disease 2019 patients, included between March 10, and April 30, 2020. SETTING: ICU of an University Hospital in Belgium. PATIENTS AND INTERVENTIONS: Critically ill adult mechanically ventilated coronavirus disease 2019 patients were eligible if they underwent a CT pulmonary angiography, as part of the routine management in case of persistent hypoxemia or respiratory deterioration. The primary endpoint of this study was the occurrence of pulmonary embolism according to the use of standard thromboprophylaxis (i.e. subcutaneous enoxaparin 4,000 international units once daily) or high regimen thromboprophylaxis (i.e. subcutaneous enoxaparin 4,000 international units bid or therapeutic unfractioned heparin). MEASUREMENTS AND MAIN RESULTS: Of 49 mechanically ventilated coronavirus disease 2019, 40 underwent CT pulmonary angiography after a median of 7 days (4-8 d) since ICU admission and 12 days (9-16 d) days since the onset of symptoms. Thirteen patients (33%) were diagnosed of pulmonary embolism, which was bilateral in six patients and localized in the right lung in seven patients. D-dimers on the day of CT pulmonary angiography had a predictive accuracy of 0.90 (95% CIs: 0.78-1.00) for pulmonary embolism. The use of high-regimen thromboprophylaxis was associated with a lower occurrence of pulmonary embolism (2/18; 11%) than standard regimen (11/22, 50%-odds ratio 0.13 [0.02-0.69]; p = 0.02); this difference remained significant even after adjustment for confounders. Six patients with pulmonary embolism (46%) and 14 patients without pulmonary embolism (52%) died at ICU discharge (odds ratio 0.79 [0.24-3.26]; p = 0.99). CONCLUSIONS: In this study, one third of coronavirus disease 2019 mechanically ventilated patients have a pulmonary embolism visible on CT pulmonary angiography. High regimen thromboprophylaxis may decrease the occurrence of such complication.

New oral anti-coagulation drugs and prostate biopsy: a call for guidelines.

BACKGROUND: Prostate biopsy is a rather frequent procedure, mostly performed in outpatient settings. Bleeding complications following this procedure require precise and delicate management of pre-, peri- and post-procedure anti-coagulation treatments. New oral anti-coagulation drugs (NOACs) are increasingly used. However, the management of such treatments is feared and not yet well known to urologists. A protocol for prostate biopsy management of NOACs seems mandatory. MATERIALS AND METHODS: A review of the literature, using Pubmed and Cochrane databases, together with analysis of several medical associations' recommendations in urology, anaesthesiology, cardiology, oncology and drug safety agency, was performed. RESULTS: There are no recommendations about NOAC management for prostate biopsy available from scientific societies. There is also a lack of specific urological studies. However, several panels of expert recommendations could be helpful in establishing standardized protocols adapted from surgery to prostate biopsy. With the growing use of NOACs, recommendations have shifted to continue anti-coagulant treatment without bridging NOACs for low bleeding risk procedures such as prostate biopsy, in carefully selected groups of patients. CONCLUSION: Extensive indications coupled with the ease of use of NOACs contribute significantly to the widespread replacement of traditional vitamin K antagonist. Knowing that heparin bridging leads to more bleeding, and in the pursuit of more autonomy and safety, urologists should be able to propose dedicated anti-coagulant management using NOACs adapted to carefully selected patients before the prostate biopsy procedure. Further studies and guidelines specific to the concept of non-bridging for anti-coagulant-requiring patients are mandatory for this routine procedure.

Management of antiplatelet therapy in patients undergoing elective invasive procedures. Proposals from the French Working Group on perioperative haemostasis (GIHP) and the French Study Group on thrombosis and haemostasis (GFHT). In collaboration with the French Society for Anaesthesia and Intensive Care Medicine (SFAR).

The French Working Group on Perioperative Haemostasis (GIHP) and the French Study Group on Haemostasis and Thrombosis (GFHT) in collaboration with the French Society for Anaesthesia and Intensive Care Medicine (SFAR) drafted up-to-date proposals for the management of antiplatelet therapy in patients undergoing elective invasive procedures. The proposals were discussed and validated by a vote; all proposals but one could be assigned with a high strength. The management of antiplatelet therapy is based on their indication and the procedure. The risk of bleeding related to the procedure can be divided into high, moderate and low categories depending on the possibility of performing the procedure in patients receiving antiplatelet agents (none, monotherapy and dual antiplatelet therapy respectively). If discontinuation of antiplatelet therapy is indicated before the procedure, a last intake of aspirin, clopidogrel, ticagrelor and prasugrel 3, 5, 5 and 7 days before surgery respectively is proposed. The thrombotic risk associated with discontinuation should be assessed according to each specific indication of antiplatelet therapy and is higher for patients receiving dual therapy for coronary artery disease (with further refinements based on a few well-accepted items) than for those receiving monotherapy for cardiovascular prevention, for secondary stroke prevention or for lower extremity arterial disease. These proposals also address the issue of the potential role of platelet functional tests and consider management of antiplatelet therapy for regional anaesthesia, including central neuraxial anaesthesia and peripheral nerve blocks, and for coronary artery surgery.

Predictors of costs from the hospital perspective of primary pulmonary embolism.

The objective of this study was to estimate the total hospital cost per patient admitted through the emergency department with a primary diagnosis of pulmonary embolism (PE), and to identify the main components and predictors of costs.Actual costs of care of 652 consecutive patients hospitalised in 10 general hospitals in Belgium, including 31 outlier patients in terms of length of stay (4.8%), were obtained by aggregating all cost components contributing to care of each patient.In both inlier and outlier patients, the mean total cost per patient increased linearly with the degree of severity of illness classes related to the All Patient Refined Diagnosis Related Group (p<0.0001). Medical procedures, nursing activities and hospitalisation accommodation were the main cost components. We identified six independent predictors of costs in inliers: age group, chronic pulmonary heart disease, heart failure, admission to intensive care unit, initial thrombolysis treatment and type of hospital. There was a statistically significant linear trend between age groups and costs (p<0.0001).An increasing burden of comorbid illness was strongly associated with increasing actual cost for caring hospitalised patients for PE. Increasing age was associated with an increase in all main cost components.

Improved venous thromboembolism prophylaxis by pharmacist-driven interventions in acutely ill medical patients in Belgium.

BACKGROUND: Forty to 50 % of hospitalized patients with an acute medical illness have risk factors for venous thromboembolism (VTE) and it has been shown that VTE prophylaxis reduced the incidence of VTE events in these patients. However, a large multinational survey, the ENDORSE study, showed that only 37 % of medical patients with VTE risk factors actually received VTE prophylaxis. OBJECTIVE: To evaluate the impact over time of pharmacist-driven interventions aiming at increasing the appropriate use of VTE prophylaxis in acutely ill medical hospitalized patients. SETTING: A Belgian urban academic hospital. METHOD: First, during 1 month, medical and nurse reports of all hospitalized medical patients were reviewed to evaluate the proportion of patients who were on prophylaxis according to clinical practice guidelines. Second, interventions were conducted and included unit-specific physician and nurse education, diffusion of educational tools summarizing VTE prophylaxis guidelines, and reminders. Third, the impact of the interventions on the proportion of patients receiving VTE prophylaxis according to clinical practice guidelines was evaluated after 3 months and 1 year. MAIN OUTCOME MEASURE: Proportion of hospitalized medical patients receiving VTE prophylaxis according to clinical practice guidelines. RESULTS: The baseline evaluation showed that 36 % (26/72) of the patients at risk of VTE received VTE prophylaxis according to clinical practice guidelines. Three months and one year after the interventions, 68 % (55/81), and 72 % (58/81) of the patients at risk of VTE received VTE prophylaxis according to clinical practice guidelines. Among patients not at risk of VTE, 15 % (21/141), 8 % (24/290), and 8 % (27/330) respectively at baseline evaluation, 3 months and 1 year after the interventions, received VTE prophylaxis. CONCLUSION: Pharmacist-driven interventions improved the proportion of acutely ill medical patients receiving VTE prophylaxis according to clinical practice guidelines and the benefit of the interventions was maintained after 1 year.

Evaluation of the cost of atrial fibrillation during emergency hospitalization.

OBJECTIVE: The number of hospitalizations for atrial fibrillation has increased dramatically. This increase, in the number of hospital stays will continue, given the growth projections based on epidemiological data, and will contribute to significantly increase expenses for the social security system.The objective of this study was to evaluate the length of hospital stay, the average cost borne by social security, and the types of hospital stay expenditures for patients admitted through the emergency department for atrial fibrillation. METHODS: Patients were identified by using the minimal clinical summaries of seven general hospitals in Belgium in 2008. Only hospitalized patients having as primary diagnosis code ICD-9-CM 42731 'atrial fibrillation'were selected for this study. Hospital billing files were analysed in order to isolate the costs borne by social security. Outliers were isolated in order not to have results influenced by patients having an atypical length of stay. RESULTS: Results show that the mean length of stay was 8.6 days and the mean cost charged to social security was euro 3,066.02 per hospital stay.The mean cost of care was strongly associated with the degree of severity index related to the APR-DRG. Approximately 85% of the total cost was related to the cost of hospital days and medical procedures with medical imaging and laboratory tests being the two main cost inductors. 18% of patients had cardioversion during their hospital stay, including 4% who had only that treatment. 19% of patients used amiodarone. Flecainide and propafenone were also used, but less frequently. CONCLUSIONS: The mean cost of care for AF patients admitted via the emergency department is strongly associated with the degree of severity. Approximately 85% of the total cost is related to the cost of hospital days and medical procedures. Hypertension is the most common secondary diagnosis. An optimal treatment of this risk factor could help to reduce the risk of atrial fibrillation, and thereby reduce the morbidity and costs associated with this disease.

Comparison of the Wells score with the simplified revised Geneva score for assessing pretest probability of pulmonary embolism.

INTRODUCTION: The Wells score is widely used in the assessment of pretest probability of pulmonary embolism (PE). The revised Geneva score is a fully standardized clinical decision rule that was recently validated and further simplified. We compared the predictive accuracy of these two scores. METHODS: Data from 339 patients clinically suspected of PE from two prospective management studies were used and combined. Pretest probability of PE was assessed prospectively by the Wells score. The simplified revised (SR) Geneva score was calculated retrospectively. The predictive accuracy of both scores was compared by area under the curve (AUC) of receiver operating characteristic (ROC) curves. RESULTS: The overall prevalence of PE was 19%. Prevalence of PE in the low, moderate and high pretest probability groups assessed by the Wells score and by the simplified revised Geneva score was respectively 2%(95% CI (CI) 1-6) and 4% (CI 2-10), 28% (CI 22-35) and 25% (CI 20-32), 93% (CI 70-99) and 56% (CI 27-81). The Wells score performed better than the simplified revised Geneva score in patients with a high suspicion of PE (p<0.05). The AUC for the Wells score and the simplified revised Geneva score was 0.85 (CI: 0.81 to 0.89) and 0.76 (CI: 0.71 to 0.80) respectively. The difference between the AUCs was statistically significant (p=0.005). CONCLUSIONS: In our population the Wells score appeared to be more accurate than the simplified revised Geneva score. The impact of this finding in terms of patient outcomes should be investigated in a prospective study.

Assessment of pretest probability of pulmonary embolism in the emergency department by physicians in training using the Wells model.

INTRODUCTION: Assessment of pretest probability should be the initial step in investigation of patients with suspected pulmonary embolism (PE). In teaching hospitals physicians in training are often the first physicians to evaluate patients. OBJECTIVE: To evaluate the accuracy of pretest probability assessment of PE by physicians in training using the Wells clinical model and to assess the safety of a diagnostic strategy including pretest probability assessment. PATIENTS AND METHODS: 291 consecutive outpatients with clinical suspicion of PE were categorized as having a low, moderate or high pretest probability of PE by physicians in training who could take supervising physicians' advice when they deemed necessary. Then, patients were managed according to a sequential diagnostic algorithm including D-dimer testing, lung scan, leg compression ultrasonography and helical computed tomography. Patients in whom PE was deemed absent were followed up for 3 months. RESULTS: 34 patients (18%) had PE. Prevalence of PE in the low, moderate and high pretest probability groups categorized by physicians in training alone was 3% (95% confidence interval (CI): 1% to 9%), 31% (95% CI: 22% to 42%) and 100% (95% CI: 61% to 100%) respectively. One of the 152 untreated patients (0.7%, 95% CI: 0.1% to 3.6%) developed a thromboembolic event during the 3-month follow-up period. CONCLUSION: Physicians in training can use the Wells clinical model to determine pretest probability of PE. A diagnostic strategy including the use of this model by physicians in training with access to supervising physicians' advice appears to be safe.

Management of venous thromboembolism.

PURPOSE: To describe the drugs used to treat venous thromboembolism (VTE) and to review particular aspects of the management (elastic stockings, thrombolysis, thrombectomy, vena cava filter). SOURCE: Our review of the literature is focused on consensus documents and recent large randomized trials. PRINCIPAL FINDINGS: Subcutaneous low molecular weight heparins (LMWH) have been shown to be both safe and effective for the initial treatment of VTE and have largely replaced unfractionated heparin, unless there is a contraindication to LMWH such as severe renal insufficiency. Low molecular weight heparins or unfractionated heparin are usually administered for five to seven days. Treatment is gradually switched from heparin to oral vitamin K antagonists (VKA) which are usually started the same day as heparin. The duration of oral anticoagulation must be tailored to the individual patient according to the presence of reversible or continuing risk factors. In patients with active cancer, long-term treatment of VTE with LMWH has been shown to be more effective than oral anticoagulation and is recommended for the first three to six months of long-term anticoagulant therapy as an alternative approach to VKA. Elastic stockings are recommended because they have been shown to prevent postthrombotic syndrome. Thrombolysis is, usually, not justified for the treatment of deep venous thrombosis, but is used in cases of massive pulmonary embolism with arterial hypotension and/or shock. Vena cava filter placement is mainly indicated in patients with a proximal deep venous thrombosis and an absolute contraindication to anticoagulation. CONCLUSIONS: The initial management of patients with acute VTE has largely been simplified due to the use of LMWH. Early conversion to VKA is recommended for the great majority of patients. New agents, such as anti-Xa or oral thrombin inhibitors, are promising alternatives to heparins or VKA.

Prevention of postoperative venous thromboembolism. Risk assessment and methods of prophylaxis.

PURPOSE: To describe risk assessment models that have been developed to stratify patients into different risk levels of postoperative venous thromboembolism (VTE) and then to review the different methods of prophylaxis and to outline the evidence supporting their effectiveness and safety. SOURCE: Our review of the literature is focused on consensus documents, recent large randomized trials and meta-analyses. PRINCIPAL FINDINGS: The risk of VTE is determined by the type of surgery and underlying patient factors. Risk assessment models are useful in stratifying patients into different VTE risk levels. However, multiple risk factors are often present in the same patient and in practice the evaluation of their relative contribution to the overall risk remains difficult. A variety of prophylactic strategies including physical and pharmacological methods have been shown to be effective in different patient groups. Patients with a moderate or high risk of VTE should receive prophylaxis consisting of an antithrombotic agent, unless contraindicated, used alone or in combination with a mechanical method. Recommendations concerning which prophylaxis to use and how intensive it should be are based mainly on data from trials using surrogate endpoints, and do not translate easily into practical decisions aiming to reduce the incidence of symptomatic events. CONCLUSION: Although risk assessment models and recommendations provided by consensus documents are of practical assistance, a decision concerning any patient is best made by combining recommendations of the literature with clinical judgment, including individual patient risk factors for thrombosis and bleeding.

Lumbar paraspinal rhabdomyolysis and compartment syndrome after abdominal aortic aneurysm repair.

Lumbar paraspinal compartment syndrome is an extremely uncommon condition that is known to occur after strainful exercise or trauma. We report on the original case of a 55-year-old man in whom lumbar paraspinal rhabdomyolysis and compartment syndrome developed after open abdominal aortic aneurysm repair, documented with technetium Tc(99m) bone scan and computed tomographic imaging, and in whom successful complete recovery was achieved with conservative management. Clinical features, pathophysiology, and diagnostic and therapeutic strategies of this unusual adverse event are discussed.