Electronic alerts for ambulatory patients with atrial fibrillation not prescribed anticoagulation: A randomized, controlled trial (AF-ALERT2).

BACKGROUND: Despite widely available risk stratification tools, safe and effective anticoagulants, and guideline recommendations, anticoagulation for stroke prevention in atrial fibrillation (AF) is under-prescribed in ambulatory patients. To assess the impact of alert-based computerized decision support (CDS) on anticoagulation prescription in ambulatory patients with AF and high-risk for stroke, we conducted this randomized controlled trial. METHODS: Patients with AF and CHA2DS2-VASc score ≥ 2 who were not prescribed anticoagulation and had a clinic visit at Brigham and Women's Hospital were enrolled. Patients were randomly allocated, according to Attending Physician of record, to intervention (alert-based CDS) versus control (no notification). The primary efficacy outcome was the frequency of anticoagulant prescription. RESULTS: The CDS tool assigned 395 and 403 patients to the alert and control groups, respectively. Alert patients were more likely to be prescribed anticoagulation within 48 h of the clinic visit (15.4 % vs. 7.7 %, p < 0.001) and at 90 days (17.2 % vs. 9.9 %, p < 0.01). Direct oral anticoagulants were the predominantly prescribed form of anticoagulation. No significant differences were observed in stroke, TIA, or systemic embolic events (0 % vs. 0.8 %, p = 0.09), symptomatic VTE (0.5 % vs. 1 %, p = 0.43), all-cause mortality (2 % vs. 0.7 %, p = 0.12), or major adverse cardiovascular events (2.8 % vs. 2.5 %, p = 0.79) at 90 days. CONCLUSIONS: An alert-based CDS strategy increased a primary efficacy outcome of anticoagulation in clinic patients with AF and high-risk for stroke who were not receiving anticoagulation at the time of the office visit. The study was likely underpowered to assess an impact on clinical outcomes. TRIAL REGISTRATION: ClinicalTrials.gov Identifier- NCT02958943.

Echocardiographic Abnormalities in Autosomal Dominant Polycystic Kidney Disease (ADPKD) Patients.

Cardiovascular abnormalities, such as left ventricular hypertrophy and valvular disorders, particularly mitral valve prolapse, have been described as highly prevalent among adult patients with autosomal dominant polycystic kidney disease (ADPKD). The present study aimed to assess echocardiographic parameters in a large sample of both normotensive and hypertensive ADPKD patients, regardless of kidney function level, and evaluate their association with clinical and laboratorial parameters. A retrospective study consisted of the analysis of clinical, laboratorial, and transthoracic echocardiograms data retrieved from the medical records of young adult ADPKD outpatients. A total of 294 patients (120 M/174 F, 41.0 ± 13.8 years old, 199 hypertensive and 95 normotensive) with a median estimated glomerular filtration rate (eGFR) of 75.5 mL/min/1.73 m2 were included. The hypertensive group (67.6%) was significantly older and exhibited significantly lower eGFR than the normotensive one. Increased left ventricular mass index (LVMI) was seen in 2.0%, mitral valve prolapse was observed in 3.4%, mitral valve regurgitation in 15.3%, tricuspid valve regurgitation in 16.0%, and aortic valve regurgitation in 4.8% of the whole sample. The present study suggested that the prevalence of mitral valve prolapse was much lower than previously reported, and increased LVMI was not seen in most adult ADPKD patients.

Extended-Duration Low-Intensity Apixaban to Prevent Recurrence in Patients with Provoked Venous Thromboembolism and Enduring Risk Factors: Rationale and Design of the HI-PRO Trial.

Patients with acute venous thromboembolism (VTE) in the setting of transient provoking factors are typically treated with short-term anticoagulation. However, the risk of recurrence may be increased in the presence of enduring risk factors. In such patients, the optimal duration of treatment remains uncertain. HI-PRO is a single-center, double-blind randomized trial. Patients with deep vein thrombosis (DVT) or pulmonary embolism (PE) following a major provoking factor, including major surgery or major trauma, who completed at least 3 months of standard-dose therapeutic anticoagulation and have at least one enduring risk factor (such as obesity or heart failure) will be considered for inclusion. Patients will be randomized to apixaban 2.5 mg twice daily or placebo for 12 months. The primary efficacy outcome will be symptomatic recurrent VTE-a composite of DVT and/or PE at 12 months after randomization. Secondary efficacy outcomes include a composite of death due to cardiovascular causes, nonfatal myocardial infarction, stroke or systemic embolism, major adverse limb events, or coronary or peripheral ischemia requiring revascularization at 12 months, and individual components of these outcomes. The primary safety outcome is major bleeding according to the International Society on Thrombosis and Haemostasis definition. The study plans to enroll 600 patients (300 per arm) to have 80% power for detecting a 75% relative risk reduction in the primary outcome. Active recruitment began in March 2021. HI-PRO will provide clinically meaningful data on whether patients with provoked VTE and enduring risk factors have fewer adverse clinical outcomes if prescribed low-intensity extended-duration anticoagulation.

Registry of Arterial and Venous Thromboembolic Complications in Patients With COVID-19.

BACKGROUND: Cardiovascular complications, including myocardial infarction, ischemic stroke, and pulmonary embolism, represent an important source of adverse outcomes in coronavirus disease-2019 (COVID-19). OBJECTIVES: To assess the frequency of arterial and venous thromboembolic disease, risk factors, prevention and management patterns, and outcomes in patients with COVID-19, the authors designed a multicenter, observational cohort study. METHODS: We analyzed a retrospective cohort of 1,114 patients with COVID-19 diagnosed through our Mass General Brigham integrated health network. The total cohort was analyzed by site of care: intensive care (n = 170); hospitalized nonintensive care (n = 229); and outpatient (n = 715). The primary study outcome was a composite of adjudicated major arterial or venous thromboembolism. RESULTS: Patients with COVID-19 were 22.3% Hispanic/Latinx and 44.2% non-White. Cardiovascular risk factors of hypertension (35.8%), hyperlipidemia (28.6%), and diabetes (18.0%) were common. Prophylactic anticoagulation was prescribed in 89.4% of patients with COVID-19 in the intensive care cohort and 84.7% of those in the hospitalized nonintensive care setting. Frequencies of major arterial or venous thromboembolism, major cardiovascular adverse events, and symptomatic venous thromboembolism were highest in the intensive care cohort (35.3%, 45.9%, and 27.0 %, respectively) followed by the hospitalized nonintensive care cohort (2.6%, 6.1%, and 2.2%, respectively) and the outpatient cohort (0% for all). CONCLUSIONS: Major arterial or venous thromboembolism, major adverse cardiovascular events, and symptomatic venous thromboembolism occurred with high frequency in patients with COVID-19, especially in the intensive care setting, despite a high utilization rate of thromboprophylaxis.

Acidente vascular cerebral da artéria de Perchehon em paciente com infarto agudo do miocárdio sem supradesnivelamento do segmento ST (IAMSEST) / Perchehon artery stroke in a patient with non-ST-segment acute myocardial infarction (IAMSEST)

INTRODUÇÃO: A artéria de Perchehon, quando ocluída, resulta em infarto talâmico paramediano bilateral. O mecanismo etiológico que leva ao comprometimento dessa artéria ainda é desconhecido, sendo atualmente, a cardioembolia considerada como um dos mecanismos etiológicos possíveis. RELATO DE CASO: Paciente do sexo feminino, 73 anos, obesa hipertensa, pré-diabética e dislipidêmica. Histórico de palpitações há um ano e diplopia/tonturas há uma semana. Admissão hospitalar com diagnóstico de infarto agudo do miocárdio sem supradesnivelamento do segmento ST (IAMSEST). No 2º. Dia, em uso de aspirina 100mg/d, clopidogrel 75mg/d e heparina em dose plena, enquanto aguardava cinecoronariografia apresentou quadro súbito de turvação visual, diplopia, sonolência evoluindo para coma (escala de coma Glasgow 9). Durante o procedimento de intubação orotraqueal, a paciente apresenta recuperação completa da consciência, mantendo ptose palpebral bilateral e monoparesia crural esquerda, com Glasgow 15. Ressonância revelou infarto paramediano bilateral. Após diagnostico iniciou a investigação etiológica do caso por meio de ultrassonografia com doppler de carótidas, antirressonância de artérias intracranianas, angiotomografia de artérias extracranianas, sendo considerados normais. Ecocardiograma: fração de ejeção do ventrículo esquerdo de 57%, átrio esquerdo com volume de 41 ml/M3 e hipocontratilidade do seguimento médio basal da parede inferior. Iniciado anticoagulante oral não antagonista da vitamina K (DOAC) devido à hipótese de acidente vascular cerebral (AVC) embólico sem fonte determinada (ESUS): regime de tripla terapia com DOAC+aspirina+clopidogrel. Cinecoronariografia não evidenciou lesões coronarianas. Ressonância cardíaca com realce inferior apical sugestivo de infarto do miocárdio com artérias coronárias não-obstrutivas (MINOCA). DISCUSSÃO: AVC da artéria de Perchehon pode apresentar recanalização espontânea precoce com sinais e sintomas de menor importância possibilitando confusão com transtornos somatoformes. Em pacientes com exame de imagem evidenciando lesão talâmica bilateral o mecanismo cardio-embólico sempre deve ser lembrado para conduta terapêutica específica. Consideração Final: Investigação etiológica completa é fundamental para definição do mecanismo e introdução de terapêutica apropriada assegurando benefícios clínicos para os pacientes. (AU)