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Introduction: Direct oral anticoagulants (DOACs) reflect anticoagulation agents given to treat or prevent thrombosis, having largely replaced vitamin K antagonists (VKAs) such as warfarin. DOACs are given in fixed daily doses and generally do not need monitoring. However, there may be a variety of reasons that justify measurement of plasma DOAC levels in individual patients. Methods: We report updated findings for DOAC testing in our geographic region, using recent data from the RCPAQAP, an international external quality assessment (EQA) program, currently with some 40–60 participants in each of the different DOAC (rivaroxaban, apixaban, dabigatran) modules, to assess laboratory performance in this area. Data has been assessed for the past 5 years (2019–2023 inclusive), with 20 samples each per DOAC. Results: Data shows a limited repertoire of assays in use, and mostly consistency in reported numerical values when assessing proficiency samples. Available assays mostly comprised reagents from four manufacturing suppliers. There was good consistency across what participants identified as 'DOAC detected', but some variability when participants attempted to grade DOAC levels as low vs moderate vs high. Inter‐laboratory/method coefficient of variation (CVs) were generally <15% for each DOAC, when present at >100 ng/mL. Conclusion: We hope our findings, reflecting on mostly consistent reporting of DOAC levels and interpretation provides reassurance for clinicians requesting these measurements, and helps support their implementation in regions where there is a paucity of test availability. [ABSTRACT FROM AUTHOR]

Aims: Use of novel anticoagulation in mechanical circulatory support is controversial. We report the rationale and design of the ApixiVad pilot trial, a pilot study testing the safety of apixaban as an anticoagulant in patients bridged to transplant (BTT) or for destination (DT) with Heartmate 3 (HM3) left ventricular assist device (LVAD). Methods and results: Apixaban has been used in small non‐randomized cohorts in LVAD patients and shown to be effective in ex vivo studies. The ApixiVAD study examines apixaban use in a multicentre, international, open‐label, randomized, controlled trial aiming to include 50 BTT or DT HM3 patients with a 1:1 randomization ratio. This event‐driven study has a maximum follow‐up period of 24 months with interim analysis at 6 months. The primary outcome is death, thromboembolic events and major bleeding, including operative bleeding and immediate transplant outcomes. The secondary outcome focuses on patients' quality of life related to anticoagulation. This investigator‐driven pilot study is not powered to determine the non‐inferiority of apixaban. An increase in primary outcome in the apixaban group of 20% will be considered a signal of harm. Conclusions: A positive outcome in the ApixiVAD study would provide the basis for future, larger, pivotal anticoagulation trials in LVAD patients. [ABSTRACT FROM AUTHOR]

Summary: Hip fracture is a common serious injury among older adults, yet the management of hip fractures for patients taking direct oral anticoagulants remains inconsistent worldwide. Drawing from a synthesis of available evidence and expert opinion, best practice approaches for managing patients with a hip fracture and who are taking direct oral anticoagulants pre‐operatively were considered by a working group of the Fragility Fracture Network Hip Fracture Audit Special Interest Group. The literature and related clinical guidelines were reviewed and a two‐round modified Delphi study was conducted with a panel of experts from 16 countries and involved seven clinical specialities. Four consensus statements were achieved: peripheral nerve blocks can reasonably be performed on presentation for patients with hip fracture who are receiving direct oral anticoagulants; hip fracture surgery can reasonably be performed for patients taking direct oral anticoagulants < 36 h from last dose; general anaesthesia could reasonably be administered for patients with hip fracture and who are taking direct oral anticoagulants < 36 h from last dose (assuming eGFR > 60 ml.min‐1.1.73 m‐2); and it is generally reasonable to consider recommencing direct oral anticoagulants (considering blood loss and haemoglobin) < 48 h after hip fracture surgery. No consensus was achieved regarding timing of spinal anaesthesia. The consensus statements were developed to aid clinicians in their decision‐making and to reduce practice variations in the management of patients with hip fracture and who are taking direct oral anticoagulants. Each statement will need to be considered specific to each individual patient's treatment. [ABSTRACT FROM AUTHOR]

Introduction Materials and Methods Results Conclusions The monitoring of unfractionated heparin (UFH) by anti‐factor Xa activity (AXA) is commonly used to ensure effective anticoagulation and prevent bleeding risk. However, in patients previously treated with an anti‐Xa direct oral anticoagulant (DOAC) switching to UFH therapy, there is a risk of interference that may lead to inappropriate anticoagulation. The first objective of this study was to validate DOAC‐Remove to remove DOAC for measuring UFH specific AXA. The second objective was to assess the length of DOAC interference on UFH monitoring and to identify potential predictive factors.This monocentric retrospective study included all patients admitted from April 2019 to April 2021 previously treated with anti‐Xa DOAC, and for whom an interference on UFH monitoring was suspected. Interference was defined as a difference in the AXA measured before and after using DOAC‐Remove >2.8‐fold standard deviation of the method.Removal with DOAC‐Remove was specific of DOAC (apixaban n = 42, rivaroxaban n = 41, UFH n = 20) and sufficient to avoid interference on UFH AXA measurement. The exact interference length was 6.0 days [IQR 3.0–11.0] for apixaban (n = 26) and 4.5 days [IQR 2.0–5.8] for rivaroxaban (n = 20). Among the 89 patients sorted based on an interference length ≤ or >3 days, 74 (83.1%) presented an interference greater than 3 days. Correlations were observed with age for apixaban and creatinine for rivaroxaban.Our results suggest that DOAC‐Remove could be of high interest in patients receiving UFH previously treated with an anti‐Xa DOAC even if DOAC was stopped for more than 3 days. [ABSTRACT FROM AUTHOR]

Introduction Methods Results Conclusions The activity of direct oral anticoagulants (DOAC) is important in acute clinical situations. Recent studies have suggested a strong influence of DOAC on the diluted Russel's Viper Venom Time (dRVVT). Therefore, it may be a suitable screening parameter for antithrombotic plasma activity of different DOAC. This prospective study aims to evaluate the sensitivity and specificity of dRVVT to detect residual DOAC activity at recommended plasma level thresholds.A total of 80 patients were recruited, with 20 each treated with one of the four approved DOAC (apixaban, edoxaban, rivaroxaban or dabigatran), respectively. Blood plasma was collected before (baseline), at plasma peak time, and 6 and 12 h after DOAC. DRVVT was measured using the screen (LA1) and confirm (LA2) assay for lupus anticoagulant and compared with DOAC plasma levels. A reference range was calculated based on the dRVVT values of 61 healthy blood donors.All DOAC significantly prolonged the dRVVT especially at higher DOAC plasma levels. The LA1 time ≥41 s had a sensitivity ≥98% to detect edoxaban, dabigatran and rivaroxaban plasma levels ≥30 ng/mL but it was only 87% for apixaban. Sensitivity was ≥98% for all DOAC with the LA2 assay ≥36 s. The negative predictive value of a DOAC plasma level <30 ng/mL and dRVVT LA2 <36 s was 99%.The dRVVT confirm assay (LA2) reliably detects residual DOAC plasma levels ≥30 ng/mL and could be useful to rapidly rule out relevant DOAC activity in emergency situations and to guide treatment decisions. [ABSTRACT FROM AUTHOR]

Background: The use of apixaban in the pediatric cardiac population is expanding. We describe our apixaban dosing and monitoring strategy in children and young adults awaiting heart transplantation, along with outcomes related to bleeding and thrombosis during wait‐list and early post‐transplant periods. Methods: This study is a retrospective, single‐center analysis of all patients receiving apixaban while awaiting cardiac transplantation. Weight‐based dosing was monitored with peak drug‐specific anti‐Xa chromogenic analysis. Significant post‐operative bleeding defined by chest tube output or need for surgical intervention. Results: From September 2020 to December 2022, 19 patients, median age 13.5 years (6.1, 15.8 years), weighing 48.9 kg (15.4, 67.6) received apixaban while awaiting transplant. Indication for apixaban was prophylaxis (n = 18, 3 with ventricular assist devices) and treatment of thrombus (n = 1). There were no clinically relevant non‐major or major bleeding, nor thrombotic events while awaiting transplant. The median time from last apixaban dose to arrival in the operating room was 23.2 h (15.6–33.8), with median random apixaban level of 37 ng/mL (28.3, 59), 6.3 h (4.8, 8.4) prior to arrival in the operating room. In this study, 32% of patients had significant post‐operative bleeding based on chest tube output post‐transplant or need for intervention. No patients meeting criteria for significant post‐operative bleeding were thought to be attributable to apixaban. Conclusions: Careful use of apixaban can be safe and effective while awaiting heart transplant. There was no appreciable increase in peri‐operative bleeding. The use of apixaban is promising in providing safe, predictable and efficacious anticoagulation while avoiding additional patient stressors. [ABSTRACT FROM AUTHOR]

Background: Information on inappropriate dosing of direct oral anticoagulants (DOACs) is scarce in the Australian context. Aim: To describe the prevalence and potential predictors of inappropriate dosing of DOACs. Methods: Patients who received DOACs during admission under a general medical unit over a 2‐year period (from January 2017 to December 2018) were retrospectively studied. Appropriateness of the dosing regimen was verified against the recommendations of the Therapeutic Goods Administration of Australia. Data were obtained from medical records and analysed in univariate and multivariate logistic regression models. The variables associated with under‐ and overdosing were also determined. Results: A total of 203 (mean age 71.6 ± 14.5 years, females 52%) patients were studied. Inappropriate dosing occurred in 44 (22%) patients: underdosing 27 (13%) and overdosing 17 (8%). Age ≥75 years (P < 0.01), lower estimated creatinine clearance (CrCl) (P < 0.01), prescription of DOAC prior to index admission (P < 0.01) and higher Charlson Comorbidity Index (P < 0.01), HAS‐BLED (P < 0.01) and CHA2DS2‐VASc (P < 0.01) scores had a significant univariate association with inappropriate dosing. However, in the multivariate logistic regression only lower CrCl (odds ratio (OR) 1.04, 95% confidence interval (CI): 1.01–1.07, P < 0.01) and prescription of DOAC prior to index admission (OR 2.62, 95% CI: 1.01–6.75, P = 0.047) remained significantly associated with inappropriate dosing. Impaired renal function also had a significant association with underdosing (OR 1.04, 95% CI: 1.01–1.07, P = 0.01) and borderline significance with overdosing (OR 1.03, 95% CI: 1.00–1.07, P = 0.06). Conclusion: Inappropriate dosing of DOACs, especially underdosing, is common in clinical practice. Clinicians should exercise due diligence when prescribing DOACs to patients with renal impairment and in outpatient settings. [ABSTRACT FROM AUTHOR]

With the increase in transcatheter procedures, the use of bioprosthetic valves has become more frequent in clinical practice. However, the optimal antithrombotic management of patients with bioprosthetic valves remains controversial. In this case report, we describe a patient with a bioprosthetic aortic valve who developed a thrombus while receiving effective dose direct oral anticoagulant (DOAC) therapy. A 73‐year‐old male patient with a bioprosthetic aortic valve replacement 2 years prior presented with a mobile thrombus and early degeneration of the valve, detected during routine follow‐up while being treated with apixaban. Although the valve thrombus regressed after switching to a different anticoagulant drug, we observed that the decreased but still high gradient persisted due to the early degeneration. Anticoagulant management of bioprosthetic valve patients demands careful attention. Although evidence supporting the use of DOACs is growing, close patient follow‐up and further evaluation in case of doubt remain critical. The development of a thrombus in a bioprosthetic valve patient who is receiving anticoagulation therapy, as in this case, highlights the need for optimal management to prevent thromboembolic complications and valve degeneration. [ABSTRACT FROM AUTHOR]

The article focuses on comparing the use of direct oral anticoagulants (DOACs) to conventional anticoagulants for the treatment of pulmonary embolism (PE). It mentions the study found that DOACs have similar efficacy and safety profiles compared to conventional anticoagulants for the treatment of PE, suggesting that DOACs offer practical advantages such as ease of use and no need for monitoring.

We utilized a case control study to determine if novel oral anticoagulants were associated with a higher risk of inpatient epistaxis admission. Adult patients admitted with a principal diagnosis of epistaxis in 2019–2021 were identified as well as a control group of patients matched 1:1 for age, sex, race, and medical comorbidities. For both cohorts, the presence or absence of an oral anticoagulant, classified as vitamin K inhibitors, direct oral anticoagulants (DOAC) or platelet inhibitors, was identified. 158 adult unique inpatient admissions with a principal diagnosis of epistaxis were identified. Vitamin K inhibition was present in 5.7% of cases versus 0.6% of controls (p = 0.02; OR 9.48, range 1.19‐75.77), DOACs in 4.4% of cases versus 5.1% of controls (p = 1.0) and platelet inhibitors in 2.5% of cases versus 3.8% of controls (p = 0.75). We concluded vitamin K inhibitors, compared to DOACs and platelet inhibitors, may be associated with higher likelihood of epistaxis admission. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation and heart failure are combined risk factors for thromboembolic events. Obese and morbidly obese individuals have been underrepresented in clinical trials studying safety and efficacy of direct oral anticoagulants (DOACs). Objectives: Study the comparative safety and efficacy of DOACs in obese and morbidly obese patients with atrial fibrillation or flutter, and concomitant congestive heart failure. Methods: In the present single‐center retrospective observational study, patients with an ICD‐9 code of atrial fibrillation or atrial flutter, and congestive heart failure on a DOAC (apixaban[n = 155], rivaroxaban[n = 335], dabigatran[n = 393]) were followed for a median 12.5 months (IQR: 22.1 months). Obesity was defined as a body mass index, BMI ≥ 30 and < 40 kg/m2 [n = 614], and morbid obesity as BMI ≥ 40 kg/m2 [n = 269]. Clinical endpoints were grouped into safety (composite of intracranial‐hemorrhage, gastrointestinal‐bleeds, hemorrhagic‐stroke, and other bleeds), and efficacy (composite of ischemic‐stroke and systemic‐embolism) endpoints. Cox proportional hazard models were used to compare safety, efficacy, and all‐cause mortality outcomes. Results: In obese patients, no statistical difference was observed in efficacy of DOACs. A statistical difference was observed in the safety of DOACs in obese patients. Apixaban was found to be safer than dabigatran [hazard ratio [HR] 0.37 (0.16‐0.87), p =.02] and rivaroxaban [HR 0.29 (0.12‐0.67), p =.004]. In morbidly obese patients, there was no overall statistical difference in the efficacy or safety of DOACs. Conclusion: In obese patients with congestive heart failure and atrial fibrillation or atrial flutter on DOACs, apixaban has the most favorable safety profile compared to rivaroxaban and dabigatran. [ABSTRACT FROM AUTHOR]

Background: One of the most catastrophic complications of Atrial fibrillation (AF) is thromboembolic stroke. Current guidelines recommend that 3 weeks of anticoagulation is adequate prior to direct current cardioversion (DCCV) to prevent thromboembolism. Here we present data regarding, which anticoagulant is most likely to show a presence of an Left atrial appendage thrombus (LAAT) on trans esophageal echocardiogram (TEE) for DCCV despite 3 weeks of anticoagulation.Objective: To investigate the effectiveness of both vitamin k antagonist (VKA) and direct oral anticoagulants (DOAC) in patients with AF as an anticoagulant for LAAT after 3 weeks of medication.Methods: This is a single-high volume tertiary center, where TEE precardioversion is the standard practice. We reviewed data over 10 months where DCCV was intended on individuals with AF who were fully anticoagulated for at least 3 weeks with either a VKA or taking a DOAC.Results: The data showed a statistical difference between patients who were fully anticoagulated for at least 3 weeks with VKA in comparison to DOACs. Patients on DOACs are significantly less likely to have an LAAT after at least 3 weeks of anticoagulation. OR = 0.04 (CI 95% 0.005-0.42; p-value < .05). Despite anticoagulation for at least 3 weeks, 40% of our patients still had a LAAT.Conclusion: Our data indicates that all patients should be required to undergo a TEE prior to DCCV. This data also adds to the current evidence and supports the use of DOAC in AF to prevent LAAT. [ABSTRACT FROM AUTHOR]

Background: The predictors of clinically significant bleeding events (CSBE) associated with direct oral anticoagulants (DOAC) are poorly characterised in the literature. Aim: To determine the incidence and predictors of CSBE in patients receiving DOAC. Methods: Patients who received DOAC during admission to a general medical unit over a 2‐year period were retrospectively studied. Following the index admission, patients were followed for 12 months or for the duration of treatment (if the latter was less than 12 months). The relevant data were obtained by review of medical records. Results: A total of 203 patients was studied over a mean follow‐up period of 293 (±81) days. The incidence of CSBE was 13.7 (95% confidence interval (CI): 9.5–21.1) per 100 person‐years. Age ≥ 75 years (P = 0.01), concurrent use of antiplatelet medications (P = 0.02) and lower estimated creatinine clearance (CrCl) (P = 0.03) had a significant univariate association with CSBE. However, in the multivariate logistic regression, only concurrent use of antiplatelet medications remained significantly associated with CSBE (adjusted odds ratio (OR) 3.6; 95% CI: 1.4–9.6; P = 0.01). Concurrent use of antiplatelet medications was also independently associated with major bleeding events (MBE) (adjusted OR 4.9; 95% CI: 1.1–21.4; P = 0.04). Although 39 (19.2%) patients received antiplatelet medications, the indications for concurrent antiplatelet use complied with current guidelines in only 3 (7.7%) patients. Conclusion: Caution should be exercised when prescribing antiplatelet medications with DOAC as this combination is a potential risk factor for both major and non‐major clinically significant bleeding events. In most patients, the concurrent use of antiplatelet medications was discordant with the current consensus guidelines. [ABSTRACT FROM AUTHOR]

Objective: Epistaxis is the most common otolaryngological emergency and up to one third of patients in treated on an inpatient basis take oral anticoagulants (OAC). Direct oral anticoagulants (DOAC), an OAC subgroup, have been on the market since 2010 and are being increasingly prescribed due to the cardiological and haematological guidelines that favour them over vitamin K antagonists (VKA), the older of the OAC subgroups. The present study aims to investigate which subgroup of epistaxis patients taking OACs has a more favourable outcome. Design/setting: A systematic review and meta‐analysis were performed according to the PRISMA 2020 statement using the PubMed and Cochrane Library databases. Continuous data were analysed and standardised mean difference (SMD) was calculated according to Hedges' g. Dichotomous data were analysed, and the Mantel‐Haenszel method was applied to establish the odds ratio (OR). Heterogeneity was assessed according to the I2 statistics. Main outcome/results: A total of eight reports covering 1390 patients were included in the final synthesis. The pooled analysis demonstrated significantly shorter hospital stays in the DOAC group (SMD = −0.22, 95% CI−0.42 to −0.02, p =.03) and a significantly higher rate of posterior bleeding in the VKA group (OR =.39, 95% CI 0.23 to 0.68, p =.001). No statistically significant differences with regard to recurrence rates, admission rates, the need for transfusion or surgical intervention (p =.57,.12,.57 and.38 respectively) were found. Conclusion: According to this meta‐analysis, epistaxis patients taking DOACs have a more favourable outcome than patients taking VKAs. [ABSTRACT FROM AUTHOR]

Introduction: Direct oral anticoagulant (DOAC)–inhibiting factor Xa (FXa‐DOAC) are being increasingly used as prophylaxis of venous thromboembolism and for prevention of stroke in patients with atrial fibrillation. In contrast to vitamin K antagonists, DOACs do not require monitoring in general. However, it is sometimes of value in the acute setting, for instance when considering a reversal agent in uncontrolled bleeding in patients on DOAC. Methods: We evaluated if a low–molecular weight heparin (LMWH)–calibrated anti–factor Xa assay could be used to estimate FXa‐DOAC concentration in the concentration range <100 ng/mL by spiking known concentrations of FXa‐DOAC and from those result calculate the FXa‐DOAC concentration from the response of the LMWH assay. This procedure was then evaluated by comparing the result with a drug‐calibrated chromogenic assay and liquid chromatography tandem mass spectrometry (LC‐MS/MS) on clinical plasma samples from patients treated with apixaban or rivaroxaban. Results: Although the measuring range was narrower for the LMWH‐calibrated assay, concentrations recalculated from the LMWH assay was comparable with those measured by the drug‐calibrated method when compared with LC‐MS/MS. Conclusion: We suggest that an LMWH‐calibrated anti–factor Xa assay can be used after characterization of the response of FXa‐DOACs to give guidance on the concentration of apixaban and rivaroxaban. Shorter turnaround time than LC‐MS/MS and the greater availability than drug‐calibrated chromogenic assays could make this a valuable option in the acute setting. [ABSTRACT FROM AUTHOR]

Introduction: Limited data were published on the management of direct oral anticoagulants in the insertion of pacemaker and cardiac monitoring devices. This study describes the management and outcomes of edoxaban, a direct oral factor Xa inhibitor, in patients undergoing pacemaker or monitoring device implantation in routine clinical practice. Methods and Results: EMIT‐AF/VTE collected data of patients from Europe, Korea, and Taiwan. Timing and duration of periprocedural interruption of edoxaban were at the treating physician's discretion. Pacemakers or monitoring devices were implanted into 136 patients who were evaluated from 5 days pre‐ until 30 days post‐procedure. The primary outcomes were the incidences of acute thromboembolic events (ATE), ischemic events, and International Society on Thrombosis and Haemostasis‐defined Major Bleeding; secondary outcomes included incidence of clinically relevant non‐major bleeding (CRNMB) and perioperative edoxaban interruption times. Conformance with European Heart Rhythm Association (EHRA) Guidance on interruption of direct oral anticoagulant therapy was variable: of the cardiac monitoring device patients, where no interruption of therapy would be expected, nonetheless, 62.5% had interruption of treatment, whereas in pacemaker procedures, where interruption would be expected, 23.4% had no interruption. No ATE or ischemic events occurred. One case of CRNMB and two of minor bleeding occurred. All bleedings occurred more than 3 days after the procedure. Conclusion/Relevance: The periprocedural complication risk for edoxaban treated patients undergoing pacemaker or invasive cardiac monitoring implantation was low. This population of patients was well managed in routine practice. [ABSTRACT FROM AUTHOR]

Background & Aims: While direct oral anticoagulants (DOACs) are increasingly used in patients with liver disease, safety data especially in advanced chronic liver disease (ACLD) are limited. Methods: Liver disease patients receiving DOAC treatment (ACLD: n = 104; vascular liver disease: n = 29) or vitamin K antagonists (VKA)/low‐molecular‐weight heparin (LMWH; ACLD: n = 45; vascular: n = 13) between January 2010 and September 2020 were retrospectively included. Invasive procedures and bleeding events were recorded. Calibrated anti‐Xa peak levels and thrombomodulin‐modified thrombin generation assays (TM‐TGAs) were measured in a subgroup of 35/28 DOAC patients. Results: Among patients receiving DOAC, 55 (41.3%) had advanced liver dysfunction (Child‐Pugh‐stage [CPS] B/C) and 66 (49.6%) had experienced decompensation. Overall, 205 procedures were performed in 60 patients and procedure‐related bleedings occurred in 7 (11.7%) patients. Additionally, 38 (28.6%) patients experienced spontaneous (15 minor, 23 major) bleedings during a median follow‐up of 10.5 (IQR: 4.0‐27.8) months. Spontaneous bleedings in ACLD patients were more common in CPS‐B/C (at 12 months: 36.9% vs CPS‐A: 15.9%, subdistribution hazard ratio [SHR]: 3.23 [95% CI: 1.59‐6.58], P <.001), as were major bleedings (at 12 months: 22.0% vs 5.0%, SHR: 5.82 [95% CI: 2.00‐16.90], P <.001). Importantly, CPS (adjusted SHR: 4.12 [91% CI: 1.82‐9.37], P <.001), but not the presence of hepatocellular carcinoma or varices, was independently associated with major bleeding during DOAC treatment. Additionally, ACLD patients experiencing bleeding had worse overall survival (at 12 months: 88.9% vs 95.0% without bleeding; P <.001). Edoxaban anti‐Xa peak levels were higher in patients with CPS‐B/C (345 [95% CI: 169‐395] vs CPS‐A: 137 [95% CI: 96‐248] ng/mL, P =.048) and were associated with lower TM‐TGA. Importantly, spontaneous bleeding rates were comparable to VKA/LMWH patients. Conclusions: Anticoagulants including DOACs should be used with caution in patients with advanced liver disease due to a significant rate of spontaneous bleeding events. [ABSTRACT FROM AUTHOR]

Due to community transmission of coronavirus disease 2019 (COVID‐19), social distancing and stay‐at‐home orders were implemented statewide in an effort to limit the spread of disease. This posed unique challenges for patients on medications requiring close and continued monitoring by clinic staff, such as anticoagulation clinics. Thus, innovative measures were implemented at Cleveland Clinic Health System (CCHS) to maintain the health and care of ambulatory patients. An initiative to evaluate patients for warfarin to direct oral anticoagulants (DOAC) conversion was used in the pharmacist‐run anticoagulation clinics. This article describes how patients were screened for eligibility, the education to pharmacists, the utilization of student learners in the process, and the workflow for provider notification of conversion. Follow up monitoring, challenges encountered, and future directions are also described. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this study was to evaluate the Hemoclot Quanti. V‐L assay in various clinical conditions. Methods: We compared the Hemoclot Quanti.V‐L assay with DNA testing and with the Pefakit assay in 60 normal (no mutation) vs carriers of the factor V (FV) Leiden mutation (56 heterozygous and three homozygous). We further investigated the interference of lupus anticoagulant on test results in normal and heterozygous individuals and of direct oral anticoagulants (DOACs) at trough and peak levels. Additionally, DOAC‐Remove was tested in samples containing DOACs at peak levels. We further evaluated the influence of FV deficiency on this quantitative assay. Results: There was a 100% agreement between the Quant. V‐L assay and DNA testing in 60 normal individuals. However, 1.85% of heterozygous and 33% of homozygous samples were falsely classified with the quantitative assay, and no misclassification was observed with the Pefakit assay. Lupus anticoagulant did not influence the test results of the quantitative assay. DOACs also interfered with test results in heterozygous patients, but this effect was prevented with the DOAC‐Remove procedure. Even mild FV deficiency affected the test results of the quantitative assay in heterozygous patients leading either to misclassification or the need for subsequent PCR testing. Conclusion: The quantitative FV‐L assay has several limitations, especially FV deficiency and the presence of DOACs have to be ruled out before running this quantitative assay. [ABSTRACT FROM AUTHOR]

Background: Information on apixaban anticoagulant activity is required to prevent major bleeding or thrombosis during its use. Methods: We enrolled 194 patients with nonvalvular atrial fibrillation (NVAF) in whom warfarin was replaced with apixaban: 105 (54.1%) received the standard dose of apixaban (5 mg twice daily [BID]; 5 mg group) and 89 (45.9%) received a reduced dose (2.5 mg BID; 2.5 mg group). Multiple regression analysis was performed to predict the prothrombin time of apixaban (PTa) based on factors including age, body weight (BW), serum creatinine, and CHA2DS2‐VASc score. Results: PTa and PT of warfarin (PTw) were significantly correlated in both groups (correlation coefficient R = 0.239 [P =.014] in the 5 mg group; R = 0.248 [P =.019] in the 2.5 mg group). PTa in the 5 mg group was predicted as follows: 16.952‐0.036 × BW +0.299 × CHA2DS2‐VASc score (P <.0004; R = 0.378). However, in the 2.5 mg group, PTa could not be predicted. The mean of the predicted and measured PTa values in the 5 mg group was 15.6 s, which was similar to the mean measured PTa of 15.5 s in the 2.5 mg group. Conclusions: PT can be predicted by a formula including simple clinical parameters in patients receiving the standard dose of apixaban. This simple predictive formula may help to stratify bleeding and thrombosis risks in patients treated with apixaban. [ABSTRACT FROM AUTHOR]

A study at our institution conducted 10 years ago identified that warfarin was under‐utilised in patients with atrial fibrillation. We replicated this study and compared the results. There was a significant increase in the proportion of patients appropriately anticoagulated (63% vs 9%, P < 0.001). Eighty‐seven percent of eligible patients were appropriately anticoagulated on discharge (86% previously). Seventy‐two percent of treated patients were prescribed a direct oral anticoagulant. Of these, 10% were discharged with a sub‐therapeutic dose without obvious explanation. [ABSTRACT FROM AUTHOR]

Background: Direct oral anticoagulants (DOACs) are increasingly used as an alternative to warfarin in patients with nonvalvular atrial fibrillation (NVAF). However, whether there is sufficient prescription of oral anticoagulants (OACs) to decrease the incidence of embolic stroke remains unclear. Methods and Results: We conducted a retrospective observational study of patients hospitalized with ischemic stroke between January 1, 2010 and December 31, 2018. During the 8 years, the annual incidence ratio of embolic stroke to all ischemic strokes did not decrease over time (21‐33%) except for that in 2018. The proportion of OAC users did not also change over time (from 23% to 45% [overall 31%], P =.78). Among the OAC users, 19% patients were warfarin users, and 12% patients were DOAC users. In 73% of warfarin users, prothrombin time was subtherapeutic, whereas in 60% of DOAC users, the dose was adequately prescribed. OACs were prescribed more often in patients with high CHADS2 score than in those with low score (P =.01). The number of patients who had no medical history of a doctor visit before admission increased significantly in the recent period of 2015‐2018 (22% vs 8% in the previous period of 2010‐2014) (P =.01). Conclusions: The incidence of embolic stroke patients without OACs did not decrease over time, and OACs in patients with NVAF have not been sufficient, even in DOAC era. In recent years, the incidence of undiagnosed AF has increased. To prevent embolic stroke, a correct AF diagnosis beforehand is important. [ABSTRACT FROM AUTHOR]

Aims: Even though the use of direct oral anticoagulants (DOACs) is safe based on clinical outcomes, drug safety also depends on appropriateness of drug prescription, which is challenging for DOACs since many patient factors need to be considered. The aim of this study was to assess the appropriateness of DOAC prescriptions and to identify risk factors of determinants for inappropriate DOAC prescriptions. Methods: A retrospective study in a nonuniversity teaching hospital was performed of hospitalized patients (≥18 years) who received an initial DOAC prescription between February and August 2018. Appropriateness of prescribing was evaluated on 8 criteria by using a modified version of the medication appropriateness index. Results: A total of 770 initial DOAC prescriptions of inpatients were evaluated: 267 patients (34.6%) had at least met 1 inappropriate criterion for a DOAC prescription. The most frequent inappropriate criterion was dosage (17.4%). Of the 4 DOACs, dabigatran (21.6%) and apixaban (21.2%) were mostly inappropriate dosed. In a multivariable analysis, reduced renal function (estimated glomerular filtration rate <50 mL/min; odds ratio [OR] = 2.35; P <.001), a diagnosis of atrial fibrillation (OR = 1.87; P =.004), and 'prescribed by surgeons' (OR = 1.9; P =.013) were independently associated with inappropriateness of prescribing. Conclusion: This study has highlighted a high degree of inappropriate prescribing of DOACs. These results underline the need for targeted interventions to improve DOAC prescribing. [ABSTRACT FROM AUTHOR]

We aimed to review the interfering effect of DOACs on tests for haemostatic function and then to discuss overcoming these with activated carbon (AC) products, thereby eliminating DOAC issues from test plasmas. Recent relevant articles were reviewed and are discussed. Laboratory tests for DOACs, lupus anticoagulant, factor assays and APC Resistance were carried out in such publications with and without an AC product on various instruments using reagents approved for diagnostic use in well‐regulated clinical laboratories. All reports on this plasma pre‐treatment by AC products agree that they extract DOACs from plasma samples with minimal effect on underlying clotting tests. The specific extraction of DOACs significantly reduced false positive lupus anticoagulant detection and provided more reliable results in clotting factor assays, APC resistance and other thrombophilia tests. Dabigatran and edoxaban seem to be adsorbed more thoroughly by AC from plasmas than rivaroxaban and apixaban. In summary, most of the AC products reviewed here appear to remove DOACs from test plasmas without significantly affecting underlying clotting tests and permit correct diagnosis of various haemostatic conditions despite the initial presence of DOACs. The application of such agents as a sample pre‐treatment to overcome the effects of DOACs for routine coagulation testing is supported by the emerging literature. [ABSTRACT FROM AUTHOR]

Background: The safety and effectiveness of edoxaban in real‐world clinical settings have not yet been elucidated thoroughly among Japanese patients with nonvalvular atrial fibrillation (NVAF). We report the one‐year interim results of ETNA‐AF‐Japan (Edoxaban Treatment in routiNe clinical prActice in patients with nonvalvular Atrial Fibrillation: UMIN000017011), an ongoing two‐year study. Methods: ETNA‐AF‐Japan is a prospective, real‐world multicenter observational study that analyzes the long‐term safety and effectiveness of edoxaban. Physicians recorded clinical characteristics, bleeding events, and clinical events of ischemic stroke and systemic embolism, among others. Results: In total, 11 569 patients with NVAF were enrolled. The demographic and clinical characteristics of the patients in the safety analysis set (n = 11 107) were a mean age of 74.2 ± 10.0 years; female sex, 40.6%; age ≥75 years, 52.4%; body weight ≤60 kg, 54.3%; creatinine clearance ≤50 mL/min, 31.2%; mean CHADS2 score of 2.2 ± 1.3. The mean treatment period was 311.2 days (median; 366.0 days), and ~80% of patients continued edoxaban treatment. In the safety analysis, the incidence of all bleeding events was 6.32% [95% CI: 5.87, 6.79] (n = 702), and for major bleeding, it was 1.08% [0.90, 1.29] (n = 120). In the effectiveness analysis set (n = 11 059), the incidence of ischemic stroke (excluding TIA) or systemic embolism was 1.10% [0.92, 1.32] (n = 122). Conclusions: At one‐year follow‐up, the results showed no major concerns about the safety and effectiveness of edoxaban in Japanese patients with NVAF in a real‐world clinical setting. [ABSTRACT FROM AUTHOR]

Background and Aim: Bleeding is an inevitable and often severe complication after endoscopic sphincterotomy (EST). We aimed to investigate the factors associated with post‐EST bleeding in patients treated with anticoagulants. Methods: The data of patients who underwent EST at 15 hospitals between July 2015 and June 2017 were extracted. We investigated the incidence of post‐EST bleeding and risk factors for bleeding in patients treated with anticoagulants. Results: One hundred forty‐nine patients undergoing EST who met the inclusion criteria were included in this study. The total‐EST bleeding (bleeding occurring during or after EST) rate did not differ between the heparin replacement (8.0%, 6/75) and continuation (16.6%, 2/12; P = 0.37) groups of warfarin users. The total‐EST‐bleeding rate in the heparin replacement group (12.9%, 4/31) was significantly higher than that in the continuation group (0%, 0/31; P = 0.016) in direct oral anticoagulant (DOAC) users. The rate of total‐EST bleeding with continuation of DOAC (0%, 0/31) was significantly lower with continuation of warfarin (16.6%, 2/12; P = 0.021). During‐EST bleeding (bleeding occurring during EST) (P = 0.0083) and precut (P = 0.033) were significant risk factors for post‐EST bleeding in all 149 patients. Heparin replacement was only a significant risk factor for total‐EST bleeding (P = 0.033) in DOAC users. Conclusion: Heparin replacement was a significant risk factor for post‐EST bleeding in DOAC users; however, there was no significant difference between the bleeding rate of heparin replacement and that of continuation groups in patients taking warfarin. During EST and precut were significant risk factors for post‐EST bleeding in all patients treated with anticoagulants. [ABSTRACT FROM AUTHOR]

Background: Activated clotting time (ACT)–guided heparinization is used during atrial fibrillation (AF) ablation. Differences in sensitivity to ACT assays have been identified among different direct oral anticoagulants (DOACs). Objective: We aimed to examine ACT just before ablation (pre‐ACT) for different ablation start times (9:00, 11:00, 13:00, or 15:00) and ablation safety outcomes in minimally interrupted (min‐Int) and uninterrupted (Unint) DOAC regimens and examine differences in pre‐ACT values among four DOACs. Methods: Consecutive patients were randomized into the min‐Int (n = 307) or Unint (n = 277) groups. DOACs examined were apixaban, dabigatran, edoxaban, and rivaroxaban. Results: No sequential changes in pre‐ACT values were observed for each DOAC used and for all four DOACs combined in the min‐Int and Unint groups. There was no meaningful difference in pre‐ACT at each ablation start time between the groups. Clinically significant differences in overall pre‐ACT were not obtained between the groups (138 ± 24 vs 142 ± 23 seconds). The pre‐ACT (baseline) value for dabigatran was on average 29 seconds higher than that for the other three DOACs. The min‐Int and Unint groups showed similar thromboembolic (0% vs 0%) and bleeding event rates (major, 1% vs 0%; all, 3.5% vs 2.5%). Conclusion: The pre‐ACT did not show a sequential change in the min‐Int and Unint groups. No notable differences in the time‐dependent change in pre‐ACT between the groups were observed. Variations in baseline ACT suggest the need for moderate adjustment of ACT for adequate modification of heparin dose for the other three DOACs. Both regimens provided similar acceptable AF ablation safety outcomes. [ABSTRACT FROM AUTHOR]

There is a little of information concerning which plasma concentrations of DOACs are safe when administering central neuraxial blocks (CNBs) and there is a wide variability in the rate of elimination, both between individuals and DOACs. Keywords: direct acting oral coagulants; DOAC; hemorrhage; neuraxial block; risk; surgery EN direct acting oral coagulants DOAC hemorrhage neuraxial block risk surgery 682 683 2 04/24/23 20230501 NES 230501 Direct oral anticoagulants (DOACs) require perioperative vigilance to reduce the risk of spinal hematoma. DOAC, direct acting oral coagulants, hemorrhage, neuraxial block, risk, surgery. [Extracted from the article]

Aims: The aim of this study was to compare the clinical effectiveness and safety of direct oral anticoagulants (DOACs) in patients with atrial fibrillation (AF) in routine clinical practice. Methods: This retrospective cohort study used linked administrative data. The study population (n = 14 577) included patients with a diagnosis of AF (confirmed in hospital) who initiated DOAC treatment in Scotland between August 2011 and December 2015. Multivariate Cox proportional hazard models were used to estimate hazard ratios of thromboembolic events, mortality and bleeding events. Results: No differences between the DOACs were observed with regard to the risk of stroke, systemic embolism or cardiovascular death. In contrast, the risk of myocardial infarction was higher among patients prescribed apixaban in comparison to those on rivaroxaban (HR 1.67, 95% CI 1.02‐2.71), and all‐cause mortality was higher among rivaroxaban patients in contrast to both apixaban (1.22 [1.01–1.47]) and dabigatran (1.55 [1.16–2.05]) patients; rivaroxaban patients also had a higher risk of pulmonary embolism than apixaban patients (5.27 [1.79–15.53]). The risk of other major bleeds was higher among rivaroxaban patients compared to apixaban (1.50 [1.10–2.03]) and dabigatran (1.58 [1.01–2.48]) patients; the risks of gastrointestinal bleeds and overall bleeding were higher among rivaroxaban patients than among apixaban patients (1.48 [1.01–2.16] and 1.52 [1.21–1.92], respectively). Conclusions: All DOACs were similarly effective in preventing strokes and systemic embolisms, while patients being treated with rivaroxaban exhibited the highest bleeding risks. Observed differences in the risks of all‐cause mortality, myocardial infarction and pulmonary embolism warrant further research. [ABSTRACT FROM AUTHOR]

Abstract: Background: A complication of chronic liver disease (CLD) is the abnormality of coagulation. In clinical practice, this increased risk of bleeding has not been identified as a protective factor against stroke or systemic embolism associated with atrial fibrillation (AF). The objective of this study was to assess the safety of direct oral anticoagulant (DOAC) agents vs warfarin in CLD patients with AF. Methods: This was a retrospective cohort study of patients with CLD and AF initiated on oral anticoagulants. Rates of all‐cause bleeding were compared between warfarin and DOAC agents. Secondary endpoints included rates of major bleeding and other risk factors for bleeding on anticoagulant therapy. Results: The all‐cause bleeding rates were similar between the groups, with 8.4% per year in the DOAC (n = 75) group and 8.8% in warfarin (n = 158) group (HR 0.9, 95% CI 0.4‐1.8). No significant difference was noted in the rate of major bleeding. In the multivariable model, higher MELD‐XI score and previous bleed were risk factors associated with increased bleeding. Conclusion: No significant differences in bleeding rates were noted in patients treated with warfarin and DOAC agents. Further studies evaluating DOAC agents are needed to better understand the optimal anticoagulation strategy in setting of CLD. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Rotational Thromboelastometry (ROTEM) is a point of care method used to monitor coagulation during surgery and to guide transfusion strategies in patients presenting with severe bleeding. The aim of our study was to determine the impact of four direct oral anticoagulants (DOACs) on 3 commonly used ROTEM tests. Methods: Whole blood samples from 20 healthy donors were spiked in vitro with apixaban, edoxaban, rivaroxaban or dabigatran at 5 different plasma concentrations (0‐1000 ng/mL). EXTEM, INTEM and FIBTEM tests were systematically performed. Results: There was a linear relationship between the increase in clotting time (CT) and plasma DOAC concentrations in both the EXTEM and INTEM tests. We found that the DOAC concentration required to double EXTEM CT was 1042 ± 225 ng/mL for apixaban, 134 ± 38 ng/mL for edoxaban, 176 ± 26 ng/mL for rivaroxaban and 284 ± 73 ng/mL for dabigatran. INTEM CT was less sensitive than EXTEM CT whatever the anticoagulant. EXTEM CT was above the normal range for 5 of 5 spiked samples when the plasma concentrations were ~1000 ng/mL for apixaban, ~100 ng/mL for edoxaban, ~200 ng/mL for rivaroxaban and ~200 ng/mL for dabigatran. Maximum Clot Firmness in EXTEM, INTEM and FIBTEM tests was not affected whatever the DOAC or its concentration. Conclusion: This study found a DOAC dose‐dependent increase in ROTEM CTs. ROTEM tests were only poorly impacted by low levels of edoxaban, rivaroxaban or dabigatran. Apixaban had only a low effect even at high concentrations. [ABSTRACT FROM AUTHOR]

The initial treatment of haemodynamically stable patients with pulmonary embolism (PE) has dramatically changed since the introduction of low molecular weight heparins (LMWHs). With the recent discovery of the direct oral anticoagulant drugs (DOACs), initial treatment of PE will be simplified even further. In several large clinical trials it has been demonstrated that DOACs are not inferior to standard therapy for the initial treatment of PE, and because of their practicability they are becoming the agents of first choice. However, many relative contraindications to DOACs were exclusion criteria in the clinical trials. Therefore, LMWHs will continue to play an important role in initial PE treatment and in some cases there still is a role for unfractionated heparin (UFH). In this review we will give an overview of the biophysical, pharmacokinetic and pharmacodynamic properties of anticoagulants currently available for the initial management of PE. In addition, we will provide a comprehensive overview of the indications for the use of UFH, LMWHs and DOACs in the initial management of PE from a pharmacokinetic/-dynamic point of view. [ABSTRACT FROM AUTHOR]

Purpose To report the use of direct oral anticoagulants (DOACs) for stroke prevention in patients with atrial fibrillation in Scotland and advocate the standardisation of drug utilisation research methods. Methods Retrospective cohort study using linked administrative data. Patients included those with a diagnosis of atrial fibrillation (confirmed in hospital) who received a first prescription for a DOAC (dabigatran, rivaroxaban, or apixaban) from September 2011 to June 2014. Drug utilisation measures included discontinuation, persistence, and adherence. Results A total of 5398 patients (mean CHA2DS2-VASc score 2.98 [SD 1.71], 89.7% with ≥5 concomitant medicines) were treated with DOACs for a median of 228 days (interquartile range 105-425). Of 35.6% who discontinued DOAC treatment, 11.0% switched to warfarin, and 48.3% reinitiated DOACs. Persistence after 12 and 18 months was 75.9% and 69.8%, respectively. Differences between individual DOACs were observed: Discontinuation rates ranged from 20.4% (apixaban) to 60.6% (dabigatran) and 12 months persistence from 60.1% (dabigatran) to 85.5% (apixaban). Adherence to treatment with all DOACs was good: Overall DOAC median medication refill adherence was 102.9% (interquartile range 88.9%-115.5%), and 82.3% of patients had a medication refill adherence > 80%. Conclusions In Scotland, adherence to DOAC treatment was good, and switching from DOAC to warfarin was low. However, discontinuation and persistence rates were variable-although treatment interruptions were often temporary. To decrease the inconsistencies in drug utilisation methods and facilitate meaningful study comparison, the use of a coherent framework-using a combination of discontinuation, persistence, and adherence-and the standardisation of measurements is advocated. [ABSTRACT FROM AUTHOR]

Background Rivaroxaban, a direct oral anticoagulant (DOAC), has become available for stroke prevention in patients with non-valular atrial fibrillation (NVAF). However, little is known about its effectiveness and safety when prescribed by general practitioners in real-life settings. Methods GENERAL is a multicenter, prospective, non-interventional observational study of patients receiving rivaroxaban for NVAF in daily clinical practice prescribed specifically by general practitioners. The target number of participating medical institutions is 500–700 clinics with fewer than 20 beds and the target number of participants is 5000. The baseline clinical data, including antidementia medication and frailty, and follow-up data including concomitant treatment and outcomes until September 2018 (maximum three years) will be collected. The primary efficacy endpoints will be stroke and/or systemic embolism and the secondary endpoints will be major bleeding meeting the ISTH guidelines, non-major and clinically relevant bleeding, onset of symptomatic stroke (ischemic/hemorrhagic), systemic embolism, deep vein thrombosis/pulmonary thromboembolism, myocardial infarction and/or cardiovascular death, and systemic embolism. Based on the provided information, the event assessment committee will investigate the endpoint-related events. The annual incidence and predictive factors for primary/secondary endpoint will be investigated based on underlying disease, age, renal function, and CHADS 2 , CHA 2 DS 2 -VASC, and HAS-BLED scores using Cox regression. We will also compare the incidence of the primary/secondary endpoint between the present study, EXPAND study, and FUSHIMI AF registry study. Results The results of this study are currently under investigation. Conclusion This study will provide important information regarding the effectiveness and safety of rivaroxaban treatment in Japanese patients with NVAF among general practitioners. [ABSTRACT FROM AUTHOR]

Keywords: CrCl; DOAC; interruption; peri-operative procedure EN CrCl DOAC interruption peri-operative procedure 188 189 2 04/19/22 20220415 NES 220415 DIRECT ORAL ANTICOAGULANTS So far, the peri-operative/periprocedural management of the direct oral anti-coagulants (DOACs) has largely been guided by pharmacokinetic data, with recommended periods of drug interruption based on drug-specific half-lives, an individual's renal function, and the assessment of operative or procedural bleeding risk.The Perioperative Anticoagulation Use for Surgery Evaluation (PAUSE) study prospectively enrolled 3007 patients with atrial fibrillation receiving anti-coagulation with a DOAC (apixaban 41.8%, rivaroxaban 36%, dabigatran 22.2%), who were planned to have an elective procedure/surgery that required anti-coagulation interruption.1 The study used a simplified and standardised management protocol (see figure below). In patients with a CrCl of 50 ml/min or higher, omit dabigatran for one day prior to low bleeding risk procedures and two days prior to high bleeding risk procedures (1C). Perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant. [Extracted from the article]

Background: Ischemic strokes in orally anticoagulated patients pose challenges for acute management and secondary prevention but the characteristics of these strokes are poorly understood. We examined the clinical and imaging features, the presumed underlying etiology and the subsequent antithrombotic management., Methods: We analyzed a consecutive series of patients enrolled into the EIDASAF study, a single center, observational study of ischemic stroke patients with a diagnosis atrial fibrillation (AF) prior to the index event who had been admitted to the Hyperacute Stroke Unit of Imperial College London between 2010 and 2017. We compared patients with oral anticoagulation therapy prior admission (OAC prior ) with those without anticoagulation (OAC naive ). Brain imaging was analyzed centrally., Results: 763 patients were included in the analysis. 481 (63%) were OAC naive while 282 (37%) were OAC prior . Patients with OAC prior were younger, more often had a previous history of stroke or transient ischemic attack (TIA), and more often suffered from hypertension and diabetes. In OAC naive, patients, large and deep middle cerebral artery infarcts occurred more often than in OAC prior patients. The groups differed significantly in the distribution of competing etiologies underlying their stroke. At discharge, OAC prior more frequently were (re)-anticoagulated compared to OAC naive patients. Within the OAC prior group, patients with recurrent strokes did not differ from those with a first stroke regarding clinical characteristics and pattern of cerebral infarction but they were less frequently anticoagulated., Conclusions: Ischemic strokes on OAC represent a significant proportion of AF-related strokes. There is an unmet need to better understand the causes underlying these strokes and to optimize the medical management., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Cerebral venous thrombosis (CVT) is caused by partial or complete occlusion of the major cerebral venous sinuses or the smaller feeding cortical veins which predispose to the risk of venous infarction and hemorrhage. Current guidelines recommend treating CVT with either low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) followed by an oral vitamin K antagonist (VKA) for 3-12 months. Direct oral anticoagulants (DOACs) have already established benefit over warfarin as a long-term treatment of symptomatic venous thromboembolic disorder like deep vein thrombosis (DVT), and pulmonary embolism (PE) given its equal efficacy and better safety profile. The benefit of DOACs over warfarin as a long-term anticoagulation for CVT has likewise been extensively studied, yet it has not been approved as first-line therapy in the current practice. We therefore performed a systematic review and meta-analysis of relevant studies to generate robust evidence regarding the safety and efficacy of DOACs in CVT. This meta-analysis demonstrates that the use of DOACs in CVT has similar efficacy and safety compared to VKAs with better recanalization rate., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: The choice of antithrombotic therapy, anticoagulants or antiplatelets, after prosthetic heart valve replacement or repair, remains a disputed topic in the literature. Antithrombotic therapies are used after heart valve intervention to reduce the rates of thromboembolic events, therefore improving patient outcomes. Different interventions may require different therapeutic regimens to achieve the most efficacious clinical outcome for patients., Methods and Discussion: This review aims to summarize and critique the available literature concerning therapeutic agents used for bioprosthetic and mechanical valves as well as for valve repair, so as to assist clinicians and researchers in making decisions with regard to their patients and research endeavors., (© 2020 Wiley Periodicals LLC.)

Background Direct oral anticoagulants ( DOAC) are being increasingly utilised for stroke prevention in atrial fibrillation ( AF) and atrial flutter. Aims To analyse the adoption and application of these drugs in a regional hospital inpatient cohort and compare with national prescribing data. Methods Digital medical records identified prescribed anticoagulants for patients admitted with AF and atrial flutter during 2013-2014. Analysis of patient demographics and stroke risk identified trends in prescribing DOAC versus warfarin. For broader comparison, data from the Pharmaceuticals Benefits Scheme were sourced to determine the nation-wide adoption of DOAC. Result Of the 615 patients identified, 505 (255 in 2013, 250 in 2014) had sufficient records to include in the study. From 2013 to 2014, DOAC prescriptions increased from 9 to 28% ( P < 0.001), warfarin and aspirin remained comparatively stable (38-34%, 22-20%), and those prescribed no medication declined (17-8%, P < 0.001). DOAC were prescribed to patients with lower CHA2DS2VASc scores than warfarin (3.6 vs 4.4; P = 0.005), lower HAS-BLED scores (1.7 vs 2.3; P < 0.01), higher glomerular filtration rates; 70 vs 63 ml/min; P = 0.002) and younger age (74 vs 77 years; P = 0.006). Nationally, warfarin prescriptions are higher in total numbers but increasing at a slower rate than DOAC, which increased 10-fold (101 158 in 2013, 1 095 985 in 2014). Conclusion DOAC prescribing grew rapidly from 2013 to 2014, regionally and nationally. Warfarin prescriptions have remained stable, indicating that more patients are being appropriately anticoagulated for AF who previously were not. DOAC were found to be prescribed to patients with lower CHA2DS2VASc and HAS-BLED scores, younger age and higher glomerular filtration rates. Aspirin therapy remains over utilised in AF. [ABSTRACT FROM AUTHOR]