Discover and read the best of Twitter Threads about #Anticoagulation
Most recents (18)
💥#McMaster #CardiologyGrandRounds by @johneikelboom
🩸 People with #AF are inadequately anticoagulated, largely related to MD hesitancy
🩸#Bleeding risk prediction tools have modest performance
🩸Bleeding risk iproportional to stroke risk, net benefit favours #antocoagulation
🩸 People with #AF are inadequately anticoagulated, largely related to MD hesitancy
🩸#Bleeding risk prediction tools have modest performance
🩸Bleeding risk iproportional to stroke risk, net benefit favours #antocoagulation
2/
🩸Few reasons to withhold #OAC, even in frail, older adults
🩸Across spectrum of #bleeding risk in AF, #stroke risk is higher
🩸#DOACs preferred over warfarin in #nonvalvular #AF
🩸Few reasons to withhold #OAC, even in frail, older adults
🩸Across spectrum of #bleeding risk in AF, #stroke risk is higher
🩸#DOACs preferred over warfarin in #nonvalvular #AF
3/
🩸Most #DOACs safe in #CKD, some require dose adjustment
🩸Dabigatran contraindicated in eGFR<30
🩸Limited RCT evidence in #Hemodialysis
#AtrialFibrillation #Anticoagulation
🩸Most #DOACs safe in #CKD, some require dose adjustment
🩸Dabigatran contraindicated in eGFR<30
🩸Limited RCT evidence in #Hemodialysis
#AtrialFibrillation #Anticoagulation
1a) Welcome to a new #accredited #tweetorial on the management of aFXa-DOAC-associated #hemorrhage and specifically the role of coag laboratory testing in these challenging cases.
1b) Our expert author is #pharmacist Craig Beavers, PharmD @beaverspharmd CV Clinical Pharmacy Specialist @UK_COP, and Immediate Past Chair of the @ACCinTouch #ACCCVT Section
2) This 🆓program is accredited for 0.5h CE/#CME for #physicians #physicianassociates #nurses #nurespractitioners #pharmacists and is supported by a grant from AstraZeneca. See statement of accreditation and faculty disclosures at cardiometabolic-ce.com/disclosures/.
1a) Welcome to a new #accredited #tweetorial on a very challenging topic: managing #ICH in a patient taking anti-FXa #DOACs! Your expert authors are both #neurointensivists: Richard Choi, DO @rkchoi @christianacare and Casey Albin, MD @caseyalbin @EmoryNeuroCrit
1b) #Physicians #Nurses #Pharmacists #physicianassociate #NPs earn 0.5h CE/#CME from @academiccme for following this 🧵
2) This program is supported by an educational grant from AstraZeneca and is intended for #HCPs. Accreditation statement and faculty disclosures at cardiometabolic-ce.com/disclosures/. Prior (& future) programs in this space, available for 🆓CE/#CME credit, at cardiometabolic-ce.com/category/antit….
1) Welcome to a new #accredited #tweetorial about an important complication of #pulmonaryembolism (#PE): chronic thromboembolic pulmonary hypertension #CTEPH. Follow this thread to earn 0.75h CE/#CME #physicians #physicianassociates #NPs #nurses #pharmacists.
2) I am Jason Weatherald @AlbertaPHdoc of @UAlberta and you may recall my previous tweetorial in this feed. It's still available for credit at cardiometabolic-ce.com/pah2/. @cardiomet_CE is your ONLY home for earning CE/#CME entirely on Twitter! Howdy to @vic_tapson @lauralynndonah1
3) This program is intended for #healthcare providers and is supported by educational grants from Actelion, Bayer, Chiesi, & AstraZeneca. Faculty disclosures are listed at cardiometabolic-ce.com/disclosures/. Prior programs, still available for credit, are at cardiometabolic-ce.com
1) Welcome to a new #accredited #tweetorial on managing #VTE at the extremes of weight & renal function. Free CE/#CME credit for following along with expert author @AryaRoopen from King’s Thrombosis Centre at King's College Hospital in London! Only the best for our learners!
2) When we think about "special populations" in #VTE, we think weight, age, and #cancer status. @aakonc already addressed the last of those (earn credit still at cardiometabolic-ce.com/antithrombotic…). Learn the rest here! Hello to @ProfMakris @bhwords @MiddeldorpS @fniainle @AliTaherMD
3) This educational program is intended for health care providers & is supported by a grant from Bristol Myers Squibb & its Alliance partner Pfizer, Inc. Faculty disclosures at cardiometabolic-ce.com/disclosures/. Credit for #physicians #physicianassociates #nurses #NPs #pharmacists
Don’t miss a new accredited #tweetorial launching TOMORROW here on @cardiomet_CE. #Interventional #cardiologist, #researcher, & #SoMe education leader @DLBHATTMD will be talking all about #aspirin, its role in #cardiovascular wellness & prevention, and new approaches to . . .
. . . formulation and dosing. Don't miss it--FOLLOW US NOW! @cpcannon @AnnMarieNavar @DrM_ODonoghue @DrMarthaGulati @practicalcardio @GuyattGH @DrMauricioCohen @SVRaoMD @ASPCardio @PlateletDoc @stephanamayer @CMichaelGibson @JJheart_doc @DrSheilaSahni @mmamas1973 @Drroxmehran
1) Welcome to an #accredited #tweetorial on the foundational role of #aspirin in #cardiovascular care. There are new approaches to #aspirin formulation & dosing. This program is accredited for 0.50h CE/#CME. I am @DLBHATTMD. #FOAMed #cardiotwitter #medtwitter
#WeekendLecture
#CerebralMicrobleeds #CMB
Radiological construct: small (2–10 mm diameter) round or ovoid #hypointense foci with associated #blooming with enhanced visibility on #MRI sequences sensitive to #susceptibility effects
thelancet.com/journals/laneu…
#CerebralMicrobleeds #CMB
Radiological construct: small (2–10 mm diameter) round or ovoid #hypointense foci with associated #blooming with enhanced visibility on #MRI sequences sensitive to #susceptibility effects
thelancet.com/journals/laneu…
#WeekendLecture
#CMB
🔬#Pathology: recent or old microhaemorrhages
🩸Microvessel injuries, ie: dilatation/fragmentation of the wall, amyloid-ß (in CAA) and fibrin extravasation
🩸Extravasation of red blood cells
🩸#hemosiderin-laden macrophages
karger.com/Article/FullTe…
#CMB
🔬#Pathology: recent or old microhaemorrhages
🩸Microvessel injuries, ie: dilatation/fragmentation of the wall, amyloid-ß (in CAA) and fibrin extravasation
🩸Extravasation of red blood cells
🩸#hemosiderin-laden macrophages
karger.com/Article/FullTe…
#WeekendLecture
In daily practice #CMB represents a radiological marker of #small vessel disease
In general:
🩸Strictly #lobar CMBs👉CAA
🩸Strictly #deep👉hypertension-related SVD ie #arteriolosclerosis
🩸Mixed 👉combination👆, but must think #hereditary #SVD, ie #CADASIL
In daily practice #CMB represents a radiological marker of #small vessel disease
In general:
🩸Strictly #lobar CMBs👉CAA
🩸Strictly #deep👉hypertension-related SVD ie #arteriolosclerosis
🩸Mixed 👉combination👆, but must think #hereditary #SVD, ie #CADASIL
#WeekendLecture
#ESUS
In most studies ~25% of ischemic stroke are classified as #cryptogenic
In 2014 the Embolic Stroke of Undetermined Source clinical construct was introduced, as a subset from cryptogenics
Criteria & diagnostic assessment were proposed
thelancet.com/journals/laneu…
#ESUS
In most studies ~25% of ischemic stroke are classified as #cryptogenic
In 2014 the Embolic Stroke of Undetermined Source clinical construct was introduced, as a subset from cryptogenics
Criteria & diagnostic assessment were proposed
thelancet.com/journals/laneu…
#WeekendLecture
#ESUS
Although a long list of causes was described, covert AF was conceived as perhaps the most important underlying mechanism
It was hypothesized that oral #anticoagulation may⏬ the risk of stroke recurence in #ESUS
#ESUS
Although a long list of causes was described, covert AF was conceived as perhaps the most important underlying mechanism
It was hypothesized that oral #anticoagulation may⏬ the risk of stroke recurence in #ESUS
#WeekendLecture
#ESUS
A systematic review in 2017 (from several authors of the pivotal paper) showed:
👉Frequency: 17% (9-25%) of IS
👉Mean age: 65
👉Recurrence: 4.5% per year
👉Younger, lower freq of vascular RFs and milder stroke vs non-ESUS IS
ahajournals.org/doi/10.1161/st…
#ESUS
A systematic review in 2017 (from several authors of the pivotal paper) showed:
👉Frequency: 17% (9-25%) of IS
👉Mean age: 65
👉Recurrence: 4.5% per year
👉Younger, lower freq of vascular RFs and milder stroke vs non-ESUS IS
ahajournals.org/doi/10.1161/st…
📌Impact of #Covid_19😷outbreaks on #anticoagulation use 💉💊
Read our #interview with the author Ippazio Cosimo Antonazzo @unimib in our thread 🧵 below ⬇️
Accepted manuscript 🆓access
thieme-connect.com/products/ejour… @ThiemeNY @ThiemeGruppe
Read our #interview with the author Ippazio Cosimo Antonazzo @unimib in our thread 🧵 below ⬇️
Accepted manuscript 🆓access
thieme-connect.com/products/ejour… @ThiemeNY @ThiemeGruppe
Why did you (and your colleagues) write this paper? What was its main purpose?
Ippazio Cosimo Antonazzo: "In the last months, the body of literature on COVID-19 pandemic impact on healthcare facilities access has increased."
1/12
Ippazio Cosimo Antonazzo: "In the last months, the body of literature on COVID-19 pandemic impact on healthcare facilities access has increased."
1/12
"However, few studies focused on potential impact of outbreak on drug utilization in the general population, particularly for those medications requiring intense monitoring and/or constant access to healthcare facilities."
2/12
2/12
Benefits of #anticoagulation 💊after major #bleeding 🩸?
Read our #interview with lead author Truman Milling
in thread 🧵 below 👇
👉Article Open access thieme-connect.com/products/ejour…
👉Editorial thieme-connect.com/products/ejour…
Read our #interview with lead author Truman Milling
in thread 🧵 below 👇
👉Article Open access thieme-connect.com/products/ejour…
👉Editorial thieme-connect.com/products/ejour…
T&H: Why did you (and your colleagues) write this paper?
TRUMAN MILLING: We saw the obvious finding that thrombotic events did not occur when clinicians restarted anticoagulation after major hemorrhage, and we wanted to explore this further.
TRUMAN MILLING: We saw the obvious finding that thrombotic events did not occur when clinicians restarted anticoagulation after major hemorrhage, and we wanted to explore this further.
What was its main purpose?
T.M: To begin to provide the evidence to move clinicians off their conservative bias toward anticoagulation decisions after major bleeding. We, patients and clinicians, naturally fear bleeding more than thrombosis, and we shouldn't.
T.M: To begin to provide the evidence to move clinicians off their conservative bias toward anticoagulation decisions after major bleeding. We, patients and clinicians, naturally fear bleeding more than thrombosis, and we shouldn't.
#INSPIRATION RCT comparing intermediate vs standard dose DVT prophylaxis, just published @jama:
-no benefit to additional anticoag in ICU patients w/ #COVID19:no reduction in mortality, MV, LOS or any 2° endpoint
-time to rethink COVID #anticoagulation?
1/
bit.ly/3vCluqK
-no benefit to additional anticoag in ICU patients w/ #COVID19:no reduction in mortality, MV, LOS or any 2° endpoint
-time to rethink COVID #anticoagulation?
1/
bit.ly/3vCluqK
INSPIRATION was a 10 site open-label RCT in 🇮🇷 comparing intermediate vs standard dose prophylaxis in ICU patients with PCR-confirmed #COVID19.
LMWH was the primary intervention (~40 mg vs 1mg/kg daily), dosed appropriately for weight; UFH was used if the GFR was too low.
2/
LMWH was the primary intervention (~40 mg vs 1mg/kg daily), dosed appropriately for weight; UFH was used if the GFR was too low.
2/
Overall the groups were balanced (total n=562) & were fairly representative of US ICU cohorts with COVID19.
The use of HFNC was very low (~3%) compared to in the US, which may reflect different practice patterns/availability.
Most patients (>90%) received corticosteroids
3/
The use of HFNC was very low (~3%) compared to in the US, which may reflect different practice patterns/availability.
Most patients (>90%) received corticosteroids
3/
Pre-print of the @remap_cap RCT of #anticoagulation for ICU patients w/ #COVID19 adds details but confirms what we learned from the press release:
- no improvement in survival or organ failure w/ therapeutic (TA) vs prophylactic anticoagulation (PA)
- medrxiv.org/content/10.110…
1/
- no improvement in survival or organ failure w/ therapeutic (TA) vs prophylactic anticoagulation (PA)
- medrxiv.org/content/10.110…
1/
This study is the amalgam of 3 large platform RCTs of TA in COVID19: @remap_cap @ACTIV4a & ATTACC.
Each trial was administered separately but as much as possible they harmonized the design so the results could be analyzed together. (a pragmatic way to enroll more pts faster)
2/
Each trial was administered separately but as much as possible they harmonized the design so the results could be analyzed together. (a pragmatic way to enroll more pts faster)
2/
There were some differences:
-REMAP enrolled suspected & confirmed infxn; the others only enrolled confirmed
-choice of anticoagulant varied
-most importantly, the definition of prophylaxis: ~1/2 the sites used standard low-dose heparin, the remainder used “intermediate dose”
3/
-REMAP enrolled suspected & confirmed infxn; the others only enrolled confirmed
-choice of anticoagulant varied
-most importantly, the definition of prophylaxis: ~1/2 the sites used standard low-dose heparin, the remainder used “intermediate dose”
3/
1/24
#EPeeps, #EHRA_ESC is proud to have the new 2020 @escardio #AFib guidelines
Here’s my personal #tweetorial about the news and the highlights of these 126 pages.
I congratulate @GerdHindricks, @tanjapotpara1 & whole team for this tremendous work. #ESCGuidelines #EHRA_Ecomm
#EPeeps, #EHRA_ESC is proud to have the new 2020 @escardio #AFib guidelines
Here’s my personal #tweetorial about the news and the highlights of these 126 pages.
I congratulate @GerdHindricks, @tanjapotpara1 & whole team for this tremendous work. #ESCGuidelines #EHRA_Ecomm
2/24
Find the new @escardio #Afib guideline document 2020 here ▶️bit.ly/2HD5RKZ.
First, let’s take a look at the "what’s new" part.
Find the new @escardio #Afib guideline document 2020 here ▶️bit.ly/2HD5RKZ.
First, let’s take a look at the "what’s new" part.
3/24
ECG documentation is required to establish the diagnosis of #AFib (either standard 12-lead ECG recording or single-lead ECG tracing of at least 30 s).
I think that this is important because now we can explicitly diagnose AF with single-lead ECGs. #wEHRAbles
ECG documentation is required to establish the diagnosis of #AFib (either standard 12-lead ECG recording or single-lead ECG tracing of at least 30 s).
I think that this is important because now we can explicitly diagnose AF with single-lead ECGs. #wEHRAbles
1/ Antidote news! There has been promise recently regarding antidotes being developed for DOACs. Before we get onto that, a quick summary of what we have so far...
2/ In the case of bleeding while on warfarin, this should be stratified by severity. Usual rule is if life/limb/sight threatening bleeding, prothrombin complex concentrate + vit K is used. If not, vitamin K +- pause/cessation of warfarin is advised.
3/ Warfarin works by inhibiting vitamin K-dependent clotting factor production. These factors are II, VII, IX and X. The 'antidote' is prothrombin complex concentrate (e.g beriplex) which is a concentrated 'soup' of factors II, VII, IX and X (and some protein C and S)
Retrospective series of n=4,389 pts w/ #COVID19 @mountSinai in @JACCJournals comparing prophylactic #anticoagulation (AC) vs therapeutic AC vs no AC:
*Prophylactic AC reduced mortality compared to no AC *Therapeutic AC no better than prophylactic AC
➡️ bit.ly/3gBpvmo
1/
*Prophylactic AC reduced mortality compared to no AC *Therapeutic AC no better than prophylactic AC
➡️ bit.ly/3gBpvmo
1/
The *unadjusted* mortality is quite different:
*Prophylactic AC 21.6%
*Therapeutic AC 28.6%
*No AC 25.6%
But one of the challenges of a retrospective study like this is there are usually significant differences between the groups, as we can see in Table 1:
2/
*Prophylactic AC 21.6%
*Therapeutic AC 28.6%
*No AC 25.6%
But one of the challenges of a retrospective study like this is there are usually significant differences between the groups, as we can see in Table 1:
2/
They use a logistic regression model to adjust mortality for differences in age, comorbidities, labs, vitals, etc
This is reasonable but you must be careful: it can overcorrect, residual confounders can persist, & it provides many opportunities to find a model that you like
3/
This is reasonable but you must be careful: it can overcorrect, residual confounders can persist, & it provides many opportunities to find a model that you like
3/
Observational study of n=786 #COVID pt who received treatment dose #anticoagulation (AC) vs n=1987 who did not. AC associated w/ decreased mortality, particularly in intubated patients (29.1% vs 62.7%).
Non-randomized & sparse on details but promising.
➡️bit.ly/35DX97f
Non-randomized & sparse on details but promising.
➡️bit.ly/35DX97f
Before getting too excited about this *observational* study remember two key points:
1. Mount Sinai made therapeutic AC their standard of care for ICU pt w/ COVID. Therefore among intubated pt comparing AC vs not is really just comparing AC to people where AC was contraindicated.
1. Mount Sinai made therapeutic AC their standard of care for ICU pt w/ COVID. Therefore among intubated pt comparing AC vs not is really just comparing AC to people where AC was contraindicated.
2. As @DrToddLee points out, this is an example of immortal time bias. A median of 2 days (range 0-5) elapsed b/w admit and beginning AC & much mortality occurs in the first 2 ICU days; thus early mortality is disproportionately counted in non-AC group ➡️bit.ly/3bbAa4N
Unfortunately #PulmonaryEmbolism is a common problem in the era of #COVID. Here's a brand new #OnePager summarizing my approach to PE, including hemodynamics, ventilation, #anticoagulation, and #thrombolysis. #FOAMed #FOAMcc
1/3
1/3
Also, continuing the @POPCoRNetwork Series of Webinars to help pediatric intensivists adapt to the adult ICU, I will be giving a webinar about PE tomorrow. 4pm PST.
You can sign up here:
You can sign up here:
Finally, if you prefer you can download the PPT and PDF versions of the PE #OnePager here. Also please share your feedback and comments, so I can make it better.
➡️onepagericu.com
3/3
➡️onepagericu.com
3/3
I know everyone is doing this, but here are my reflections after 2 wks in #ICU w/ #COVID19. Also includes lessons from our outstanding collaboration w/ #RapidResponseTeam
(1/12)
(1/12)
Much discussion on clinical phenotypes, but like any disease, #COVID19 is a spectrum. Here are 3 big phenotypes I saw
(2/2)
(2/2)
I’m more worried about running out of #intensivist, #RespiratoryTherapists, etc than running out of #ventilators. Given wide spectrum of disease, true expertise in mech ventilation needed. No 1-size-fits-all approach here
#COVID19 #VentilatorShortage
(3/12)
#COVID19 #VentilatorShortage
(3/12)
