In 2011 we reviewed clinical updates and controversies surrounding anticoagulation bridge therapy in patients with atrial fibrillation (AF). Since then, options for oral anticoagulation have expanded with the addition of four direct oral anticoagulant (DOAC) agents available in the United States. Nonetheless, vitamin K antagonist (VKA) therapy continues to be the treatment of choice for patients who are poor candidates for a DOAC and for whom bridge therapy remains a therapeutic dilemma. This literature review identifies evidence and guideline and consensus statements from the last 5 years to provide updated recommendations and insight into bridge therapy for patients using a VKA for AF. Since our last review, at least four major international guidelines have been updated plus a new consensus document addressing bridge therapy was released. Prospective trials and one randomized controlled trial have provided guidance for perioperative bridge therapy. The clinical trial data showed that bridging with heparin is associated with a significant bleeding risk compared with not bridging; furthermore, data suggested that actual perioperative thromboembolic risk may be lower than previously estimated. Notably, patients at high risk for stroke have not been adequately represented. These findings highlight the importance of assessing thrombosis and bleeding risk before making bridging decisions. Thrombosis and bleeding risk tools have emerged to facilitate this assessment and have been incorporated into guideline recommendations. Results from ongoing trials are expected to provide more guidance on safe and effective perioperative management approaches for patients at high risk for stroke.
Background/IntroductionHeart Failure (HF) management has advanced, however hospitalisation rates and mortality remain high. Maintaining euvolaemia is key to preventing decompensation but can be challenging. The Inferior Vena Cava (IVC) is a pliable reservoir for circulating volume, and changes in its shape during respiratory cycles are recognized as markers of intravascular volume status, albeit not routinely used in HF management.PurposeTo assess the reproducibility and test the clinical utility of using the IVC as a marker of volume status in a chronic HF population as well as to track change in IVC metrics in response to volume removal.MethodsThis was a multicentre study conducted between St. Vincent’s University Hospital (SVUH) and St. Michael’s Hospital (SMH) in Dublin. Stable outpatients were enrolled in prospective fashion during routine scheduled heart failure visits to SMH. Reproducibility was measured by three repeated measurements of maximal IVC diameter (IVCd) and collapsibility index (CI) at 0, 1 and 24 hours. Recompensating HF patients were enrolled prospectively from attendances to SVUH emergency department with acute decompensated heart failure. IVC metrics after admission were followed daily for 48 hours and then at 14 days post-admission. Dialysis patients were enrolled from patients undergoing intermittent haemodialysis in SVUH for stable chronic kidney disease. IVC metrics were measured at commencement, midpoint and end of dialysis. Data collected were correlated with markers of volume overload including natriuretic peptide (BNP).ResultsA total of 60 patients were included, 40 in the stable cohort and 10 each in the dialysis and recompensating arms. Serial IVC measurements over 24 hours showed good reproducibility, with an average standard deviation around the mean of 1.3 mm for IVCd and 7% for CI. When examining the stable cohort, patients with a dilated or poorly collapsible IVC had a significantly higher N-terminal pro B-type NP (3682 pg/mL vs 490 pg/mL, p=0.015) and poorer glomerular filtration rate (55 ml/kg/min vs 69 ml/kg/min p=0.029). Patients in the dialysis arm had an overall IVCd reduction of >30% over the course of their treatment which correlated with a 15% rise in haematocrit. Patients in the recompensating arm experienced a 30% reduction in IVCd during inpatient treatment over 48 hours. This subsequently rose after discharge back to similar size as their IVCd at enrollment, potentially reflecting the fact that the first month post-discharge is where rehospitalisation rates are highest.Conclusion(s)Measurement of IVC metrics appears to reflect volume status as well as matching fluid shifts in response to dialysis and diuretics. Use of the IVC to more precisely maintain euvolaemia in volume-dependent patients may deserve greater attention as a therapeutic target.Abstract 56 Table 1 Normal IVCd andIVCCI High IVCd or low IVCCI p value E/e’ 13 19 0.02 NTpro BNP (pg/mL) 3682 490 0.015 BNP (pg/mL) 652 329 0.013 eGFR (mL/kg/1.73 m2) 55 69 0.029
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