Non-vitamin K antagonist oral anticoagulants (NOACs) include thrombin inhibitor dabigatran and coagulation factor Xa inhibitors rivaroxaban, apixaban, edoxaban, and betrixaban. NOACs have several benefits over warfarin, including faster time to the achieve effect, rapid onset of action, fewer documented food and drug interactions, lack of need for routine INR monitoring, and improved patient satisfaction. Local hemostatic measures, supportive care, and withholding the next NOAC dose are usually sufficient to achieve hemostasis among patients presenting with minor bleeding. The administration of reversal agents should be considered in patients on NOAC's with major bleeding manifestations (life-threatening bleeding, or major uncontrolled bleeding), or those who require rapid anticoagulant reversal for an emergent surgical procedure. The Food and Drug Administration (FDA) has approved two reversal agents for NOACs: idarucizumab for dabigatran and andexanet alfa for apixaban and rivaroxaban. The American College of Cardiology (ACC), American Heart Association (AHA), and Heart Rhythm Society (HRS) have released an updated guideline for the management of patients with atrial fibrillation that provides indications for the use of these reversal agents. In addition, the final results of the ANNEXA-4 study that evaluated the efficacy and safety of andexanet alfa were recently published. Several agents are in different phases of clinical trials, and among them, ciraparantag has shown promising results. However, their higher cost and limited availability remains a concern. Here, we provide a brief review of the available reversal agents for NOACs (nonspecific and specific), recent updates on reversal strategies, lab parameters (including point-of-care tests), NOAC resumption, and agents in development.

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ObjectiveTo evaluate if imaging studies such as CT pulmonary angiography (CTPA) or ventilation–perfusion (V/Q) scan are ordered according to the current guidelines for the diagnosis of pulmonary embolism (PE).MethodsWe performed a retrospective observational cohort study in all adult patients who presented to the Sparrow Hospital Emergency Department from January 2014 to December 2016 and underwent CTPA or V/Q scan. We calculated the Wells’ score retrospectively, and d-dimer values were used to determine if the imaging study was justified.ResultsA total of 8449 patients underwent CTPA (93%) or V/Q scan (7%), among which 142 (1.7%) patients were diagnosed with PE. The Wells’ criteria showed low probabilities for PE in 96 % and intermediate or high probabilities in 4 % of total patients. Modified Wells’ criteria demonstrated PE unlikely in 99.6 % and PE likely in 0.4 % of total patients. D-dimer was obtained in only 37 % of patients who were unlikely to have a PE or had a low score on Wells’ criteria. Despite a low or unlikely Wells’ criteria score and normal d-dimer levels, 260 patients underwent imaging studies, and none were diagnosed with PE.ConclusionMore than 99 % of CTPA or V/Q scans were negative in our study. This suggests extraordinary overutilisation of the imaging methods. D-dimer, recommended in patients with low to moderate risk, was ordered in only one-third of patients. Much greater emphasis of current guidelines is needed to avoid inappropriate utilisation of resources without missing diagnosis of PE.

DesCripTionA 56-year-old man with a known history of type 2 diabetes mellitus, hypertension, nephrolithiasis and gout presented with fatigue and flank pain for 3 days. The above symptoms were associated with fevers and chills. On admission, the patient's vitals were remarkable for fever with maximum temperature (T max) 39.1°C, hypotension requiring pressor support and tachycardia. On auscultation, he had reduced air entry at lung bases, distended abdomen, bipedal oedema and petechial rash over the upper extremities and the trunks. In addition, there was purplish discolouration over the left medial sacral area. Laboratory work-up was remarkable for elevated white cell count 21.4x10 9 /L (4.0-12.0x10 9 /L), creatinine 7.98 mg/dL (0.60-1.40 mg/dL), anion gap of 25, erythrocyte sedimentation rate of 70 mm/hour (0-20 mm/hour), total bilirubin of 4.9 mg/dL (0.2-1.2 mg/dL) and lipase 422 U/L (0-140 U/L). Platelet count was 31×10 3 /µL (150-400 10 3 /µL), aspartate aminotransferase of 71 U/L (10-40 U/L) and alanine aminotransferase of 37 U/L (3-45 U/L). Septic shock was suspected, and the patient was placed on empiric coverage with piperacillin-tazobactam and vancomycin. His CT scan of the abdomen (figures 1 and 2) showed left emphysematous pyelonephritis and a 4 mm obstructing proximal left ureteral stone (figure 3). Urology was consulted, and the patient underwent cystoscopy with left ureteral stent placement. Interval CT abdomen and pelvis on the fourth day of antibiotic treatment showed resolution of air from the left pelvicalyceal system; however, it showed air bubbles within L5/S1 vertebral bodies and L5-S1 disc which was suggestive of emphysematous osteomyelitis (EO) (figures 4 and 5). The patient developed acute kidney injury, so antibiotics were switched to intravenous meropenem and linezolid. Blood cultures grew Escherichia coli (E. coli), linezolid (5 days) was then discontinued and meropenem (7 days) was then switched to ceftriaxone. Soon, he developed hives, it was attributed to ceftriaxone and was shifted to aztreonam which was renally dosed. Transoesophageal echo was performed since he had prolonged E. coli bacteraemia and was negative for vegetations. The blood cultures also cleared up, and he showed clinical improvement. He was subsequently discharged on aztreonam. A follow-up MRI of the back was recommended in 8 weeks.

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Background Selection of an appropriate antithrombotic regimen in patients requiring oral anticoagulation (OAC) undergoing percutaneous coronary intervention (PCI) still remains a challenge. An ideal 9–2regimen should balance the risk of bleeding against ischemic benefit. Methods A comprehensive literature search for studies comparing triple antithrombotic therapy (TAT) vs double antithrombotic therapy (DAT) in patients requiring OAC undergoing PCI was performed in clinicalTrials.gov, PubMed, Web of Science, EBSCO Services, Cochrane Central Register of Controlled Trials, Google Scholar, and various scientific conference sessions from inception to May 1st, 2019. A meta‐analysis was performed using random‐effects model to calculate risk ratio (RR) and 95% confidence interval (CI). Results Fifteen studies were eligible and included 13 967 patients, of which 7349 received TAT and 6618 received DAT. Compared with DAT, TAT was associated with lower risk of myocardial infarction (RR, 0.82; 95%CI, 0.69–0.98; P = .03) and stent thrombosis (RR, 0.66; 95%CI, 0.46–0.96; P = .03). There was no difference in risk of trial defined major adverse cardiac events, all‐cause mortality, and stroke between two groups. Compared with DAT, TAT was associated with higher risk of trial defined major bleeding (RR, 1.67; 95%CI, 1.38–2.01; P < .00001), including thrombolysis in myocardial infarction major bleeding (RR, 1.81; 95%CI, 1.47–2.24; P < .00001) but no significant difference in risk of intracranial bleeding. Conclusion In patients requiring OAC undergoing PCI, TAT was associated with a lower risk of myocardial infarction but with a significantly higher risk of major bleeding when compared with DAT.

Background: Atrial Fibrillation (AF) is the most common cardiac arrhythmia and hypertension is the most common risk factor associated with AF. The addition of renal sympathetic nerve denervation (RSDN) to pulmonary vein isolation (PVI) in AF patients with hypertension has been reported to improve clinical outcomes. Methods: A systematic search was performed for studies on patients with AF and hypertension that compared RSDN with PVI versus PVI-alone. Risk ratio (RR) for categorical variables and mean difference (MD) for continuous variables with 95% confidence intervals were used. Results: Seven studies with a total of 734 patients were included. A total of 340 patients were in the RSDN + PVI group (46.32%) and 394 (53.67%) in the PVI group. A total of 608 patients had paroxysmal AF (83%) while 126 patients had persistent AF (17%). At 12 months follow-up, RSDN + PVI decreased the overall risk of AF recurrence in hypertensive patients with RR 0.60 [95% CI 0.50-0.72, P < .00001]. A subgroup analysis performed in patients with drug-resistant hypertension showed a similar reduction in AF recurrence with RR 0.61 [95% CI: 0.47-0.79, P = .0002). Procedure duration MD + 28.05 min [95% CI: 18.88-37.23, P < .00001] and fluoroscopy duration MD + 5.59 min [95% CI: 3.31-8.19, P < .00001] were significantly longer with the RSDN + PVI group. There was no significant difference in complications between the two groups. Conclusion: The addition of RSDN to PVI in patients with AF and hypertension appears safe and decreases AF recurrence. Similar results were observed in patients with drugresistant hypertension. Larger trials are needed to confirm these results.