Extensive skin necrosis in an elderly woman on dabigatran

Dabigatran, a novel oral anticoagulant, is a direct thrombin inhibitor and is being increasingly used owing to the advantage of dosing without the need for laboratory monitoring. While extensive skin necrosis is known to be associated with oral anticoagulants such as warfarin and factor Xa inhibitors, dabigatran toxicity typically manifests with bleeding, especially in the elderly. We describe a 70-year-old woman who was prescribed dabigatran for the treatment of unprovoked deep venous thrombosis. She developed bleeding diathesis along with extensive skin necrosis and acute kidney injury shortly after commencing the drug. Haemodialysis was given in view of dabigatran toxicity and complications of kidney dysfunction which resolved promptly over a week. However, the patient succumbed to severe sepsis from secondary skin infections. It is crucial to closely monitor for signs of dabigatran toxicity, especially in the elderly patients.

BETWEEN THE DEVIL AND DEEP BLUE SEA - ANTICOAGULATION IN CARDIOEMBOILC STROKE

Stroke is the commonest cause of mortality and morbidity after coronary artery disease. According in India stroke factsheet updated in 2021, the estimated age-adjusted prevalence rate for stroke ranges between 84-262/100,000 in rural and 334-424/100,000 in urban areas. Ischemic stroke is the commonest followed by cardioembolic which is 20% which may be higher in developing countries because of illiteracy and lower socioeconomic status. Cardioembolic strokes are usually severe in presentation and prone for early recurrence. The risk of long term recurrence and mortality are also high. Hemorrhagic transformation occurs in up to 71% of cardioembolic strokes. Atrium, ventricle and valves are the high-risk origins. This article highlights the importance of balancing between thromboembolism and bleeding risks while making therapeutic decisions. Anticoagulation is indicated both for primary and secondary stroke prevention. The role of Novel oral anticoagulant versus warfarin and they edge over as they don't need INR monitoring .Thrombogenic atrial substrate even in the absence of atrial brillation can predispose to atrial thromboembolism.TEE allows better visualization (aortic atheromas, patent foramen ovale, atrial septal aneurysms) of earlier crytogenic lesions elucidating a cause and thereby reducing the embolic risk. Because of varied etiology and presentation, a tailored individual approach is needed

Assessment of Association Between Venous Occlusion and Infection of Cardiac Implantable Electronic Devices

The increasing number of patients treated with cardiac implantable electronic devices (CIEDs) and indications for complex pacing requires system revisions. Currently, data on venous patency in repeat CIED surgery involving lead (re)placement or extraction are largely missing. This study aimed to assess venous patency and risk factors in patients referred for repeat CIED lead surgery, emphasizing CIED infection. All consecutive patients requiring extraction, exchange, or additional placement of ≥1 CIED leads during reoperative procedures from January 2015 to March 2020 were evaluated in this retrospective study. Venography was performed in 475 patients. Venous patency could be assessed in 387 patients (81.5%). CIED infection with venous occlusion was detected in 74 patients compared with venous occlusion without infection in 14 patients ( P < .05). Concerning venous patency, novel oral anticoagulant medication appeared to be protective ( P < .05; odds ratio [OR]: .35). Infection of the CIED appeared to be strongly associated with venous occlusion (OR: 16.0). The sensitivity was only 64.15%, but the specificity was 96.1%. Number of leads involved and previous CIED procedures were not associated with venous occlusion. In conclusion, in patients with CIED, venous occlusion was strongly associated with device infection, but not with the number of leads or previous CIED procedures.

Reversible Neurological Adverse Reaction to Apixaban

Prescriptions for the novel oral anticoagulant factor Xa inhibitors (rivaroxaban, apixaban, edoxaban) have equalled or exceeded those for vitamin K antagonists in many clinical settings requiring chronic anticoagulation, and those of injectable heparins for deep vein thrombosis prophylaxis. The authors report the case of an 80-year-old woman followed by her cardiologist for permanent atrial fibrillation who was prescribed apixaban. Within a few days the patient developed neurological symptoms of imbalance and non-vertiginous dizziness, headache, confusion/disorientation and asthenia. Her symptoms began to resolve after the drug was stopped, with return to baseline function within 72 h. The plasma concentration of apixaban was 4 times higher than the laboratory upper limit of normal. Symptoms did not recur when the patient was switched to rivaroxaban therapy.

Stroke due to Left Atrial Appendage Thrombus after Pulmonary Vein Isolation despite Novel Oral Anticoagulant: A Case Report

In patients with atrial fibrillation, catheter ablation is suggested to reduce the mortality rate and is thus frequently performed. However, peri- and postprocedural thromboembolic complications as well as high recurrence rates of atrial fibrillation limit its advantages and require concomitant anticoagulation. With the advent of novel oral anticoagulants (NOACs), fixed dosing without routine laboratory monitoring became feasible. Nevertheless, several factors are associated with either an overdose or an insufficient drug activity of NOACs. We report on a patient with atrial fibrillation undergoing catheter ablation and cardioversion suffering from ischemic stroke despite being under oral anticoagulation. It turned out that the drug activity of the NOACs used was repeatedly insufficient in spite of regular intake and adequate dosing. In sum, drug activity controls should be taken into consideration in patients with thrombotic events despite oral anticoagulation with NOACs.

A liquid chromatography-tandem mass spectrometry method for the determination of apixaban in human plasma and its application to pharmacokinetics studies in the Indian population

Apixaban is a novel oral anticoagulant intended to treat and prevent blood clots and to prevent strokes in patients with nonvalvular atrial fibrillation.

Risk management in patients with atrial fibrillation and comorbid conditions: potentialities of edoxaban

The review article presents current data on the clinical and prognostic significance, as well as on the prevalence of comorbidities in patients with atrial fibrillation (AF). The prevalence of hypertension, diabetes and heart failure in patients with AF is discussed according to the Russian and foreign registry studies, randomized clinical trials. The problem of the effect of comorbidity on the risk of embolism and bleeding in AF is outlined. Potentialities of a novel oral anticoagulant edoxaban (based on the ENGAGE AF-TIMI 48 trial) for managing the risks of thromboembolic and bleeding events in AF and comorbidities. Sub-analyzes of the ENGAGE AF-TIMI 48 trial were discussed, which demonstrated efficacy comparable to warfarin in the embolism prevention and higher safety against bleeding, regardless of the comorbidity profile.

Abstract 17102: Lower Rate of Device-Related Thrombosis in Watchman Patients Undergoing a Genotype-Tailored Antithrombotic Strategy

Introduction: Loss-of-function (LOF) polymorphisms of the cytochrome P450 2C19 (CYP2C19) gene are associated with reduced hepatic bioactivation of clopidogrel. Hypothesis: To evaluate the prevalence of LOF polymorphisms of CYP2C19 and the incidence of device-related thrombosis (DRT) when clopidogrel is replaced with half dose novel oral anticoagulant (NOAC) in patients with reduced clopidogrel metabolism. Methods: Consecutive Watchman patients were genotyped for CYP2C19 polymorphisms. Patients with reduced clopidogrel metabolism received half dose NOAC plus aspirin during the “dual antiplatelet therapy (DAPT) phase” post-Watchman implantation (between 45 days and 6 months). The incidence of DRT among genotyped patients (Group I, n=401) and a control group without genotypization (Group II, n=357) which received standard DAPT is reported. Results: Overall, 758 Watchman patients were included (mean age: 75±8 yrs, 63% males, CHA 2 DS 2 -VASc: 4.6±1.5; HAS-BLED: 3.2±1.1). Of the 401 Group 1 patients, 25.69% (n=103) were reduced clopidogrel metabolizers. In 87.4% of them, clopidogrel was replaced with half-dose NOAC during the “DAPT phase” post-Watchman implantation whereas 12.6% received ASA plus full-dose NOAC due to the presence of a significant peri-device leak. During the “DAPT phase”, DRT was documented in 1 (0.2%) patient of Group I and 7 (1.96%) patients of Group II (p=0.029). On multivariate analysis, a genotype-tailored antithrombotic strategy was associated with a significant reduction in DRT (odds ratio: 0.11; 95% confidence interval: 0.01 - 0.98; p-value: 0.048). Conclusions: Approximately 25% of our Watchman patients had clopidogrel resistance. Substitution of clopidogrel with half dose NOAC in reduced clopidogrel metabolizers significantly reduced the incidence of DRT.