1b) Follow this 🧵to earn 0.5hr 🆓 CE/#CME on your only source for expert-authored #MedEd in the #cardiometabolic space delivered wholly on X–or whatever we now call Twitter!#FOAMed #FOAMcc @MedTweetorials #cardiotwitter #neurotwitter
— cardio-met (@cardiomet_CE) September 12, 2023
3) Direct Oral #Anticoagulants (#DOACs) have been shown to be at least as effective 💪and safer 🛡️than #VKA in mgmt of life-threatening 🩸. They’re more convenient than VKA as they don’t require monitoring, are given in fixed doses, & have fewer drug-drug interactions #DDIs. pic.twitter.com/ZgJ3q9tHi1
— cardio-met (@cardiomet_CE) September 12, 2023
5) An important ❓is how to reverse the effects of #DOACs (including the commonly used anti Xa DOACs such as #rivaroxaban & #apixaban) in an #ICH and #GIB in the #emergencydepartment #ED. The main options are #Andexanet_alfa & 4-factor prothrombin complex concentrate (#4F_PCC).
— cardio-met (@cardiomet_CE) September 12, 2023
7a) We used a multicenter, observational cohort study of the #EHR from 354 US hospitals to help answer the in-hospital mortality question between #reversal and #repletion in #DOAC-related bleeds pic.twitter.com/dSQ59u8VS0
— cardio-met (@cardiomet_CE) September 12, 2023
8) This is the largest dataset yet. Over 2100 subjects in each group! Mean age 65. 40% #rivaroxaban, 60% #apixaban. pic.twitter.com/tNVci3NyNW
— cardio-met (@cardiomet_CE) September 12, 2023
10) What about #dosages? Low-dose #andexanet alfa was used in 69% of cases, & the median single dose of 4F-#PCC was 2200 units. Bleed locations (GI v ICH v other critical compartment) were also evenly weighted between treatment groups. pic.twitter.com/0qWBXqMIxO
— cardio-met (@cardiomet_CE) September 12, 2023
12) In-hospital mortality across ALL bleed types was 50% lower for patients treated with #andexanet alfa vs #4F_PCC pic.twitter.com/lDArGMUkMW
— cardio-met (@cardiomet_CE) September 12, 2023
14) Let’s look at what we DO have . . . subgroups that allow us to explore this further . . .
— cardio-met (@cardiomet_CE) September 12, 2023
16a) 🚨–another💰💰 SLIDE!
— cardio-met (@cardiomet_CE) September 12, 2023
>10% absolute difference in inhospital #mortality for pts with #ICH rec'ing #andexanet vs 4F-#PCC. Significant 45% lower odds of in-hospital mortality compared to 4F-PCC. pic.twitter.com/TbrLbEWJky
17b) 3⃣ Pts with #CKD and #HF were more likely to die. Finally, 4⃣: ⏱️! Time to tx matters in #ICH. Taking >30 minutes to initiate reversal ⬆️ in-hospital mortality by almost 2.5-fold! Need to prevent that #hematoma_expansion. pic.twitter.com/eLgdto9Suc
— cardio-met (@cardiomet_CE) September 12, 2023
19a) 🚨–💰💰yet again!
— cardio-met (@cardiomet_CE) September 12, 2023
Significantly lower in-hospital ☠️by >50% with #andexanet compared to 4F-#PCC. Never been seen before! Sensitivity analysis in only patients with an AIMS65 score, still significant ⬇️in in-hospital morality with use of andexanet alfa vs. 4F-PCC. pic.twitter.com/VOpLypUcw5
21) What make these data so special? Take a 🔭 at how they stack up to comparative prior pubs.
— cardio-met (@cardiomet_CE) September 12, 2023
Largest dataset by several fold – we have power, others do not, giving them higher risk of type 2 error. pic.twitter.com/xbF7ccCfmK
23) It's a wrap! 🎁
— cardio-met (@cardiomet_CE) September 12, 2023
🔑Largest study to compare #andexanet vs. 4F-#PCC, overcoming many limitations of prior comp data
🔑50% ⬇️odds of in-hospital ☠️for pts receiving andexanet alfa vs. 4F-PCC. This significantly lower mortality was consistent for pts with ICH & GI bleeds. pic.twitter.com/jUdXNnJ4Gk
25a) So what did YOU learn? Which of these anticoagulated pts might NOT be appropriate for early aFXa-DOAC reversal?
— cardio-met (@cardiomet_CE) September 12, 2023
a. #Melena, chronic anemia, SBP 100
b. Hematochezia, SBP 80 after 2L NS
c. Active hematemesis, known 3v #CAD
d. #UGIB, tenuous VS, “only blood” seen via endoscope
25c) It's a. Shorter time to reversal improved in-hops mortality in #ICH, but was not signif in #GIB. #Diabetes & time since last DOAC dose (<8 vs 8-18h) didn't impact ☠️for either group, and h/o #liver dz was signif for #GIB but not #ICH!
— cardio-met (@cardiomet_CE) September 12, 2023
26) So go to https://t.co/Ex1liPLjyh and claim your 0.5hr 🆓 CE/#CME because you were SMART and followed this 🧵. Greg Fermann MD @GregoryFermann & Paul Dobesh PharmD thank you for joining and urge you to FOLLOW @cardiomet_ce!
— cardio-met (@cardiomet_CE) September 12, 2023