2a) 2⃣ very cool aspects of this work: first, it's truly #multidisciplinary, with international authors from #emergencymedicine, #gastroenterology, #surgery, & #hematology. Second, it has roots not in ancient 🇬🇷 but in 1940s and 1950s, courtesy of Dalkey and Helmer pic.twitter.com/xZP6QMDD9c
— cardio-met (@cardiomet_CE) November 1, 2023
3) This program is accredited for 0.5hr CE/#CME and is intended for #healthcare providers. It is supported by an independent educational grant from AstraZeneca. Statement of accreditation & faculty disclosures are at https://t.co/gvXca4G9Xm.
— cardio-met (@cardiomet_CE) November 1, 2023
FOLLOW US for more #MedEd #FOAMed
5a) So the #Delphi method, as above, was first introduced by the #RAND Corporation in the 1950s to prepare forecasts of future technological capabilities of potential interest to the military 🪖 pic.twitter.com/u6UToTvas8
— cardio-met (@cardiomet_CE) November 1, 2023
5c) @US_FDA approved of #andexanet alfa for reversal of major and life-threatening 🩸in the setting of #DOAC #anticoagulation, but there has been uncertainty among clinicians as to just what defines "life-threatening" #GIB and therefore . . .
— cardio-met (@cardiomet_CE) November 1, 2023
6a) How big a problem is this? Well, 🩸is the #1 complication of #anticoagulation-related #emergencydepartment visits. The most common 🩸in this setting is #GIB. Mortality rates > 10% are reported for upper GIB requiring hospitalization even without anticoagulation on board. pic.twitter.com/pesSIS7vYt
— cardio-met (@cardiomet_CE) November 1, 2023
7a) Understanding what defines life-threatening #GIB can help ensure a standardized tx approach, reduce delays to tx, & improve patient outcomes. Most recent #guidelines from @AmCollegeGastro & @CanGastroAssn are from 2011 consensus report & do not address #DOAC-related GIB.
— cardio-met (@cardiomet_CE) November 1, 2023
8a) This group conducted a #Delphi panel exercise to define & contextualize “life-threatening” #GIB among 8 selected expert practitioners based on their experience, knowledge, and consensus.
— cardio-met (@cardiomet_CE) November 1, 2023
9a) Their consensus-building approach consisted of 2 rounds of survey questionnaires, followed by virtual, real-time consensus-building exercises.
— cardio-met (@cardiomet_CE) November 1, 2023
9c) They also specifically reviewed the NICE guidance on the potential use of #andexanet alfa to reverse an #FXa inhibitor in the presence of a potentially life-threatening #GIB (https://t.co/BNts5T7MaQ) and measures of hemodynamic instability & shock. pic.twitter.com/8P0pS4VZvr
— cardio-met (@cardiomet_CE) November 1, 2023
11) The panel reached consensus in 4⃣ areas:
— cardio-met (@cardiomet_CE) November 1, 2023
🩸 definition + clinical signs of #DOAC-related, life-threatening #GIB
🩸signs/sx of hypovolemia & hemodynamic instability
🩸factors related to mortality risk in these pts
🩸decision-making considerations for use of DOAC reversal tx
12b) Most common sites for a life-threatening bleed: upper (eg esophageal/gastric/duodenal) >> lower (colonic, jejunal, ileal) pic.twitter.com/yPVORLnU1J
— cardio-met (@cardiomet_CE) November 1, 2023
13b) #Hypotension is the clearest objective sign of hypovolemia; #SBP <90 is an important sign. #Tachycardia must be interpreted in context (eg for pts taking rate-altering drugs, such as beta blocker therapy & #CCBs.
— cardio-met (@cardiomet_CE) November 1, 2023
15a) 4⃣ Decision-making considerations for the administration of #FXa #DOAC reversal therapy
— cardio-met (@cardiomet_CE) November 1, 2023
💉hypovolemia and hemodynamic instability, overt bleeding, and the amount of time elapsed since the last dose of an FXa inhibitor are most important considerations
16) Panel consensus shown here: pic.twitter.com/3PX0jlIQ9f
— cardio-met (@cardiomet_CE) November 1, 2023
17b) 🩸Panelists agreed that this decision should be individualized and recommended reversal therapy within 1 h of initial #emergencydepartment evaluation, when possible. pic.twitter.com/u4YdkfbJPE
— cardio-met (@cardiomet_CE) November 1, 2023
18b) It's c. #UGI sources are more common in life-threatening #GIB, esp #PUD, #NSAID gastritis, & esophageal #varices. Choices a, b, & d are all correct. Important #comorbidities are 🫀, 🫘 , & #liver disease, as well as #malignancy.
— cardio-met (@cardiomet_CE) November 1, 2023
19b) It's c. Although the incidence risk of #GIB may be higher with rivaroxaban than with apixaban, AND the dosing of #andexanet for reversal may differ by anti-#FXa agent, this does not enter into the decision whether or not to #reverse.
— cardio-met (@cardiomet_CE) November 1, 2023
20) So you don't need an ORACLE (get it, #Delphi??) to tell you that you just earned 0.5hr 🆓 CE/#CME from @cardiomet_ce. Claim your certificate now at https://t.co/uHASaIa7Sj. And thanks to #BrooksCashMD, @GregoryFermann et al for this fascinating article!
— cardio-met (@cardiomet_CE) November 1, 2023