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