2) This program is a #journalclub. The reviewed article is at https://t.co/TwtVzbcO82. It comes from the Golden Jubilee National Hospital, Clydebank, UK. ๐ด๓ ง๓ ข๓ ณ๓ ฃ๓ ด๓ ฟ๐ฌ๐ง The authors are #NawwarAlAttara #AhmedSedeeka Philip McCall @philipmccall #JenniferTravers pic.twitter.com/L2ZoX8EA66
— cardio-met (@cardiomet_CE) December 20, 2023
4a) This program is intended for #HCPs and is supported by an independent educational grant from AstraZeneca. Faculty disclosures and statement of accreditation at https://t.co/gvXca4G9Xm.#FOAMed #CardioTwitter #MedTwitter @MedTweetorials
— cardio-met (@cardiomet_CE) December 20, 2023
5) Therapeutic #anticoagulation creates concern for adequate #hemostasis when an invasive procedure or surgery cannot be delayed. When the anticoagulant is a #DOAC the concern may be even greater because it is often difficult to assess anticoagulation status "stat."
— cardio-met (@cardiomet_CE) December 20, 2023
7a) Therefore #reversal in a pt with acute #aortic syndrome represents a quandary. The patient IS bleeding, usually into a false lumen, and the bleeding is contained. But . . . 1โฃ surgery is the usual tx for type A dissection as there is a risk for fatal rupture.
— cardio-met (@cardiomet_CE) December 20, 2023
8) So to our subject article–what did these clinicians face? 3 pts who required repair of type A #aorticdissection while under the influence of a #DOAC. #Andexanet was administered as a bolus of 400mg IV followed by IV infusion. Patient details: pic.twitter.com/sL6XfOQPuz
— cardio-met (@cardiomet_CE) December 20, 2023
9b) Hey, this is accredited #MedEd, so we can talk off-label as long as that's clearly stated. #Andexanet is not approved for reversal of #edoxaban, but rather only for #apixaban & #rivaroxaban. And then there's that whole reversal-for-surgery issue. Anyway . . .
— cardio-met (@cardiomet_CE) December 20, 2023
11) On that concern, see ๐https://t.co/GlzyrTvqZj and ๐ https://t.co/63j5ZwySbX, among others.
— cardio-met (@cardiomet_CE) December 20, 2023
12b) They noted that the intramural clot within the dissected aorta was semi-liquid, and in fact, they saw clots in the #CPB reservoir, indicating insufficient heparinization. pic.twitter.com/y7PGwasE9F
— cardio-met (@cardiomet_CE) December 20, 2023
13b) . . . heparin reversal with #protamine was evidenced by the return of #ACT to pre-heparinization levels (<130s), but excessive diffuse intraoperative bleeding was noted.
— cardio-met (@cardiomet_CE) December 20, 2023
14b) . . . but, it resulted in failure of the #ACT test to demonstrate therapeutic heparinization. This created confusion as to whether the pt was resistant to heparin, or whether the #andexanet was causing unresponsiveness to heparin.
— cardio-met (@cardiomet_CE) December 20, 2023
14d) This also impacts anti-#FXa activity testing (including the #ACT). As yet there have been no prospective studies in vascular surgery patients requiring #UFH after #andexanet dosing to reverse #DOAC anticoag.
— cardio-met (@cardiomet_CE) December 20, 2023
14f) The authors of that case report, including @heleenapostel @elhambidar, provided this very engaging graphic of their explanation of the case. pic.twitter.com/4aKjaqQxb1
— cardio-met (@cardiomet_CE) December 20, 2023
15b) . . . falsely elevated anti-#FXa activity levels will be detected โก๏ธpotential substantial underestimation of the reversal activity of andexanet.
— cardio-met (@cardiomet_CE) December 20, 2023
16b) . . . create the need for higher doses of heparin as heparin effect is also inhibited by andexanet complicating the perioperative monitoring of anticoagulation during #CPB. The use of anti-#FXa activity assays is unreliable in these conditions.
— cardio-met (@cardiomet_CE) December 20, 2023
17b) The correct answer is c. Andexanet is approved to reverse the anticoagulant effects of anti-#FXa #DOACs #apixaban & #rivaroxaban; mechanistically should work equally well on #edoxaban and #LMWH, but not approved at this time (fewer pts in #ANNEXa_4 tx'd w/ these agents).
— cardio-met (@cardiomet_CE) December 20, 2023
18b) It's a. This effect can impair or even fully neutralize the effect of heparin โก๏ธ subtherapeutic anticoagulation despite repeated heparin boluses.
— cardio-met (@cardiomet_CE) December 20, 2023
19) And that's it! You can now claim your 0.5hr ๐ CE/#CME at https://t.co/QLd5gFRMVG. And please FOLLOW US for more #MedEd delivered wholly by #tweetorial!
— cardio-met (@cardiomet_CE) December 20, 2023
๐ to @connors_md & @md_pollack. Happy holidays!!