2) The article is at 🔓https://t.co/pcn3xUfoWf and our content expert for this program is the 1⃣st author, Kevin Sheth MD @sheth_kevin, Professor of #Neurology & #Neurosurgery from @YaleMed & the Yale Center for Brain & Mind Health (CBMH) 🧠 pic.twitter.com/2W0Kp7COKB
— cardio-met (@cardiomet_CE) February 28, 2024
4) #Intracerebral #hemorrhage #ICH is the deadliest #stroke subtype & is the most-feared🩸complication of #anticoagulation, including treatment with anti-#FXa #DOACs, which carry a much lower risk for ICH than do #VKAs.
— cardio-met (@cardiomet_CE) February 28, 2024
5b) For example, check out @Ash_Shoamanesh's programs at https://t.co/lgW9NON4ff and https://t.co/bQ4qvD5Dzb, and @md_pollack's 🧵at https://t.co/6sb8aUmcC8 . . . and still earn 🆓 CE/#CME from learning there! pic.twitter.com/z0yGxDsbuw
— cardio-met (@cardiomet_CE) February 28, 2024
7) This was a #cohort study of data from the @American_Heart Get With The Guidelines #GWTG–Stroke quality improvement registry. Direct-arriving pts w #ICH tx'd w/ anticoagulant #reversal within 24 hours of symptom onset across 465 US hospitals 2015-2021 were included.
— cardio-met (@cardiomet_CE) February 28, 2024
9a) Primary exposure variable was #DTT time, defined as time from hospital arrival to start of #reversal agent administration, analyzed by < or > 60mins, by time as a continuous variable, & by prespecified windows of 0 to 60min, 61 to 90min, 91 to 120min, & > 120min.
— cardio-met (@cardiomet_CE) February 28, 2024
10a) So here we go:
— cardio-met (@cardiomet_CE) February 28, 2024
#⃣ 484,361 pts with primary #ICH
#⃣ 2,447 hospitals
#⃣ 17,465 pts were direct-arriving w/ #anticoagulation-associated ICH, within 24h of last known well
#⃣ 9,492 had known reversal intervention status (documented use or nonuse of reversal agents). pic.twitter.com/yP72GYvvWQ
10c) Of those 7,469 pts ⤴️:
— cardio-met (@cardiomet_CE) February 28, 2024
#⃣ 4,616 (85.0%) #warfarin-treated pts had a #reversal intervention
#⃣ 2,766 (70.5%) anti-#FXa #DOAC-treated pts had a #reversal intervention
#⃣ 101 (64.7%) dabigatran-treated pts had a #reversal intervention pic.twitter.com/cfcUYu2rJH
11b) Demographic, clinical, & hospital characteristics were generally similar between pts who did & did not receive #reversal interventions. Pts who were reversed had slightly higher #SBP & were more likely to arrive by 🚑.
— cardio-met (@cardiomet_CE) February 28, 2024
12) Now, back to ⏲️: For the 5,224 pts receiving a #reversal intervention with documented workflow times, median (IQR) symptom onset-to-treatment time was 232 (142-482) min, and the median (IQR) #DTT time was 82 (58-117) min. pic.twitter.com/b87AlLNzEi
— cardio-met (@cardiomet_CE) February 28, 2024
14) As per 👇, independent hospital-level predictors were of DTT </= 60 min were:
— cardio-met (@cardiomet_CE) February 28, 2024
🏥hospital region
🏥being a teaching hospital
🏥annual #ICH volume
🏥#stroke certification status
🏥higher annual volume of #reversal treatments pic.twitter.com/QHl0YR3JsK
16a) So now to where "the rubber meets the road": what was the impact of #DTT on clinical outcomes?
— cardio-met (@cardiomet_CE) February 28, 2024
🧠 Use of a reversal agent in 60min or less was associated with ⬇️ in-hospital #mortality in both unadjusted (OR=0.78; 95% CI, 0.70-0.87) & adjusted (OR=0.74; 0.62-0.88) analyses pic.twitter.com/souuum9LMJ
17) Re secondary outcomes, there was no significant association between #DTT time & functional outcome by #mRS.
— cardio-met (@cardiomet_CE) February 28, 2024
However, earlier #reversal intervention was associated with the composite of discharge to home, inpatient rehab, & #SNF.
18b) And timing matters! In a cohort of 5000+ pts for whom time of #reversal was available, earlier tx was associated with ⬇️in-hospital mortality or d/c to hospice, and ⬆️ likelihood of d/c to home or inpatient rehab.
— cardio-met (@cardiomet_CE) February 28, 2024
20) And after all, these findings are consistent with and extend what we already knew about the pathophysiology of #ICH expansion and neurological deterioration in #anticoagulation-associated ICH and with prior research on #reversal interventions in this patient population. pic.twitter.com/fE222Bm1CV
— cardio-met (@cardiomet_CE) February 28, 2024
21b) DTT times of < 60min most clearly demonstrated a time-dependent effect of #coagulopathy #reversal, which could be even greater effect with earlier initiation.
— cardio-met (@cardiomet_CE) February 28, 2024
22b) Perhaps broader (and early) use of a specific #reversal strategy could yield even greater benefit. But as we talk about ⬆️yield, let's not overlook that this study shows that < 1 in 3 pts with #ICH on #anticoagulants were reversed within 60min. We must improve!
— cardio-met (@cardiomet_CE) February 28, 2024
23b) It's d. Pts w/ #ICH & a LOWER #NIHSS were more likely to be reversed earlier; a-c all correlated to #DTT</= 60min.
— cardio-met (@cardiomet_CE) February 28, 2024
Reversal </= 60min was associated with which of the following?
a. ⬇️in-hosp 🪦
b. d/c to home or to inpt rehab
c. better long-term outcomes
d. a & b
24) Congratulations! You just earned 0.75h 🆓 CE/#CME 🇺🇸🇬🇧🇨🇦🇪🇺 ! Claim your certificate at https://t.co/2nCq5Usxq4 and FOLLOW US for more #MedEd in the #cardiometabolic space! Thanks especially to content expert @sheth_kevin!
— cardio-met (@cardiomet_CE) February 28, 2024