1b) #Physicians #Nurses #Pharmacists #physicianassociate #NPs earn 0.5h CE/#CME from @academiccme for following this 🧵 pic.twitter.com/WTdiTjcABR
— cardio-met (@cardiomet_CE) October 18, 2022
3) And we start with a case . . . 79♂️ with HTN, Afib on #apixaban, HLD, #DM, in his usual state of health til this am. He develops headache, L-sided weakness. His wife calls EMS. He presents to ED as a pre-🏥 stroke alert. Initial VS 213/110, HR 78, RR 13, satting 100% on NRB.
— cardio-met (@cardiomet_CE) October 18, 2022
4b) His #NIHSS (https://t.co/OaxcCsSZpO) is a 7. He undergoes a #CT which demonstrates the following: pic.twitter.com/k5kmWBM6Uv
— cardio-met (@cardiomet_CE) October 18, 2022
6) In the acute setting, the focus is always on
— cardio-met (@cardiomet_CE) October 18, 2022
A–Airway protection (💨 )
B–Bleeding: here, anticoagulation reversal (🩸🤚)
C–Circ: here, lowering the blood pressure (👇BP)
Fortunately, the patient has a GCS 15. Our focus then is initially on B&C
8) The newest spontaneous ICH #sICH guidelines place focus on
— cardio-met (@cardiomet_CE) October 18, 2022
1⃣ Organizing systems of care to rapidly triage pts w/ #sICH
2⃣ Preventing secondary injury
3⃣ Understanding underlying etiology with a focus on the small vessel disease that results in many ICH cases. pic.twitter.com/DpUAfSir0j
10) Additionally, the CT #angiogram can provide valuable information by ruling out large vessel etiologies (#aneurysm, #AVM) or by identifying a #spot_sign, another marker than may portend early hemorrhage expansion.
— cardio-met (@cardiomet_CE) October 18, 2022
See https://t.co/4EhPHKvvYj pic.twitter.com/R8UpaCn6M4
11b) However, even though acute perihematomal oligemia was demonstrated using #MRI and #CTP, we also learned from #PET and nuclear studies that this oligemia reverses thanks to #autoregulation.
— cardio-met (@cardiomet_CE) October 18, 2022
👉https://t.co/JkHXFfG4UV
👉https://t.co/mfiJxFoCEt
👉🔓https://t.co/x54Dw0dDJt pic.twitter.com/waKXbzn1BO
13) If these benefits outweigh potential risks of acute BP lowering, then what target should we aim for?
— cardio-met (@cardiomet_CE) October 18, 2022
15) If these two trials tested the same thing, why were the differences so disparate? Well, if you compare the actual BP’s between the 2⃣ trials, it’s almost as if 3⃣ groups existed:
— cardio-met (@cardiomet_CE) October 18, 2022
👉the INTERACT control
👉the INTERACT intervention/ATACH control
👉the ATACH intervention: pic.twitter.com/m0sYtHqSN3
17) ⚠ Remember individual patient characteristics take preference & there can be no blanket treatment for all. If someone has truly ⬆️ICP (massive hemorrhage, cerebellar hemorrhage with hydro) & is in extremis, acute BP ⬇️may still lead to 🧠⤵️perfusion & make things worse. ⚠
— cardio-met (@cardiomet_CE) October 18, 2022
19) Similarly, aggressively lowering the #BP too fast and too hard can also lead to worsened outcomes as demonstrated in an #ATACH sub-study: (🔓https://t.co/T9gbFHvxvZ ) pic.twitter.com/UX0ZyxlfhB
— cardio-met (@cardiomet_CE) October 18, 2022
21) While an #INTERACT pre-planned analysis demonstrated that patients with less #BP variability had better outcomes (https://t.co/lTsebVKnu3), we still don’t know what agents are best (gtt vs. IV push) but the goal is limiting variability🏆. pic.twitter.com/BCXyPS83tH
— cardio-met (@cardiomet_CE) October 18, 2022
23) Remember B (bleeding) back in our ABCD priorities for this pt? We must move on to #anticoagulation reversal. He takes apixaban! Remember Factor Xa Inhibitors (FXa 🛑) act by binding to the active site of FXa, thus preventing the conversion of #prothrombin to #thrombin: pic.twitter.com/G8z7WCxiIW
— cardio-met (@cardiomet_CE) October 18, 2022
25) Mark your response and RETURN TOMORROW for the correct answer, more education and your link to 🆓CE/#CME! 👋@stephanamayer @critcaremed @alimkakeng @MiddeldorpS @connors_md @walinjom @CDernigo @MicieliA_MD @MayaHolsen @johnfanikos @beaverspharmd @SnayCardsPharmD
— cardio-met (@cardiomet_CE) October 18, 2022
26b) So did you answer the question in tweet 24 above? If not, scroll back ⤴️and commit! pic.twitter.com/hQzeAHv87s
— cardio-met (@cardiomet_CE) October 19, 2022
28) aPCC/4F-PCC contain coagulation factors and likely increase thrombin generation through the replenishment of these factors, but do not change FXa activity.
— cardio-met (@cardiomet_CE) October 19, 2022
👉4F-#PCC (KCentra specifically) is dosed at 25-50 units/Kg (up to 100kg; max dose = 5000 units)
30) Andexanet is a FXa imitator molecule with ⬆️ affinity for FXa🛑, thus displacing the FXa🛑. This means that FXa interacts with #thrombin again!
— cardio-met (@cardiomet_CE) October 19, 2022
Dosage (low= 880mg, high = 1760mg) depends on FxA 🛑 dosage and timing of last dose: (https://t.co/GbDtR1ujkX) pic.twitter.com/HcZW1KQJvI
32) #Andexanet was granted temporary @US_FDA approval for reversal of FXa🛑 after ANNEXA-4 was released: 🔓https://t.co/8YZ1dGX6pX. The reason for temporary approval? Patients were excluded if: GCS<7, ICH vol >60cc, or patient needed surgery (EVD or evacuation).
— cardio-met (@cardiomet_CE) October 19, 2022
34) Whether #andexanet_alfa receives final FDA approval for reversal will depend on the results of the extension study (see: https://t.co/MJ28ErHrDo), which will include a surgical arm. Ideally, there will also be a RCT to directly determine which reversal strategy is best.
— cardio-met (@cardiomet_CE) October 19, 2022
36) Practically speaking, time to reversal is critically important #timeisbrain (🧠 = ⏰)!
— cardio-met (@cardiomet_CE) October 19, 2022
Whichever approved agent is most rapidly available should be administered.
37b) Family reported a 5mg BID dose which he had last taken 10 hours prior. This is low dose reversal.
— cardio-met (@cardiomet_CE) October 19, 2022
👉5 vials reconstituted and given as bolus + infusion
👉Bolus: 400mg IV administered at 30mg/min (~14 mins)
👉Infusion: 480mg IV given @ 4mg/min x 120 mins pic.twitter.com/nQg3uH1Fzz
38) Pt underwent repeat CT head at 6h to assess for hematoma expansion & the hemorrhage appeared unchanged (phew!😥).
— cardio-met (@cardiomet_CE) October 19, 2022
An interval study btwn 6 and/or at 24 hours is recommended in guidelines to assess for the possibility of 🩸 expansion & to determine the final hematoma volume. pic.twitter.com/jftY80UXmO
40) #ICH care in the ICU should then focus on
— cardio-met (@cardiomet_CE) October 19, 2022
🤔Diagnostic workup, often with MRI to look for evidence of microbleeds in the deep territory (chronic hypertension) or cortex (associated with CAA).
💥Management of elevated #ICP as needed
🚶Early rehabilitation
42) Quick #ICH Reminder 2:
— cardio-met (@cardiomet_CE) October 19, 2022
👉Currently, Seizure PPX is 🛑
👉cEEG can be used to detect sz in pts with unexplained AMS
👉PEACH demonstrated ⬇ in EEG sz with levetiracetam; this small trial was terminated early, underpowered, & no clinical sz were detected.
👉Further study needed! pic.twitter.com/tHmH40rtvQ
44) Closing points:
— cardio-met (@cardiomet_CE) October 19, 2022
🧠 #ICH can be life-threatening and devastating and rapid action is required
🧠 🔎 on airway management, #BP control, and anticoagulation reversal
👉 #Andexanet or #aPCC/4F#PCC are reasonable for DOAC reversal – but give tx fast!
46) @rkchoi & @caseyalbin & @academiccme thank you for joining & learning with us! Now go to https://t.co/ODUtDv2HV9 and claim your 0.5h 🆓CE/#CME . . . and FOLLOW US for more education by #cardiometabolic experts!
— cardio-met (@cardiomet_CE) October 19, 2022