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Melamed R, Tierney DM, Xia R, Brown CS, Mara KC, Lillyblad M, Sidebottom A, Wiley BM, Khapov I, Gajic O. Safety and Efficacy of Reduced-Dose Versus Full-Dose Alteplase for Acute Pulmonary Embolism: A Multicenter Observational Comparative Effectiveness Study. Crit Care Med 2024; 52:729-742. [PMID: 38165776 DOI: 10.1097/ccm.0000000000006162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2024]
Abstract
OBJECTIVES Systemic thrombolysis improves outcomes in patients with pulmonary embolism (PE) but is associated with the risk of hemorrhage. The data on efficacy and safety of reduced-dose alteplase are limited. The study objective was to compare the characteristics, outcomes, and complications of patients with PE treated with full- or reduced-dose alteplase regimens. DESIGN Multicenter retrospective observational study. SETTING Tertiary care hospital and 15 community and academic centers of a large healthcare system. PATIENTS Hospitalized patients with PE treated with systemic alteplase. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Pre- and post-alteplase hemodynamic and respiratory variables, patient outcomes, and complications were compared. Propensity score (PS) weighting was used to adjust for imbalances of baseline characteristics between reduced- and full-dose patients. Separate analyses were performed using the unweighted and weighted cohorts. Ninety-eight patients were treated with full-dose (100 mg) and 186 with reduced-dose (50 mg) regimens. Following alteplase, significant improvements in shock index, blood pressure, heart rate, respiratory rate, and supplemental oxygen requirements were observed in both groups. Hemorrhagic complications were lower with the reduced-dose compared with the full-dose regimen (13% vs. 24.5%, p = 0.014), and most were minor. Major extracranial hemorrhage occurred in 1.1% versus 6.1%, respectively ( p = 0.022). Complications were associated with supratherapeutic levels of heparin anticoagulation in 37.5% of cases and invasive procedures in 31.3% of cases. The differences in complications persisted after PS weighting (15.4% vs. 24.7%, p = 0.12 and 1.3% vs. 7.1%, p = 0.067), but did not reach statistical significance. There were no significant differences in mortality, discharge destination, ICU or hospital length of stay, or readmission after PS weighting. CONCLUSIONS In a retrospective, PS-weighted observational study, when compared with the full-dose, reduced-dose alteplase results in similar outcomes but fewer hemorrhagic complications. Avoidance of excessive levels of anticoagulation or invasive procedures should be considered to further reduce complications.
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Affiliation(s)
- Roman Melamed
- Department of Critical Care, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN
| | - David M Tierney
- Department of Graduate Medical Education, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN
- Department of Medicine, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN
| | - Ranran Xia
- Department of Pharmacy, Mayo Clinic, Rochester, MN
| | - Caitlin S Brown
- Department of Pharmacy, Mayo Clinic, Rochester, MN
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN
| | - Kristin C Mara
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Matthew Lillyblad
- Department of Pharmacy, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN
| | - Abbey Sidebottom
- Department of Care Delivery Research, Allina Health, Minneapolis, MN
| | - Brandon M Wiley
- Department of Medicine, Los Angeles General Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Ivan Khapov
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Ognjen Gajic
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
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Wolfe A, Phillips A, Tierney DM, Melamed R, Qadri G, Lillyblad M, Smith C, St Hill C, Stenzel AE, Beddow D, Kirven J, Kethireddy R, Patel L. Retrospective Analysis of Direct-Acting Oral Anticoagulants (DOACs) Initiation Timing and Outcomes After Thrombolysis in High- and Intermediate-Risk Pulmonary Embolism. Clin Appl Thromb Hemost 2023; 29:10760296231156414. [PMID: 36890702 PMCID: PMC9998410 DOI: 10.1177/10760296231156414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023] Open
Abstract
Direct-acting oral anticoagulants (DOACs) are prescribed in the treatment of venous thromboembolism, including pulmonary embolism (PE). Evidence is limited regarding the outcomes and optimal timing of DOACs in patients with intermediate- or high-risk PE treated with thrombolysis. We conducted a retrospective analysis of outcomes among patients with intermediate- and high-risk PE who received thrombolysis, by choice of long-term anticoagulant agent. Outcomes of interest included hospital length of stay (LOS), intensive care unit LOS, bleeding, stroke, readmission, and mortality. Descriptive statistics were used to examine characteristics and outcomes among patients, by anticoagulation group. Patients receiving a DOAC (n = 53) had shorter hospital LOS compared to those in warfarin (n = 39) and enoxaparin (n = 10) groups (mean LOS 3.6, 6.3 and 4.5 days, respectively; P < .0001). This single institution retrospective study suggests DOAC initiation <48 h from thrombolysis may result in shorter hospital LOS compared to DOAC initiation ≥48 h (P < .0001). Further larger studies with more robust research methodology are needed to address this important clinical question.
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Affiliation(s)
- Adam Wolfe
- Department of Graduate Medical Education, 21878Abbott Northwestern Hospital, 5531Allina Health, Minneapolis, MN, USA
| | - Angela Phillips
- Department of Graduate Medical Education, 21878Abbott Northwestern Hospital, 5531Allina Health, Minneapolis, MN, USA
| | - David M Tierney
- Department of Graduate Medical Education, 21878Abbott Northwestern Hospital, 5531Allina Health, Minneapolis, MN, USA
| | - Roman Melamed
- Department of Critical Care, 21878Abbott Northwestern Hospital, 5531Allina Health, Minneapolis, MN, USA
| | - Ghazi Qadri
- Department of Internal Medicine, 21878Abbott Northwestern Hospital, 5531Allina Health, Minneapolis, MN, USA
| | - Matthew Lillyblad
- Department of Pharmacy, 21878Abbott Northwestern Hospital, 5531Allina Health, Minneapolis, MN, USA
| | - Claire Smith
- Care Delivery Research, 5531Allina Health, Minneapolis, MN, USA
| | | | | | - David Beddow
- Department of Internal Medicine, 21878Abbott Northwestern Hospital, 5531Allina Health, Minneapolis, MN, USA
| | - Justin Kirven
- Department of Internal Medicine, 21878Abbott Northwestern Hospital, 5531Allina Health, Minneapolis, MN, USA
| | - Rajesh Kethireddy
- Department of Internal Medicine, 21878Abbott Northwestern Hospital, 5531Allina Health, Minneapolis, MN, USA
| | - Love Patel
- Department of Internal Medicine, 21878Abbott Northwestern Hospital, 5531Allina Health, Minneapolis, MN, USA
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Behrend K, Lillyblad M, Skelton P, Stanberry L, Garberich RF, Eckman PM, Hryniewicz K. Serotonergic antidepressants and hospitalization for bleeding in patients supported with a continuous flow left ventricular assist device. J Heart Lung Transplant 2021; 40:1599-1604. [PMID: 34419371 DOI: 10.1016/j.healun.2021.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 05/18/2021] [Accepted: 06/28/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Continuous flow left ventricular assist devices (CF -LVAD) improve survival in patients with advanced heart failure, but confer risk of bleeding complications. Serotonergic antidepressants (SA) are commonly used in heart failure patients receiving LVADs, but their inhibitory effect on platelet function may contribute to bleeding risk. METHODS We performed a retrospective analysis of LVAD patients at our institution from 2016 -2019 comparing patients treated with SA after LVAD to those without SA. Demographic and clinical variables related to bleeding were collected on discharge from index hospitalization for CF-LVAD implantation and on admission for any bleeding event. The primary endpoint was incidence of bleeding requiring hospitalization after discharge. Secondary endpoints included overall number of admissions for bleeding, time to first hospitalization for a bleeding event, and incidence rate of hospitalizations for bleeding per patient year. RESULTS 100 patients met inclusion criteria for the study. A total of 5 patients without a history of SA use and 31 patients who were prescribed SA after CF -LVAD implant were readmitted for a bleeding event after initial implant hospitalization (15% vs 46%, p = 0.004). Bleeding rate per person year (0.3 vs 0.61, p = 0.01) were significantly less in patients without SA use. Age-adjusted multivariable analysis found SA use to be associated with a hospitalization for bleeding (HR 2.3, 95% CI 0.99 -5.4). The higher incidence of hospitalization for bleeding was driven by non-gastrointestinal anatomical sites (6% vs 28%, p = 0.02) with a HR 7.7 (95% CI 0.96 -62). CONCLUSIONS SA treatment after CF-LVAD implantation was associated with an increased risk for bleeding complications requiring hospitalization, particularly non-gastrointestinal bleeding.
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Affiliation(s)
- Keith Behrend
- Abbott Northwestern Hospital and Minneapolis Heart Institute, Part of Allina Health, Minneapolis, Minnesota.
| | - Matthew Lillyblad
- Abbott Northwestern Hospital and Minneapolis Heart Institute, Part of Allina Health, Minneapolis, Minnesota
| | - Paige Skelton
- Abbott Northwestern Hospital and Minneapolis Heart Institute, Part of Allina Health, Minneapolis, Minnesota
| | - Larissa Stanberry
- Abbott Northwestern Hospital and Minneapolis Heart Institute, Part of Allina Health, Minneapolis, Minnesota
| | - Ross F Garberich
- Abbott Northwestern Hospital and Minneapolis Heart Institute, Part of Allina Health, Minneapolis, Minnesota
| | - Peter M Eckman
- Abbott Northwestern Hospital and Minneapolis Heart Institute, Part of Allina Health, Minneapolis, Minnesota
| | - Katarzyna Hryniewicz
- Abbott Northwestern Hospital and Minneapolis Heart Institute, Part of Allina Health, Minneapolis, Minnesota
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Patel L, Gandhi D, Westergard E, Ornes M, Lillyblad M, Skeik N. COVID-19 and venous thromboembolism: Known and unknown for imaging decisions. World J Radiol 2021; 13:64-74. [PMID: 33815684 PMCID: PMC8006055 DOI: 10.4329/wjr.v13.i3.64] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/02/2021] [Accepted: 03/22/2021] [Indexed: 02/06/2023] Open
Abstract
As we continue to fight against the current coronavirus disease-2019 (COVID-19) pandemic, healthcare professionals across the globe are trying to answer questions surrounding how to best help patients with the up-to-date available science while awaiting the development of new therapies and mass vaccination. Since early in the pandemic, studies indicated a heightened risk of venous thromboembolism (VTE) in COVID-19 infected patients. There have been differing expert opinions about how to assess pretest probability of VTE in this patient population. This has been partly due to the high prevalence of respiratory failure in this patient population and the use of D-dimer as a prognostic test which is also frequently elevated in patients with COVID-19 in absence of VTE. Some experts have argued for an approach similar to usual care with testing if clinical suspicion is high enough. Some have argued for more routine screening at different points of care. Others have even suggested empiric therapeutic anti-coagulation in moderate to severely ill COVID-19 patients. In the following article, we review and summarize the most current literature in hopes of assisting clinicians in decision making and guidance for when to be concerned for VTE in COVID-19 patients. We also discuss research gaps and share pathways currently being used within our institution.
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Affiliation(s)
- Love Patel
- Division of Hospital Medicine, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN 55407, United States
| | - Darshan Gandhi
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, United States
| | - Emily Westergard
- Department of Graduate Medical Education, Abbott Northwestern Hospital, Minneapolis, MN 55408, United States
| | - Michael Ornes
- Division of Hospital Medicine, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN 55407, United States
| | - Matthew Lillyblad
- Department of Pharmacy, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN 55407, United States
| | - Nedaa Skeik
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN 55407, United States
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Miranda DF, Stanberry L, Lillyblad M, Bradley SM, Bennett MK. Oral Vasodilator Protocol among Advanced Decompensated Heart Failure Patients Managed with Intravenous Vasodilator Therapy. J Card Fail 2018. [DOI: 10.1016/j.cardfail.2018.07.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Hryniewicz K, Moazami N, Lillyblad M, Shao E, Feldman D, Maxfield C, Cabuay B, Carter E, Sun B. 37 Optimal Medical Management and Lowering LVAD Speed Prevents Progression of Aortic Insufficiency. J Heart Lung Transplant 2012. [DOI: 10.1016/j.healun.2012.01.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Hryniewicz K, Lillyblad M, Shao E, Feldman D, Cabuay B, Sun B, Moazami N. 791 Avoiding RVADs: Pre-Operative Optimization Is the Best Predictor of Need for RVADs. J Heart Lung Transplant 2012. [DOI: 10.1016/j.healun.2012.01.808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Moazami N, Feldman D, Hryniewicz K, Lillyblad M, Cabuay B, Shao E, Sun B. 782 Aggressive Preoperative Optimization Is a Better Determinant of Survival Than Current Risk Models for Acute Cardiogenic Shock. J Heart Lung Transplant 2012. [DOI: 10.1016/j.healun.2012.01.799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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