Anticoagulation for Patients with Venous Thromboembolism: When is Extended Treatment Required?

The need for extended venous thromboembolism (VTE) treatment beyond 3 to 6 months is usually determined by balancing the risk of recurrence if treatment is stopped against the risk of bleeding from continuing treatment. The risk of recurrence, and in turn the decision to extend, can be determined through the nature of the index event. Patients with VTE provoked by surgery or trauma (major transient risk factors) are recommended to receive 3 months of anticoagulation therapy because their risk of recurrence is low, whereas patients with VTE provoked by a major persistent risk factor, such as cancer, or those considered to have “unprovoked” VTE, are recommended to receive an extended duration of therapy based on an established high risk of recurrence. Nonetheless, recent evidence and new guidance identify that this approach fails to consider patients with risk factors classed as minor transient (e.g., impaired mobility and pregnancy) or minor persistent (e.g., inflammatory bowel disease and congestive heart disease). Indeed, the risk of recurrence with respect to VTE provoked by minor persistent risk factors has been demonstrated to be not dissimilar to that of VTE without identifiable risk factors. This review provides an overview of the available data on the risk of recurrence according to the underlying cause of VTE, a critical evaluation of evidence from clinical studies on the available anticoagulants for extended VTE treatment, models of risk prediction for recurrent VTE and bleeding, and guidance on how to apply the evidence in practice.

AB0308 NO SIGNS OF CONGESTIVE HEART DISEASE PROGRESSION IN PATIENTS WITH RHEUMATOID ARTHRITIS ON IL-6 RECEPTOR ANTAGONIST AFTER 12 MONTHS TREATMENT

Background:N-terminal pro-brain natriuretic peptide (NT-proBNP) is a known marker of heart dysfunction, mainly described in patients with high activity of rheumatoid arthritis (RA). Further knowledge of the influence of the IL-6 receptor antagonist, tocilizumab (TCZ), on NT-proBNP levels and systolic heart function is yet to be obtained.Objectives:Access the effect of 12 months TCZ therapy on NT-proBNP levels, transthoracal ehocardiography results and analyze the association between congestive heart disease progression and RA activity.Methods:37 RA patients (pts) (31F/6M); median age 56,5 [48; 63,5] years; disease duration 48 [6; 348] months; DAS28 score 6,15 [5,44; 6,45]; rheumatoid factor (RF)+100%; anti–citrullinated protein antibody (ACPA) + 79,6% were treated in an open-label study with TCZ (8 mg/kg every 4 weeks). Identification of NT-pro-BNT in blood serum, transthoracal ultrasound evaluation of left ventriculum ejection fraction (LVEF), E/A ratio performed at baseline and 12 months.Results:11 (29,7%) pts had congestive heart disease (CHD) (II functional class of NYHA), 7 (18,9%) pts having signs of mild left ventricular dysfunction (LVD) as dyspnea, shortness of breath, cardiotropic treatment remained the same in the course of the study. After 12 month TCZ treatment as RA activity lowered (DAS28 2.32 [1,75; 3,15], р<0,05), NT-proBNP levels decreased (100,95 [57.9; 117.6] pg/ml to 90,46 [33.62; 106.6] pg/ml), along with elevation of LVEF (60,75 [60; 70]% to 67,68 [62.5; 73.5], p = 0,001). Increase of E/A (0,97 [0.8; 1.17] to 1,04 [0.7; 1.42] correlated with decrease of NT-proBNP level (r = -0,63, p=0,036). Raise of LVEF over 12 months correlated with decrease of RA activity according to SDAI scale (r= -0,670, p<0,05). No significant relationship between NT-proBNP levels, LVEF, E/A and other scales measuring RA activity was found. Clinically all patients had improvement in evaluation of their health and no signs of CHD or RVD progression were found.Conclusion:Use of TCZ in patients with active RA showed none to positive influence on heart condition, specifically, lowering NT-proBNP levels, improving LVEF and reducing clinical signs of LVD.References:[1]Pan Y, Li D, Ma J, Shan L, Wei M. NT-proBNP test with improved accuracy for the diagnosis of chronic heart failure. Medicine (Baltimore). 2017 Dec;96(51):e9181.[2]D Novikova, I Kirillova, E Markelova et al. The first report of significantly improvement of NT-proBNP level in rheumatoid arthritis patients treated with tofacitinib during 12-month follow-up, European Heart Journal, Volume 40, Issue Supplement_1, October 2019, ehz745.0836.[3]Pappas DA, Nyberg F, Kremer JM et al. Clin Rheumatol. 2018 Sep;37(9):2331-2340.Disclosure of Interests:None declared

Streptococcus canis Bacteremia in a Renal Transplant Recipient

A middle-aged man presented with fever and shortness of breath. He had significant history of congestive heart disease and received deceased donor renal transplant 2 years prior to presentation. He was febrile and found to have sepsis. His initial blood cultures grew Streptococcus canis. Streptococcus canis causes rare infection in humans, and this is most likely the first case in the renal transplant population.

Abstract 19941: Clinical and Demographic Characteristics According to Dosage Among New Initiators and/or Switchers From Warfarin Non-valvular Atrial Fibrillation Patients on Apixaban, Dabigatran and Rivaroxaban

Background: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia [1-3] with increasing prevalence in the aging [4]. With the advent of the three NOACs including apixaban, dabigatran and rivaroxaban, it is important to characterize patients prescribed with the different dosage of treatment in the real-world setting. Purpose: To describe the baseline clinical and demographic characteristics of NVAF patients on apixaban (5 mg vs 2.5 mg -reduced), rivaroxaban (20mg vs reduced dose: 15 mg or 10 mg), and dabigatran (150 mg vs reduced 75 mg). Methods: A retrospective cohort study was conducted using MarketScan Earlyview ® data. NVAF patients ≥18 years with a minimum of 1 year baseline period were included if they either received a NOAC or were switched from warfarin to NOAC during the study period of Jan 1, 2013 to October 31, 2014. Results: For NVAF patients , the majority of the patients were on the standard dosage (Table 1). Similarly for each NOAC, patients using low dosage versus standard dosage were older, had a greater stroke risk, had a prior history of bleeding and were sicker in terms of presence of congestive heart disease, renal disease and Charleson comorbidity index. Patients switching from warfarin had on average a large number of missing dosage data, and if switching to apixaban were more likely to be prescribed the reduced dose than the 5 mg dose. No clear trend was observed for patients switching to dabigatran or rivaroxaban. More than 15% Apixaban and rivaroxaban patients switched from warfarin while only <6% dabigatran patients switched from warfarin. Conclusion: AF patient initiated with standard dosages of NOACs had better clinical and demographic characteristics than patients initiated with reduced dosages of NOAC. Table 1.