Emilie P. Belley-Cote

Background: Antithrombotic-associated intracranial hemorrhage (ICH) is a life-threatening condition, and rapid treatment in the setting of antithrombotic agents may limit hematoma expansion and improve outcomes. This focused update evaluated the available evidence after publication of the 2016 guidelines. Methods: The Neurocritical Care Society, in conjunction with the Society of Critical Care Medicine, generated five questions to guide a systematic review and meta-analysis. Three of these questions update prior recommendations, while two are newly introduced. Each question followed a Population, Intervention, Comparator, Outcome (PICO) framework and focused on the management of acute ICH including spontaneous intraparenchymal hemorrhage (IPH) and traumatic ICH. The topics addressed were: (1) andexanet alfa versus 4-factor prothrombin complex concentrate (4F-PCC) for treatment of oral factor Xa inhibitor effects; (2) platelet transfusion versus no transfusion for treatment in the setting of antiplatelet agent use; (3) desmopressin versus no desmopressin for treatment in the setting of antiplatelet agent use; (4) treatment of anticoagulant effects versus no treatment in the setting of small IPH; and (5) use of viscoelastic hemostatic assays (VHAs) to treat coagulopathy in traumatic ICH. Recommendations were developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Results: The panel generated eight recommendations. For patients with acute ICH, the panel issued the following conditional recommendations: use 4F-PCC rather than andexanet alfa for the treatment of the anticoagulant effects of factor Xa inhibitors, avoid platelet transfusion in non-neurosurgical patients with spontaneous IPH on antiplatelet agents, administer platelet transfusion in patients with spontaneous IPH on aspirin who are undergoing surgery, and use VHAs to guide treatment of coagulopathy in traumatic ICH. The panel was unable to issue recommendations regarding platelet transfusion for treatment of antiplatelet effects in traumatic ICH, use of desmopressin for treatment of antiplatelet effects, or treatment of anticoagulant effects in small IPH. Conclusions: The guideline writing panel provided new conditional recommendations for the treatment of antithrombotic-associated acute ICH. These recommendations are intended for consideration along with the patient’s clinical status and patient-specific factors.

Background and Aims: New-onset atrial fibrillation (AF) is the most common complication of cardiac surgery. We aimed to describe the incidence of postoperative AF (POAF), its management, and its relationship to long-term outcomes in a prospective multi-centre cohort, as our current understanding comes primarily from registries and single-centre studies. Methods: VISION Cardiac Surgery was a prospective cohort of adults who underwent cardiac surgery in 12 countries. The association of POAF with outcomes occurring between 30 days and 1 year postoperatively was estimated using a multivariable Cox model adjusted for patient and operative characteristics and for antithrombotic therapies. Results: Among 12 234 patients (55.3% isolated coronary artery bypass grafting), 31.8% had POAF within 30 days of surgery. The proportion of participants with POAF who received anticoagulation alone at hospital discharge was 15.6%, 54.3% received antiplatelets alone, 23.9% received anticoagulation and antiplatelets, and 6.3% received neither; 48.8% were receiving amiodarone. At 1 year, clinical AF was detected in 6.9% of patients with POAF compared to 0.6% in those without [adjusted hazard ratio (aHR), 11.30; 95% confidence interval (CI) 8.17–15.70]. The primary composite outcome of stroke or vascular death occurred in 2.3% of patients with POAF and 1.5% in those without POAF (aHR 1.32; 95% CI 0.99–1.77). Patients with POAF had a higher risk of all-cause death (3.0% vs 1.7%; aHR 1.54; 95% CI 1.18–2.00). Conclusions: New-onset POAF occurs in a third of patients after cardiac surgery; its antithrombotic and antiarrhythmic management varies. Patients with POAF have increased risks of both clinical AF and of all-cause death in the year following surgery.