Inpatient Insights

Dose reduction of edoxaban could benefit older patients with AFib

In older patients with AFib who take anticoagulants for stroke prevention, bleeding is increased compared with younger patients, leading physicians to often prescribe lower than recommended doses in older patients. Researchers on the ENGAGE AF-TIMI 48 trial team sought to determine whether patients 80 years and older with AFib benefit from lower-dose anticoagulants, even in the absence of prespecified dose-reduction criteria.

The ENGAGE AF-TIMI 48 trial was a parallel-design, double-blind, global clinical trial that randomized older patients with AFib to receive either oral edoxaban 30 mg once daily; edoxaban 60 mg once daily; or warfarin. Results of the study, published on July 10, 2024, in JAMA Cardiology, indicated that major bleeding events were lower in patients randomized to receive edoxaban 30 mg per day, compared with either edoxaban 60 mg per day (in patients without dose-reduction criteria), or warfarin (irrespective of dose-reduction status), without an offsetting increase in ischemic events.

The researchers concluded that these data support the concept that lower-dose anticoagulants, such as edoxaban 30 mg, may be considered in older patients with AFib even in the absence of dose-reduction criteria. ■

Low-dose aspirin safe for prevention of VTE after total knee arthroplasty

A study published in the July 17, 2024, issue of The Journal of Bone and Joint Surgery sought to characterize the clinical use of various chemoprophylactic agents in patients undergoing total knee arthroplasty (TKA) and determine the efficacy of aspirin compared with other agents in patient groups stratified by venous thromboembolism (VTE) risk profiles.

The researchers used a national database to determine the proportion of patients undergoing TKA who received low-dose aspirin versus other chemoprophylaxis between 2012 and 2022 and determined VTE risk profiles on the basis of comorbidities. The odds ratios between various classes of thromboprophylaxis in patients with high and low risk of VTE were calculated along with the odds of deep-vein thrombosis (DVT), pulmonary embolus (PE), bleeding events, infections, mortality, and hospitalizations in the 90-day postoperative period for propensity-matched cohorts receiving low-dose (81 mg) aspirin only versus other prophylaxis, segregating patients by VTE risk profile. A total of 126,692 patients undergoing TKA across 60 health care organizations were included.

The researchers found that the proportion of patients receiving low-dose aspirin increased from 7.65% to 55.29% between 2012 and 2022, whereas the proportion of patients receiving other chemoprophylaxis decreased from 96.25% to 42.98%. Low-dose-aspirin-only use increased to approximately 50% in both high-risk and low-risk populations but was more likely among low-risk patients. Both low-risk and high-risk patients in the low-dose-aspirin-only cohorts had decreased odds of DVT, PE, bleeding, infections, and hospitalizations compared with other prophylaxis regimens.

  The authors concluded that their findings support the recent International Consensus Meeting on Venous Thromboembolism statement by showing that low-dose aspirin is a safe and effective method of prophylaxis in patients across various risk profiles. ■

What VTE risk assessment models could improve patient outcomes?

The American Society of Hematology (ASH) has endorsed the use of risk assessment models as an approach to individualize venous thromboembolism (VTE) prophylaxis by balancing overuse (excessive risk of bleeding) and underuse (risk of avoidable VTE). Although ASH has endorsed IMPROVE (International Medical Prevention Registry on Venous Thromboembolism) risk assessment models—the only models to assess short-term bleeding and VTE risk in acutely ill medical inpatients—it noted that no risk assessment models have been thoroughly analyzed for their effect on patient outcomes.

In a study published in the August 2024 issue of Blood Advances, researchers from the Medical University of South Carolina and Indiana University Northwest aimed to validate the IMPROVE models and adapt them into a simple, fast-and-frugal (FFT) decision tree to evaluate the impact of VTE prevention on health outcomes and costs. The researchers used three methods: the “best evidence” from ASH guidelines, a “learning health system paradigm” combining guideline and real-world data from the Medical University of South Carolina (MUSC), and a “real-world data” approach based solely on MUSC data retrospectively extracted from electronic records.

They found that the most effective VTE prevention strategy used the FFT decision tree based on an IMPROVE VTE score of greater than or equal to 2 or greater than or equal to 4 and a bleeding score of less than 7. This method could prevent 45% of unnecessary treatments, saving approximately $5 million annually for patients such as the MUSC cohort. They recommended integrating IMPROVE models into hospital EHRs as a point-of-care tool, thereby enhancing VTE prevention in hospitalized medical patients. ■

Tenecteplase could be effective for patients after ischemic stroke

Tenecteplase has been shown to be an effective thrombolytic agent for patients with stroke who are treated within 4.5 hours after the onset of stroke, but data on effectiveness beyond 4.5 hours are limited. A global group of researchers conducted a trial involving 516 Chinese patients, with ischemic stroke due to large-vessel occlusion, most of whom did not undergo endovascular thrombectomy.

Patients were randomly assigned to receive tenecteplase (0.25 mg/kg body weight; maximum dose, 25 mg) or standard medical treatment between 4.5 and 24 hours after the time that the patient was last known to be well. The primary outcome was the absence of disability, defined as a score of 0 or 1 on the modified Rankin scale, at day 90. The key safety outcomes were symptomatic intracranial hemorrhage and death.

Results of the study, published on June 14, 2024, in NEJM, showed that treatment with tenecteplase resulted in a higher percentage of patients with a modified Rankin scale score of 0 or 1 at 90 days than standard medical treatment. Mortality at 90 days was 13.3% with tenecteplase and 13.1% with standard medical treatment, and the incidence of symptomatic intracranial hemorrhage within
36 hours after treatment was 3.0% and 0.8%, respectively. ■