Rapid Clinical Updates: Updates on Anticoagulation for Hospitalists-Slides

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The "Update on Anticoagulation for Hospitalists" summarizes recent advances and critical considerations in anticoagulation therapy, particularly relevant for inpatient management. Key topics include the latest evidence and guidelines regarding direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs), with specific focus on high-risk clinical scenarios.<br /><br />For antiphospholipid syndrome, recent reviews suggest avoiding DOACs given insufficient evidence for safety and efficacy across different antibody profiles. After transcatheter aortic valve replacement (TAVR), a meta-analysis offers nuanced insights: although DOACs are increasingly used, the majority of evidence stems from patients also having atrial fibrillation, and outcomes vary.<br /><br />In managing chronic coronary disease, updated guidelines endorse tailored strategies such as short triple therapy (1–4 weeks) post-PCI in patients with atrial fibrillation, followed by dual or single antithrombotic therapy depending on bleeding and thrombotic risks.<br /><br />A significant advance concerns apixaban use in patients with end-stage kidney disease (ESRD) on hemodialysis. Although pivotal trials excluded this population, emerging randomized controlled trials (RENAL-AF and AXADIA-AFNET) found no excess bleeding or mortality risk with apixaban compared to warfarin in atrial fibrillation. Observational data also support apixaban for venous thromboembolism (VTE) in dialysis patients, showing less major bleeding compared to warfarin. Nonetheless, dosing for acute VTE remains uncertain.<br /><br />Regarding stroke management, the ELAN trial demonstrated that early initiation of DOACs post-atrial fibrillation-related ischemic stroke is safe: starting within 2 days for minor/moderate strokes and at 6-7 days for major strokes reduces delays in protection without increasing hemorrhagic transformation.<br /><br />On anticoagulation bridging for mechanical heart valve patients with acute ischemic stroke, observational data suggest no benefit and potential harm with increased bleeding when bridging therapy (e.g., LMWH) is started early.<br /><br />In summary, recent evidence supports cautious expansion of DOAC use in traditionally excluded populations, early anticoagulation after stroke in AFib patients, and questions routine bridging in mechanical valve-associated stroke. These updates inform hospitalist practice aiming to balance thrombotic and bleeding risks effectively.

Keywords

Anticoagulation

Hospitalists

Direct Oral Anticoagulants (DOACs)

Vitamin K Antagonists (VKAs)

Antiphospholipid Syndrome

Transcatheter Aortic Valve Replacement (TAVR)

Atrial Fibrillation

End-Stage Kidney Disease (ESRD)

Stroke Management

Mechanical Heart Valve Bridging