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Idarucizumab (PRADAXA ®) as a sole reversal agent in an unstable hemorrhagic shock patient on an unknown anticoagulant with elevated protime/international normalized ratio (PT/INR).
We present a case of an 85-year-old female with an unknown medication history, shortness of breath and severe anemia due to an upper gastrointestinal bleed. Laboratory abnormalities were significant for INR 6.43 and serum creatinine 2.21  mg/dL.
Source: The American Journal of Emergency Medicine - February 5, 2021 Category: Emergency Medicine Authors: Sara Kutner, Nicholas Scaturo, Brett Williams Source Type: research

Thyrotoxicosis and bilateral internal carotid artery dissections
Cervical artery dissection is a rare but important diagnosis to consider in young patients presenting with stroke. Multiple etiologies of cervical artery dissections have been previously reported, but the association with thyrotoxicosis is extremely rare. A previously healthy 43-year-old female presented to the emergency department with new symptoms related to thyrotoxicosis and bilateral internal carotid artery dissections. Her atrial fibrillation and hypertension resolved by treating the underlying hyperthyroidism with methimazole and propranolol.
Source: The American Journal of Emergency Medicine - June 26, 2020 Category: Emergency Medicine Authors: Thomas Winter, Eyal Kraut, Kristjan Thompson Tags: Case Report Source Type: research

A rare case of thyrotoxicosis and bilateral internal carotid artery dissections
Cervical artery dissection is a rare but important diagnosis to consider in young patients presenting with stroke. Multiple etiologies of cervical artery dissections have been previously reported, but the association with thyrotoxicosis is extremely rare. A previously healthy 43-year-old female presented to the emergency department with new symptoms related to thyrotoxicosis and bilateral internal carotid artery dissections. Her atrial fibrillation and hypertension resolved by treating the underlying hyperthyroidism with methimazole and propranolol.
Source: The American Journal of Emergency Medicine - June 25, 2020 Category: Emergency Medicine Authors: Thomas Winter, Eyal Kraut, Kristjan Thompson Source Type: research

Throwing it in reverse: An update on reversal of oral factor Xa inhibitors
In recent years, the use of oral Factor Xa (FXa) inhibitors such as rivaroxaban and apixaban, have seen more extensive utilization for stroke prevention in non-valvular atrial fibrillation and the prevention/treatment of venous thromboembolisms [1,2]. Some studies have shown a similar bleed risk between FXa inhibitors and warfarin while other studies demonstrated a decreased risk for a bleed with FXa inhibitors. Despite a possible decreased risk, the paucity of data available for treating an acute major bleed due to FXa inhibitors has led some clinicians to shy away from their use.
Source: The American Journal of Emergency Medicine - April 7, 2019 Category: Emergency Medicine Authors: Brian W. Gilbert, Jacob A. Reeder, Mohammed A. Alkhalifah, David A. Moran, Michael A. Corvino Source Type: research

Contribution of routine cardiac biological markers to the etiological workup of ischemic stroke
Optimization of the detection of atrial fibrillation following stroke is mandatory. Unfortunately, access to long-term cardiac monitoring is limited in many centers. The aim of this study was to assess the potential usefulness of three routine biological markers, troponin, D-dimers and BNP, measured in acute stroke phase in the selection of patients at risk of cardio-embolic stroke.
Source: The American Journal of Emergency Medicine - May 17, 2018 Category: Emergency Medicine Authors: C. Tomich, J.S. Liegey, S. Sagnier, S. Olindo, M. Poli, S. Debruxelles, F. Rouanet, P. Renou, I. Sibon Source Type: research

Emergency medicine considerations in atrial fibrillation
Atrial fibrillation (AF) is an abnormal heart rhythm which may lead to stroke, heart failure, and death. Emergency physicians play a role in diagnosing AF, managing symptoms, and lessening complications from this dysrhythmia.
Source: The American Journal of Emergency Medicine - February 2, 2018 Category: Emergency Medicine Authors: Brit Long, Jennifer Robertson, Alex Koyfman, Kurian Maliel, Justin R. Warix Source Type: research

Management of Factor Xa inhibitor-associated life-threatening major hemorrhage: A retrospective multi-center analysis
This study describes a cohort of patients with FXa inhibitor-associated life-threatening bleeding events, their clinical characteristics, interventions and outcomes.
Source: The American Journal of Emergency Medicine - August 19, 2017 Category: Emergency Medicine Authors: Truman J. Milling, Carol L. Clark, Charles Feronti, Shlee S. Song, Sam S. Torbati, Gregory J. Fermann, Jeffrey Weiss, Dony Patel Source Type: research

The challenge of coprescription of antiplatelet therapy and oral anticoagulants
The coexistence of symptomatic carotid artery stenosis and nonvalvular atrial fibrillation (NVAF) in the recently reported 85year old man [1] bears out the findings of the study which documented a 24.3% prevalence of high-grade (50% or more) carotid artery stenosis among 103 consecutive NVAF patients (mean age 69) who presented with stroke [2]. Among these patients with high-grade stenosis 66.7% had stenosis ipsilateral to the cerebral infarct [2]. Given the fact that patients with symptomatic carotid artery stenosis are at high risk of stroke recurrence and/or worsening neurological disability during the first 14days foll...
Source: The American Journal of Emergency Medicine - May 22, 2017 Category: Emergency Medicine Authors: Oscar M.P. Jolobe Source Type: research

Preclinical and clinical data for factor Xa and “Universal” reversal agents
Oral Factor Xa (FXa) inhibitors, a growing class of direct-acting anticoagulants, are frequently used to prevent stroke and systemic embolism in patients with atrial fibrillation and to prevent and treat venous thromboembolism. These drugs reduce the risk of clotting at the expense of increasing the risk of bleeding, and currently they have no specific reversal agent. However, andexanet alfa, a recombinant modified FXa decoy molecule, is in a late-phase clinical trial in bleeding patients, and ciraparantag, a small molecule that appears to reverse many anticoagulants including the FXa inhibitors, is in development.
Source: The American Journal of Emergency Medicine - September 27, 2016 Category: Emergency Medicine Authors: Truman J. Milling, Scott Kaatz Tags: Review Source Type: research

Safety of Direct Oral Anticoagulants: Insights from Postmarketing Studies
Direct oral anticoagulants (DOACs) have been marketed in the United States since 2010. While numerous large-scale prospective phase 3 outcomes studies have documented the effectiveness of DOACs for the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, the primary safety concern with all of these drugs —as it is with the more established oral anticoagulant warfarin—is the risk of major bleeding. Postmarketing surveillance studies (PMSS) provide the opportunity to evaluate the safety of these recently approved drugs across a spectrum of patients that may be broader than those in...
Source: The American Journal of Emergency Medicine - September 27, 2016 Category: Emergency Medicine Authors: Todd C. Villines, W. Frank Peacock Tags: Review Source Type: research

Stroke prevention in real-life practice
We have greatly enjoyed reading the recently published article by McIntyre et al [1] . The authors distributed a 16-question, Web-based survey to Canadian residency programs and each scenario involved a 76-year-old man with new atrial fibrillation (AF) and a CHADS2 score of 3. The authors revealed the discordance between clinical guidelines for stroke prevention in AF and the practice of Canadian emergency medicine residents. Despite ranking the risk of adverse events as their most important consideration and the superior safety profile of those non –vitamin K antagonist oral anticoagulants (NOACs), residents underused ...
Source: The American Journal of Emergency Medicine - June 5, 2016 Category: Emergency Medicine Authors: Özcan Başaran, Volkan Doğan, Eda Özlek, Bülent Özlek, Murat Biteker Tags: Correspondence Source Type: research

Stroke Prevention in Real-life Practice
We have greatly enjoyed reading the recently published article by McIntyre et al. (1). The authors distributed a 16-question, web-based survey to Canadian residency programs and each scenario involved a 76-year-old man with new atrial fibrillation (AF) and a CHADS2 score of 3. The authors revealed the discordance between clinical guidelines for stroke prevention in AF and the practice of Canadian emergency medicine residents. Despite ranking the risk of adverse events as their most important consideration and the superior safety profile of that non-vitamin K antagonist oral anticoagulants (NOACs), residents underused this ...
Source: The American Journal of Emergency Medicine - June 5, 2016 Category: Emergency Medicine Authors: Özcan Başaran, Volkan Doğan, Eda Özlek, Bülent Özlek, Murat Biteker Source Type: research

Stroke prevention for patients with atrial fibrillation: values and preferences of Canadian emergency medicine trainees
Atrial fibrillation (AF) is the most common serious cardiac arrhythmia, and it is associated with a 5-fold increase in the risk of ischemic stroke [1 –3] . This risk can be reduced by up to 64% with oral anticoagulation (OAC) [4] . Many patients are first diagnosed with AF in the context of visit to the emergency department (ED), and AF can account for 1% or more of ED visits [5–7] . Clinical risk stratification for stroke and bleeding and subsequent prescription of OAC are the cornerstones of management of AF.
Source: The American Journal of Emergency Medicine - May 12, 2016 Category: Emergency Medicine Authors: William F. McIntyre, Zardasht Oqab, Payam Yazdan-Ashoori, Kieran L. Quinn, Erik M. van Oosten, Wilma M. Hopman, Adrian Baranchuk Tags: Correspondence Source Type: research

Stroke Prevention for Patients with Atrial Fibrillation: Values and Preferences of Canadian Emergency Medicine Trainees
Atrial Fibrillation (AF) is the most common serious cardiac arrhythmia and it is associated with a five-fold increase in the risk of ischemic stroke[1–3]. This risk can be reduced by up to 64% with oral anticoagulation (OAC)[4]. Many patients are first diagnosed with atrial fibrillation (AF) in the context of visit to the emergency department (ED) and AF can account for 1% or more of ED visits[5–7]. Clinical risk stratification for stroke and bleeding and subsequent prescription of OAC are the cornerstones of management of AF.
Source: The American Journal of Emergency Medicine - May 12, 2016 Category: Emergency Medicine Authors: William F. McIntyre, Zardasht Oqab, Payam Yazdan-Ashoori, Kieran L. Quinn, Erik M. van Oosten, Wilma M. Hopman, Adrian Baranchuk Tags: Correspondence Source Type: research

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