Rajak, Kripa

Background: Rivaroxaban is a novel oral anticoagulant suggested as an alternative to low molecular weight heparin (LMWH). However, its efficacy and safety compared to LMWH for treating venous thromboembolism (VTE) in cancer patients remain unclear. Hypothesis: This study aims to compare the efficacy and safety of rivaroxaban against LMWH for treating VTE in cancer patients. Methods: We conducted a literature search for relevant articles on PubMed, Google Scholar, and Embase. Outcomes were pooled using the DerSimonian and Laird random-effects model as risk ratios (RR) with 95% confidence intervals (CI). A p-value of <0.05 was considered statistically significant. Results: A total of 14368 cancer patients (Rivaroxaban: 4378 and LMWH: 9990) from 13 studies were included with an average age of 62.5 and 61.9 respectively. At 3 months, rivaroxaban was associated with a decreased risk of recurrent VTE (RR 0.73, 95% CI: 0.59, 0.86, p<0.05) and bleeding-related hospitalization (RR 0.79, 95% CI: 0.61, 0.97, p<0.05) with statistical signifcant whereas, major bleeding (RR 0.87, 95% CI: 0.09, 1.65), non-major bleeding (RR 0.84, 95% CI: 0.60, 1.08) and all-cause mortality (RR 0.91, 95% CI: 0.72, 1.09) were comparable. At 6 months, rivaroxaban was associated with a decreased risk of all-cause mortality (RR 0.80, 95% CI: 0.62, 0.97, p<0.05), and bleeding-related hospitalization (RR 0.81, 95% CI: 0.65, 0.98, p<0.05) whereas major bleeding (RR 0.88, 95% CI: 0.52, 1.24), non-major bleeding (RR 0.85, 95% CI: 0.42, 1.29) and recurrent VTE (RR 0.83, 95% CI: 0.64, 1.01) were comparable. At 12 months, rivaroxaban was associated with a decreased risk of mortality (RR 0.71, 95% CI: 0.50, 0.92, p<0.05), however non-major bleeding (RR 1.38, 95% CI: 0.83, 1.94), cancer-associated thrombosis recurrence (RR 0.94, 95% CI: 0.73, 1.16), and bleeding (RR 0.70, 95% CI: 0.26, 1.15) were comparable. Conclusion: While rivaroxaban is associated with low adverse outcomes suggesting its use in treating VTE in cancer patients, further research is recommended.

Background: Mineralocorticoid receptor antagonists (MRAs) have emerged as potential therapy to prevent atrial fibrillation (AF). However, inconsistent results of MRAs effect on perioperative AF have been reported in the literature in patients undergoing cardiac surgery. To our knowledge, this is the first metanalysis to assess the effect of MRAs on occurrence of perioperative AF in patients undergoing cardiac surgery. Method: We searched different electronic databases from inception to April 30th, 2023, for randomized controlled trials (RCTs) and observational studies that evaluated the use of MRAs in patients with heart failure and left ventricular ejection fraction (LVEF) 30-50% who were referred for Coronary Artery Bypass Grafting (CABG) and/or valve surgery without any AF history. Primary outcome was occurrence of perioperative AF. Three independent reviewers selected and appraised the data. A random-effects meta-analysis was performed to estimate pooled odds ratios (OR) and 95% confidence intervals (CI). Result: We included 4 studies, 1 RCT and 3 observational cohorts, with a cumulative number of 1,128 patients with mean age 65.15 years. 412(36.5%) received an MRA (spironolactone or eplerenone). The follow up duration was 5 days to 1 month. During follow-up, 118 (28.64%) patients treated with MRAs, developed AF, compared to 224 (31.28%) patients, without MRA treatment. However, metanalysis showed that there is no significant reduction in occurrence of perioperative AF in MRA treated patients (OR: 0.88 CI: 0.58-1.33 p=0.55), I2 53%; Figure] Conclusion: Experimental data have shown that MRA blockade prevents perioperative AF in animal models but our metanalysis demonstrated that MRAs were not protective for perioperative AF in patients undergoing cardiac surgery. Larger trials in humans are warranted to evaluate its efficacy, particularly in patients undergoing cardiac surgery.

Background: Inclisiran is a first-in-class, cholesterol-lowering small interfering RNA based therapy for treatment of atherosclerosis or familial hypercholesterolemia as an adjunct to maximally tolerated statin therapy. Since approval by FDA in December 2021, it is getting increasingly popular due to biannual regimen. During trials and upon review for FDA approval, it exhibited injection site reaction, arthralgia, urinary tract infection, diarrhea, and dyspnea. Objective: In view of increased usage, it is important to establish a side effect profile of inclisiran in general population since the ORION 9, 10 and 11 trials. Methods: We explored reported adverse events (AEs) of inclisiran using FDA Adverse Event Reporting System (FAERS). A total of 472 AEs were reported until September 2022. 44.49% AEs were reported by healthcare professionals (HCPs), which were further analyzed. AEs were analyzed in men (35.2%) vs women (45.2%) and in three age groups of 18-64, 65-85, and >85 years. Results: A total of 100 (47%) events were serious including 38% hospitalization and 14% deaths. The most frequently reported AE was surprisingly dyspnea in conjunction with cough (21.9%) followed by myalgia (15.2%), injection site pain (5.2%), arthralgia (4.3%), diarrhea (4.3%), rash (3.3%) and fatigue (2.4%). Most AEs were consistent with ORION trial except elevated LDL (8.2%), acute myocardial infarction (AMI) (7.6%), hyponatremia (6.6%), acute kidney injury (AKI) (3.3%) and headache (2.4%). It was reported more in women of age group 65-85 years. Discussion: The events of death and hospitalization after initiating inclisiran could have been associated with AMI, AKI and hyponatremia that are newly reported since the trial, however the temporality and mechanisms are unknown. Even though the trial has shown that this drug is relatively safe, physicians must be vigilant about the new developments to avoid decompensation in vulnerable patients. Its use in patients with pulmonary disease can worsen dyspnea. Conclusion: With the current increasing use of inclisiran, there is a need for more data on safety profile. In future, further randomized trials are required to better assess the safety profile focusing on temporality and mechanisms of AMI and AKI in relation to inclisiran.

The Impella® (Abiomed; Danvers, MA) pumps are percutaneous, transvalvular mechanical circulatory support (MCS) devices that propel blood from left ventricle to aorta that are used to augment cardiac output in management of high-risk percutaneous coronary intervention (HRPCI), acute heart failure, or cardiogenic shock. These systems utilize a flow of purge fluid that runs countercurrent to the blood flow which prevents inline thrombosis and protein deposition. Guidelines generally recommend heparin-dextrose purge fluid, with BBPS reserved for patients with heparin intolerance or active bleeding. We present the first case of use of BBPS as an elective choice for purge fluid in a patient with severe cardiogenic shock.Patient is 56-year-old male with known history of hypertension, diabetes and hyperlipidemia who presented with acute onset shortness of breath secondary to acute heart failure in the setting of myocardial infarction. He underwent a HRPCI for a non revascularizable three vessel coronary artery disease. He was readmitted for cardiogenic shock complicated with ventricular tachycardia, fibrillation and high risk of sudden cardiac death, necessitating inpatient transplant evaluation. Left heart catheterization showed pulmonary artery pressure of 59/63, wedge of 29 and cardiac index of 2 on 0.125mcg/kg/hr of milrinone. He received aggressive diuresis, antiarrhythmics and inotropic support. With increasing milrinone requirement, Impella 5.5 was placed and his antiplatelet regimen was changed from oral prasugrel to intravenous cangrelor with aspirin. A clinical decision was made to use BBPS instead of heparin purge, based on institutional experience and clinical data. Purge pressure, flow, lactate dehydrogenase and hematocrit have remained stable about 1.5ml/hr, 500mm Hg, 230U/L and 30% respectively for 22 days post-impella placement as the patient awaits transplantation.Limited retrospective studies and animal data, have shown no change in purge pressure/flow with BBPS. However, most of the data remains limited to use in heparin-intolerant patients. Our experience has indicated the possibility to use BBPS without systemic anticoagulation with no short-term complication,however conclusive trial data needs to be generated.