CLINICAL CARE PATHWAY AND MANAGEMENT OF MAJOR BLEEDING ASSOCIATED WITH NON-VITAMIN K ANTAGONIST ORAL ANTICOAGULANTS: A MODIFIED DELPHI CONSENSUS FROM SAUDI ARABIA AND UAE

Background: The non-vitamin K antagonist oral anticoagulants (NOACs) have become the mainstay anticoagulation therapy for patients requiring oral anticoagulants (OACs) in the Gulf Council Cooperation (GCC) countries. The frequency of NOAC-associated major bleeding is expected to increase in the Emergency Department (ED). Nonetheless, we still lack local guidelines and recommendations for bleeding management in the region. The present Delphi-based consensus aims to establish a standardized and evidence-based clinical care pathway for managing NOAC-associated major bleeding in the Kingdom of Saudi Arabia (KSA) and the United Arab Emirates (UAE). Methods: We adopted a three-step modified Delphi method to develop evidence-based recommendations through two voting rounds and an advisory meeting between the two rounds. A panel of 11 experts from the KSA and UAE participated in the consensus development. Results: Twenty-eight statements reached the consensus level. These statements addressed key aspects of managing major bleeding events associated with NOACs, including the increased use of NOAC in clinical practice, clinical care pathways, and treatment options. Conclusion: The present Delphi consensus provides evidence-based recommendations and protocols for the management of NOAC-associated bleeding in the region. Patients with major NOAC-induced bleeding should be referred to a well-equipped ED with standardized management protocols. A multidisciplinary approach is recommended for establishing the association between NOAC use and major bleeding. Treating physicians should have prompt access to specific reversal agents to optimize patient outcomes. Real-world evidence and national guidelines are needed to aid all stakeholders involved in NOAC-induced bleeding management

The reproducibility of coronary calcium scoring on multiple software platforms

IntroductionCoronary Artery Calcium (CAC) Scoring has been validated as an accurate tool to risk stratify patients without known coronary artery disease. The aim of this analysis is to evaluate the reproducibility of CAC calculated on different commercial softwares.MethodsWe included 159 patients who underwent CAC scoring with use of 64- slice multidetector computed tomography (CT) with prospective electrocardiographic gating for clinical reasons. The data sets were evaluated on two different commercially available softwares (4DM from INVIA, Ann Arbor, MI (software A) and Smart score from General Electric, Milwaukee, WI (software B)) by two blinded independent readers using the method of Agatston with a threshold of 130 Hounsfield units. Comparative analysis of CAC scores between the different software was performed by using Spearman rank correlation and Bland Altman analysis.ResultsEach software produced different absolute numeric results for Agatston score. CAC was detected on 107 scan on both softwares. A total of 59 scans (37%) had the same reading of which 50 patients are without detected calcium. In contrast, CAC reading were within 10 units in 86 scans (52%) There was excellent statistical correlation between the two softwares (r=0.948, p<0.001) for both scoring software. Bland Altman analysis showed significant variability at high calcium score. When grouped in the different prognostically validated CAC groups, (CAC of 0, 1–9, 10–99, 100–300, >400), 132 (87%) of the scans were in the same group by both softwares.ConclusionOur analysis shows that there is a close correlation between the different software calculation of CAC, although the different CAC software different absolute CAC scores. The two software concordantly classified 87% of the study population prognostically

Prevalence and Clinical Characteristics of Lacunar Stroke: A Hospital-Based Study

Lacunar stroke (LS) is responsible for one-quarter of the overall number of ischemic strokes with long-term complications and carries health and economic issues for patients and health care systems. Therefore, we aimed to investigate lacunar versus non-lacunar strokes in a tertiary academic center. From February 2016 to July 2019, all patients admitted to the stroke unit were retrospectively reviewed. We included LS patients and compared them to other TOAST subtypes. Hemorrhagic stroke and conditions mimicking stroke were excluded. Regression analysis was done to determine LS predictors and outcomes. A 35.5% rate of LS among 989 ischemic stroke patients was found. Most patients (71.9%) were males. Lower National Institutes of Health Stroke Scale (NIHSS) scores at admission and negative history for cardiac diseases were predictors for LS in our population. At discharge, LS patients had low NIHSS scores and shorter hospitalization periods compared to non-LS patients. In conclusion, LS was prevalent among ischemic stroke patients in our cohort. Future studies are highly needed with long follow-up intervals to identify the stroke recurrence, complications, and outcomes

Stroke Seasonality and Weather Association in a Middle East Country: A Single Tertiary Center Experience

Background: Stroke is a medical condition that leads to major disability and mortality worldwide. Some evidence suggests that weather and seasonal variations could have an impact on stroke incidence and outcome. However, the current evidence is inconclusive. Therefore, this study examines the seasonal variations and meteorological influences on stroke incidence and outcome in the largest city in Saudi Arabia.Methods: From February 2016 to July 2019, we retrospectively reviewed data from all patients with acute ischemic (AIS) or hemorrhagic stroke (HS) admitted to the stroke unit in a tertiary academic center in Saudi Arabia. The corresponding daily meteorological data were obtained for the same period. We considered the months from November to March as the cold season and April to October as the hot season.Results: The final cohort included 1,271 stroke patients; 60.89% (n = 774) cases occurred in the hot season, while 39.1% (n = 497) in the cold season. Males accounted for 69.6% (n = 884) of the cases. The proportion of ischemic stroke was 83.2% [hot season 83.9% (n = 649) vs. cold season 82.3% (n = 409)]. We found no statistically significant difference between seasons (hot or cold) in stroke incidence, severity [National Institutes of Health Stroke Scale (NIHSS)], hospital course (pneumonia, thromboembolism, intensive care stay, or length of stay), or outcome [modified Rankin scale (mRS) on discharge and death].Conclusions: In Riyadh, Saudi Arabia, our study found no impact of weather or seasonal variations on stroke incidence, hospital course, or outcomes. However, our findings warrant further research in different country regions.</jats:p