ECG Case n° 2

A 57 year-old-patient is brought in Emergency Department by ambulance complaining of fever, swelling and erythema of the left leg .

Medical History: not relevant.

Vital Signs: BP 130/80 mmHg, HR 90 bpm, SpO2 96% room air, RR 22/min, GCS 15, T 38°C.

Arterial Blood Gas analysis:

ECG. 1

ECG ANSWER and INTERPRETATION

Rate:

  • 85 min

Rhythm:

  • Regular P waves

Axis:

  • -75°

Intervals:

  • PR – normal (<200ms) and regular
  • QRS – Wide (>120ms); rSR’ morphology V1-V3: RBBB.
  • QT – 360ms (QTc Bazett 430ms)

Waves and Segments:

  • P waves: left atrial abnormality (negative component>positive component)
  • Q waves DII-DIII-aVF: >0.04ms and Q>R
  • S wave in DI
  • ST depression V1-3 and DI-aVL
  • T waves: negative V1-V3, DIII, aVR
  • SIQIIITIII (McGinn-White): S wave in DI, Q waves DIII, negative T waves in DIII

DIFFERENTIAL DIAGNOSIS

The ECG changes described may be seen with any cause of acute or chronic disease that causes right ventricular strain:

AcuteChronic
Severe pneumonia
Exacerbation of COPD /asthma
Pneumothorax
Recent pneumonectomy
Upper airway obstruction
Pulmonary Embolism  
Chronic obstructive pulmonary disease
Recurrent small PEs
Cystic fibrosis
Interstitial lung disease
Severe kyphoscoliosis
Obstructive sleep apnoea
Pulmonary Ipertension

OUTCOME

There were no focal changes in lung parenchyma on chest radiographs.

The patient was allergic to iodinated contrast media (anaphylactic shock): A pulmonary scintigraphy was then performed in the suspicion of pulmonary embolism.

IMG. 1-4: Pulmonary scintigraphy

Ventilation images document areas of impaired ventilation in the posterior basal area of the left lung; Perfusion images document perfusion deficit in the posterior basal segment.

Conclusion: compatible with pulmonary embolism.

The patient was treated with Apixaban and discharged after a few days.

TRICKS

ECG changes associated with acute pulmonary embolism are nonspecific and may be seen in other condition [1-5]. The ECG in Pulmonary Embolism (PE) lacks sensitivity and specificity: it is neither sensitive nor specific enough to diagnose or exclude PE.

ECG changes in PE are related to dilation of the right atrium and right ventricle, right ventricular ischaemia, heart rotation and position shift, increased sympathetic tone due to pain, anxiety and hypoxia.

The most common findings are sinus tachycardia (44%) and nonspecific ST-segment and T-wave changes (50 %). The most specific finding is simultaneous T wave inversions in the inferior (II, III, aVF) and right precordial leads (V1-4), representing high pulmonary artery pressures; T wave inversion in lead V1 plus lead III was only seen in 1% of ACS patients versus 88% of patients with PE. 

Other ECG changes in pulmonary embolism include:

  • Complete or incomplete RBBB (18%)
  • Right ventricular strain pattern –  T wave V1-4 ± II, III, aVF
  • Right axis deviation – (16%)
  • Dominant R wave in V1 representing acute right ventricular dilatation.
  • Right atrial enlargement  – P wave in lead II > 2.5 mm (9%)
  • SIQIIITIII –neither sensitive nor specific. Abnormalities historically considered to be suggestive of PE (S1Q3T3 pattern, right ventricular strain, new incomplete right bundle branch block) are uncommon (less than 10 percent) [6-7].
  • Clockwise rotation
  • Atrial tachyarrhythmias – AF, flutter, atrial tachycardia (8%)

Normal ECG is present in 9-26% of cases.

ECG abnormalities that are associated with a poor prognosis [1,2,4]:

●Atrial arrhythmias

● Right heart strain + RBBB

●Bradycardia (<50 beats per minute) or tachycardia (>100 beats per minute)

●Complete right bundle branch block

●Inferior Q-waves (leads II, III, and aVF)

●Anterior ST-segment changes and T-wave inversion (V1-V3)

●SIQIIITIII


AUTHORS

Dr. Lorenzo Pelagatti

Emergency Department – Nuovo Ospedale di Prato S. Stefano – Prato, Tuscany, Italy

High Dependency Unit – AOU Careggi – Florence, Tuscany, Italy


Dr. Franco Lai

Emergency Department – Nuovo Ospedale di Prato S. Stefano – Prato, Tuscany, Italy

REFERENCES

  1. Geibel A, Zehender M, Kasper W, Olschewski M, Klima C, Konstantinides SV. Prognostic value of the ECG on admission in patients with acute major pulmonary embolism. Eur Respir J. 2005 May;25(5):843-8. doi: 10.1183/09031936.05.00119704. PMID: 15863641.
  2. Ferrari E, Imbert A, Chevalier T, Mihoubi A, Morand P, Baudouy M. The ECG in pulmonary embolism. Predictive value of negative T waves in precordial leads–80 case reports. Chest. 1997 Mar;111(3):537-43. doi: 10.1378/chest.111.3.537. PMID: 9118684.
  3. Rodger M, Makropoulos D, Turek M, Quevillon J, Raymond F, Rasuli P, Wells PS. Diagnostic value of the electrocardiogram in suspected pulmonary embolism. Am J Cardiol. 2000 Oct 1;86(7):807-9, A10. doi: 10.1016/s0002-9149(00)01090-0. PMID: 11018210.
  4. Shopp JD, Stewart LK, Emmett TW, Kline JA. Findings From 12-lead Electrocardiography That Predict Circulatory Shock From Pulmonary Embolism: Systematic Review and Meta-analysis. Acad Emerg Med. 2015 Oct;22(10):1127-37. doi: 10.1111/acem.12769. Epub 2015 Sep 22. PMID: 26394330; PMCID: PMC5306533.
  5. Co I, Eilbert W, Chiganos T. New Electrocardiographic Changes in Patients Diagnosed with Pulmonary Embolism. J Emerg Med. 2017 Mar;52(3):280-285. doi: 10.1016/j.jemermed.2016.09.009. Epub 2016 Oct 11. PMID: 27742402.
  6. Panos RJ, Barish RA, Whye DW Jr, Groleau G. The electrocardiographic manifestations of pulmonary embolism. J Emerg Med. 1988 Jul-Aug;6(4):301-7. doi: 10.1016/0736-4679(88)90367-8. PMID: 3225435.
  7. Thames MD, Alpert JS, Dalen JE. Syncope in patients with pulmonary embolism. JAMA. 1977 Dec 5;238(23):2509-11. PMID: 578884

SITOGRAPHY

  1. Dr Smith’s ECG Blog
  2. https://litfl.com 

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

Il ruolo del medico e dell’infermiere di PS nella rete di donazione/trapianto

A cura della Dott.ssa Sara Bagatti, Coordinatrice locale alla donazione di organie tessuti del Nuovo Ospedale Santo Stefano di Prato e dell’Azienda Ospedaliero Universitaria Careggi, nonchè coordinatrice dell’Area Vasta Toscana Centro, un interessante panoramica e disamina sul ruolo medico ed infermieristico nella rete di donazione e trapianto in Dipartimento di Emergenza- Urgenza.

Un Grazie alla Dott.ssa Sara Bagatti.

Grazie e Buona visione!

Reversal therapy for anticoagulant and antiplatelet-associated life-threatening and major bleeding

  1. Introduction
  2. Warfarin
  3. UFH and LMWH
  4. Fondaparinux
  5. Dabigatran
  6. Rivaroxaban, Edoxaban and Apixaban
  7. Antiplatelet drugs
  1. INTRODUCTION

Bleeding is the most common complication of antiaggregants and anticoagulants. The rate of major bleeding among users of vitamin K antagonists (VKAs) is 1.5% to 5.2% per year; low-molecular-weight heparin (LMWH) and intravenous unfractionated heparin (UFH) are associated with about 2% and 5.5% respectively of major bleeding complications [1-2]. Bleeding complications range from about 2% to 3% with direct oral anticoagulants (DOACs) [3].

Major bleeding is defined as:

  • bleeding causing haemodynamic instability
  • symptomatic bleeding in a critical organ: intracranial, intraspinal, intraocular, retroperitoneal, intraarticular or pericardial, or intramuscular (if causing compartment syndrome)
  • bleeding causing a fall in hemoglobin > 2 g/dL or more
  • bleeding leading to transfusion of ≥ 2 UI of packed red blood cells
  • resulting in death

according to the ISTH criteria [4].

DRUGMONITORINGREVERSAL
WarfarinPT/INRVitamin K
PCC
FFP
UFHApttProtamine
LMWHanti-factor Xa levelProtamine
Fondaparinuxanti-factor Xa levelNo specific antidote
PCC
rFVIIa
Andexanet alfa
Aripazine
Dabigatran (Pradaxa)ECT, Hemoclot® thrombin inhibitor assay, PT, aPTT.Idracizumab
Ciraparantag/ aripazine/PER977*
Rivaroxaban (Xarelto)
Apixaban (Eliquis)
Edoaxaban (Lixiana)
anti-factor Xa levelAndexanet alfa
Ciraparantag/ aripazine/PER977*
PCCFVIIa
TAB. 1: Anticoagulant, Monitoring, Reversal. *Aripazine is still in clinical trials.

In patients with hypofibrinogenemia, cryoprecipitate may be used to keep fibrinogen levels above 100 to 150 mg/dL depending on the severity of bleeding.

For all patients with major bleeding administration of an antifibrinolytic agent like tranexamic acid or epsilon-aminocaproic acid is suggested.

2. WARFARIN

Warfarin and other Coumarin derivatives act by inhibiting the synthesis of vitamin K dependent clotting factors, which include Factors II, VII, IX and X (FIG. 1), and the anticoagulant proteins C and S: The reverting agents act by restoring the synthesis of vitamin K dependent clotting factors or by providing vitamin K dependent clotting factors.

FIG. 1: Warfarin: Mechanism of Action
SETTINGASH Guideline – 2018ACCP Guideline – 2012
Life-threatening bleeding
Any INR
4-factor PCC
Vitamin K (intravenous)
Hold warfarin
4-factor PCC
Vitamin K (intravenous)
Hold warfarin
No bleeding
INR >10
(No recommendations given)Vitamin K (oral)
Hold warfarin
No bleeding
INR 4.5 to 10
Hold warfarin
No vitamin K
Hold warfarin
Vitamin K (low dose, oral) is optional
TAB. 2 –  ASH Guideline (2018) and ACCP Guideline (2012) recommendations [5,6]
ProductTime to EffectDuration of EffectEvidence of Efficacy for Warfarin RevesalRisk of Thrombosis
Oral vitamin K24 hDays++++NS
Intravenous vitamin K8–12 hDays++++NS
Fresh frozen plasmaImmediate12–24 h++NS
PCCImmediate12–24 h++++ (Higher with activated PCC)
Recombinant factor VIIaImmediate2–6 h+++
TAB. 3: Reverse agents: Time to effect, Duration, Risk of thrombosis

Vitamin K is indicated for warfarin reversal if (TAB. 2):

  • INR of >10 or 4.5 to 10 in the presence of other risk factors for bleeding. 
  • INR is >10, NO active bleeding or minor bleeding (Vitamin K alone)
  • In case of persistent INR elevation: Vitamin K administration can be repeated every 12 h

Fresh frozen plasma (FFP) or prothrombin complex concentrate (PCC) may be necessary in bleeding patients:

  • In cases of major bleeding: PCC or FFP are given to reverse the immediate action of warfarin
  • vitamin K is given to maintain the reversal effect against warfarin as the half-life for warfarin is 72 hours

Patients should repeat coagulation profile to ensure warfarin reversal. 3 – 5 units of FFP (10-15 mL/kg IV) are necessary to increase plasma coagulation factors by ∼15% to 25% [7].

PCC provides 3 (II,IX,X; does not contain factor VII) or 4 coagulation factors (Factors II, VII, IX, and X), depending on the preparation: 

  • is preferred to FFP in cases of major bleeding [8]
  • In a clinical trial that randomly assigned 216 patients with warfarin-associated bleeding to receive PCC or FFP with intravenous vitamin K, PCC was found to be at least as effective as FFP with similar hemostasis (72% vs 65%) and similar length of hospital stay (median 4.5 vs 4.2 days).
  • The dose of PCC varies depending on INR, ranging from 25 to 50 units/kg. Higher dose: 5000 UI. If rFVIIa is used to supplement 3-factor PCC, a lower dose is preferred (20 mcg/kg)
  • Recombinant-activated factor VIIa (rFVIIa) is used off-label for warfarin reversal: it corrects INR but not fully restore hemostasis [9].

Two case series have reported thromboembolism rates ≥10% with rFVIIa [10,11]; a randomized trial compared two doses of rFVIIa (80 and 20 mcg/kg) with placebo: thromboembolic events were similar in the three groups, but severe events were more common in those who received high-dose rFVIIa [12].

1. 4-factor PCC (4F PCC) is the preferred approach:
1. Give 4F PCC 1500 to 2000 Units IV over 10 min. Check INR 15 minutes after completion of the infusion. If INR is not ≤1.5, give additional 4F PCC.[Body weight-based and INR-based dosing: 25 UI/kg for INR 2 – 4; 35 UI/kg for INR 4 – 6; 50 UI/kg for INR >6 (maximum: 5000 UI)]
2. + vitamin K 10 mg IV (in 10 – 20 min).
2. If 4F PCC is not available: 3-factor PCC (3F PCC)
1. Give 3F PCC 1500 to 2000 units IV over 10 minutes. Check INR 15 minutes after completion of the infusion. If INR is not ≤1.5, give additional 3F PCC.
2. + Factor VIIa 20 mcg/kg IV OR  FFP 2 units IV.
3. + vitamin K 10 mg IV (in 10 – 20 min).
3. If neither is available: FFP.
1. 2 units IV by rapid infusion Check INR 15 minutes after completion of infusion:- If INR ≥1.5:  2 additional units of FFP IV rapid infusion. Repeat process until INR ≤1.5.
2. + vitamin K 10 mg IV (in 10 – 20 min)
TAB. 4: Reversal therapy in patients  receiving vitamin K antagonists

3. UFH AND LMWH

Heparin binds reversibly to ATIII and leads to instantaneous inactivation of factors IIa and Xa. The heparin-ATIII complex can also inactivate factors IX, XI, XII and plasmin.  The mechanism of action of heparin is ATIII-dependent. It acts mainly by accelerating the rate of the neutralization of certain activated coagulation factors by antithrombin. The antithrombotic effect of heparin is correlated to the inhibition of factor Xa (FIG. 2).

FIG. 2: Unfractionated heparin (UFH) and Low molecular weight heparins (LMWH): Mechanism of action

First: Discontinue heparin.  

Protamine sulfate is a reversal agent that completely reverses UFH:

  • 1 mg of protamine sulfate neutralizes 100 units of heparin (eg 4000 UI : 40 mg of Protamine)
  • The number of heparin units to be corrected depends on the heparin units administered and the time since the last administration (Heparin half-life: 1-2 h): if 4000 units was given 2 h ago, the number of units would be 2000 and the dose of protamine would be 20 mg).
  • Alternatively a fixed dose of 50 mg or 25 mg may be given: someone give 50 mg while others give 25 mg followed by 25 mg if needed (eg, persistently prolonged aPTT).
  • Protamine must be given by slow intravenous infusion (infusion rate < 20 mg/min or 50 mg/10-minute), because rapid infusion cause hypotension, particularly at high doses. Other related adverse effect are: cardiovascular collapse, noncardiogenic pulmonary edema, catastrophic pulmonary vasoconstriction, and pulmonary hypertension.
  • In case of persistently high aPTT levels repeat doses may be given
  • Protamine is derived from fish sperm and may elicit an allergic reaction, especially in previously exposed.

Protamine sulfate completely reverses the action of UFH but not of LMWH. A potential reversal agent for LMWH, aripazine is under development:

  • Andexanet is preferred rather than protamine: efficacy was demonstrated in the ANNEXA-4 study where a small group of 16 people received LMWH [13].
  • Protamine is less effective in reversing the effect of LMW heparin: Protamine only reverses ∼ 60 %  due to decreased binding to the shorter heparin chains. (is a reasonable treatment option if LMWH have been administrated within the previous 12 hours):
    • LMWH administered < 8 h: 1 mg protamine per 1 mg of enoxaparin.
    • LMWH administered ≥ 8 h, or if it has been deemed that a second dose of protamine is necessary: 0.5 mg protamine per 1 mg of enoxaparin.

4. FONDAPARINUX

Fondaparinux is a synthetic heparin pentasaccharide with a sequence identical to that found in heparin which acts by binding to antithrombin and inducing a conformational change that causes inhibition of factor Xa (half-life: 17-21 h).

FIG. 3: Fondaparinux: Mechanism of action
  • Protamine sulfate is ineffective for fondaparinux reversal.
  • Andexanet is a reasonable option if it is available: It is a catalytically inactive form of factor Xa able to bind and sequester direct factor Xa inhibitors and is likely to be effective also for reversing indirect-acting factor Xa inhibitors like fondaparinux. [14,15].
  • aPCC and rFVIIa may provide reversal against fondaparinux activity: clinical data are limited to in vitro studies rather than management of patients with bleeding [16,17]; aPCC better normalize thrombin generation time than rFVIIa. The high thrombotic risk of these agents should always be kept in mind and weighed against the bleeding risk.

5. DABIGATRAN

Dabigatran reversibly binds to the active site on the Factor II (Thrombin), preventing thrombin-mediated activation of coagulation factors. 

FIG. 4: Dabigatran: mechanism of action [18]

Dabigatran has an emergency reversal agent: Idarucizumab. It is an anti-dabigatran monoclonal antibody fragment. Other options, If Idarucizumab is not available, are PCC and FFP. 

If idarucizumab if available this is the drug of choice, rather than clotting factor products (aPCC, PCC, or plasma).

Unabsorbed dabigatran can be removed from the gastrointestinal tract using oral activated charcoal if the last dose was within 2 h. Dabigatran can also be removed by hemodialysis.

Idarucizumab:

  • The dose is 5 g, administered either as two consecutive infusions (2.5 g + 2.5 g) or as a bolus. Repeat dosing may be appropriate in selected cases as overdose or persistently prologed aPTT.
  • Use idarucizumab alone: Do not combine with PCC, aPCC, or rFVIIa.
  • Thrombosis were more common with idarucizumab: These are associated with due to the patient’s underlying thrombotic risk factors.

Other:

  • Activated PCC: dose of 50 to 80 units/kg. The aFVII activates the free factor X and may bypass dabigatran effect and promote clotting.
  • Alternatively, 4-factor or 3-factor PCC at a dose of 50 units/kg would be reasonable. Three-factor PCC may be supplemented with rFVIIa or plasma. 
  • Activated charcoal and dialysis

6. RIVAROXABAN, EDOXABAN and APIXABAN

Apixaban, Edoxaban and Rivaroxaban are direct inhibitor of free and clot-bound factor Xa.

FIG. 5: Apixaban, Edoxaban, Rivaroxaban: mechanism of action.

For patients with major bleeding and anticoagulation with a factor Xa inhibitor, andexanet alfa or 4F  PCC are indicated. These agents have not been directly compared in a randomized trial. 

  • Discontinue factor Xa inhibitor
ANDEXANETIn patients who received a lower dose of factor Xa inhibitor (rivaroxaban ≤10 mg, apixaban ≤5 mg, edoxaban ≤30 mg) or ≥ 8 h since the last dose of factor Xa inhibitor: bolus of 400 mg at 30 mg/min over 30 minutes, followed by an infusion of 480 mg given at 4 mg/min for up to 120 minutes.
For those who receives a higher dose of factor Xa inhibitor, unknown dose or <8 h:  bolus of 800 mg at 30 mg/min over 30 minutes, followed by an infusion at 960 mg given at 8 mg/min for up to 120 minutes
Do not combine andexanet with PCC, aPCC or rFVIIa.
4F PCC50 units/kg, or a fixed-dose regimen (2000 – 2500 units) 

Unabsorbed anticoagulant can be removed from the gastrointestinal tract using oral activated charcoal.

7. ANTIPLATELET  DRUGS

The AABB (American Association of Blood Banks) developed this guidelines on appropriate use of platelet transfusion in adult patients:

Recommendation 1The AABB recommends that platelets should be transfused prophylactically to reduce the risk for spontaneous bleeding in hospitalized adult patients with therapyinduced hypoproliferative thrombocytopenia. The AABB recommends transfusing hospitalized adult patients with a platelet count of 10 × 10^9 cells/L or less to reduce the risk for spontaneous bleeding. The AABB recommends transfusing up to a single apheresis unit or equivalent. Greater doses are not more effective, and lower doses equal to one half of a standard apheresis unit are equally effective. (Grade: strong recommendation; moderate-quality evidence)
Recommendation 2The AABB suggests prophylactic platelet transfusion for patients having elective central venous catheter placement with a platelet count less than 20 × 10^9 cells/L. (Grade: weak recommendation; low-quality evidence)
Recommendation 3The AABB suggests prophylactic platelet transfusion for patients having elective diagnostic lumbar puncture with a platelet count less than 50 × 10^9 cells/L. (Grade: weak recommendation; very-low-quality evidence)
Recommendation 4The AABB suggests prophylactic platelet transfusion for patients having major elective nonneuraxial surgery with a platelet count less than 50 × 10^9 cells/L. (Grade: weak recommendation; very-low-quality evidence)
Recommendation 5The AABB recommends against routine prophylactic platelet transfusion for patients who are nonthrombocytopenic and have cardiac surgery with cardiopulmonary bypass. The AABB suggests platelet transfusion for patients having bypass who exhibit perioperative bleeding with thrombocytopenia and/or evidence of platelet dysfunction. (Grade: weak recommendation; very-low-quality evidence)
Recommendation 6The AABB cannot recommend for or against platelet transfusion for patients receiving antiplatelet therapy who have intracranial hemorrhage (traumatic or spontaneous). (Grade: uncertain recommendation; very-low-quality evidence)
TAB 5: Platelet Transfusion: A Clinical Practice Guideline From the AABB [19].

Due to the low level of evidence it was not possible to establish clear guidelines regarding the transfusion of platelets during therapy with antiplatelet agents.

DEVELOPMENT OF REVERSAL AGENTS FOR ANTIPLATELET THERAPY IS AN AREA OF UNMET NEED

Platelet transfusion:

  • Platelets should be transfused in patients with a low platelet count (less than 50,000/microL) who are receiving antiplatelet agents (APT).
  • In patients with intracerebral hemorrhage (ICH) who are receiving antiplatelet agents, the decision to transfuse platelets is based on:  size of the bleeding, patient’s level of consciousness and clinical factors. For neurosurgery, platelets are transfused prophylactically for a preprocedure platelet count less than 80 – 100 × 10^9 cells/L (low-quality data supporting this threshold) >>> Patients with ICH taking antiplatelet therapy should be transfused platelets only if planned for neurosurgical intervention but not if receiving medical management [20].
  • Patients with upper gastrointestinal haemorrhage on APT do not benefit from platelet transfusions. They benefit from urgent endoscopic control of bleeding and proton pump inhibition only [20].
  • The optimal dose of platelets and the timing of transfusion in patients on antiplatelet therapy are currently unknown; however, it must be borne in mind that:
    • Clopidogrel or prasugrel: wait at least 6 -8 hours after the last dose. 
    • Ticagrelor: consider transfusion especially if the last dose was >24 hours prior.
    • Aspirin half life: 20 min
  • Platelets should not be transfused in patients with normal platelet counts who are on antiplatelet medications [21]. 
  • Platelet and plasma transfusions should be considered in patients who receive massive RBC transfusions (>3 units of packed RBCs within one hour).
  • Consider the use of pre-operative intravenous tranexamic acid which proved  to improve the platelet function of those exposed to APT, resulting in a reduction in bleeding and transfusion.
  • rFVIIa may limit bleeding (Off -label): it acts by reversing the effects of APT on thrombin generation [22].  The increase the risk of arterial thromboembolic events is a major side effect:   rFVIIa should be considered only as a last source. 
  • Desmopressin may be a useful agent to reduce bleeding and transfusion requirements for people with platelet dysfunction or with a history of recent antiplatelet drug administration (GRADE quality of evidence: very low to moderate) [23].

AUTHORS

Dr. Lorenzo Pelagatti

Emergency Department – Nuovo Ospedale di Prato S. Stefano – Prato, Tuscany, Italy

High Dependency Unit – AOU Careggi – Florence, Tuscany, Italy


Dr. Franco Lai

Emergency Department – Nuovo Ospedale di Prato S. Stefano – Prato, Tuscany, Italy

REFERENCES

  1. Dhakal P, Rayamajhi S, Verma V, Gundabolu K, Bhatt VR. Reversal of Anticoagulation and Management of Bleeding in Patients on Anticoagulants. Clin Appl Thromb Hemost. 2017 Jul;23(5):410-415. doi: 10.1177/1076029616675970. Epub 2016 Oct 26. PMID: 27789605.
  2. Chai-Adisaksopha, C, Crowther, M, Isayama, T, Lim, W. The impact of bleeding complications in patients receiving target-specific oral anticoagulants: a systematic review and meta-analysis. Blood. 2014;124(15):2450–2458.
  3. Juergens, CP, Semsarian, C, Keech, AC, Beller, EM, Harris, PJ. Hemorrhagic complications of intravenous heparin use. Am J cardiol. 1997;80(2):150–154.
  4. Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM, Hanna M, Al-Khalidi HR, Ansell J, Atar D, Avezum A, Bahit MC, Diaz R, Easton JD, Ezekowitz JA, Flaker G, Garcia D, Geraldes M, Gersh BJ, Golitsyn S, Goto S, Hermosillo AG, Hohnloser SH, Horowitz J, Mohan P, Jansky P, Lewis BS, Lopez-Sendon JL, Pais P, Parkhomenko A, Verheugt FW, Zhu J, Wallentin L; ARISTOTLE Committees and Investigators. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011 Sep 15;365(11):981-92. doi: 10.1056/NEJMoa1107039. Epub 2011 Aug 27. PMID: 21870978.
  5. Witt DM, Nieuwlaat R, Clark NP, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: Optimal management of anticoagulation therapy. Blood Adv 2018; 2:3257.
  6. ​Holbrook A, Schulman S, Witt DM, et al. Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e152S.
  7. Ansell, J, Hirsh, J, Hylek, E, Jacobson, A, Crowther, M, Palareti, G; American College of Chest Physicians . Pharmacology and Management of the Vitamin K Antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(suppl 6):160S–198S.
  8. Huttner, HB, Schellinger, PD, Hartmann, M. Hematoma growth and outcome in treated neurocritical care patients with intracerebral hemorrhage related to oral anticoagulant therapy: comparison of acute treatment strategies using vitamin K, fresh frozen plasma, and prothrombin complex concentrates. Stroke. 2006;37(6):1465–1470.
  9. Garcia, DA, Crowther, MA. Reversal of warfarin: case-based practice recommendations. Circulation. 2012;125(23):2944–2947
  10. Diringer MN, Skolnick BE, Mayer SA, Steiner T, Davis SM, Brun NC, Broderick JP. Thromboembolic events with recombinant activated factor VII in spontaneous intracerebral hemorrhage: results from the Factor Seven for Acute Hemorrhagic Stroke (FAST) Trial. Stroke. 2010; 41:48–53.
  11. Robinson MT, Rabinstein AA, Meschia JF, Freeman WD. Safety of recombinant activated factor VII in patients with warfarin-associated hemorrhages of the central nervous system. Stroke. 2010; 41:1459–1463.
  12. Mayer SA, Brun NC, Begtrup K, Broderick J, Davis S, Diringer MN, Skolnick BE, Steiner T; FAST Trial Investigators. Efficacy and safety of recombinant activated factor VII for acute intracerebral hemorrhage. N Engl J Med. 2008 May 15;358(20):2127-37. doi: 10.1056/NEJMoa0707534. PMID: 18480205.
  13. Connolly SJ, Crowther M, Eikelboom JW, Gibson CM, Curnutte JT, Lawrence JH, Yue P, Bronson MD, Lu G, Conley PB, Verhamme P, Schmidt J, Middeldorp S, Cohen AT, Beyer-Westendorf J, Albaladejo P, Lopez-Sendon J, Demchuk AM, Pallin DJ, Concha M, Goodman S, Leeds J, Souza S, Siegal DM, Zotova E, Meeks B, Ahmad S, Nakamya J, Milling TJ Jr; ANNEXA-4 Investigators. Full Study Report of Andexanet Alfa for Bleeding Associated with Factor Xa Inhibitors. N Engl J Med. 2019 Apr 4;380(14):1326-1335. doi: 10.1056/NEJMoa1814051. Epub 2019 Feb 7. PMID: 30730782; PMCID: PMC6699827.
  14. Connolly SJ, Crowther M, Eikelboom JW, Gibson CM, Curnutte JT, Lawrence JH, Yue P, Bronson MD, Lu G, Conley PB, Verhamme P, Schmidt J, Middeldorp S, Cohen AT, Beyer-Westendorf J, Albaladejo P, Lopez-Sendon J, Demchuk AM, Pallin DJ, Concha M, Goodman S, Leeds J, Souza S, Siegal DM, Zotova E, Meeks B, Ahmad S, Nakamya J, Milling TJ Jr; ANNEXA-4 Investigators. Full Study Report of Andexanet Alfa for Bleeding Associated with Factor Xa Inhibitors. N Engl J Med. 2019 Apr 4;380(14):1326-1335. doi: 10.1056/NEJMoa1814051. Epub 2019 Feb 7. PMID: 30730782; PMCID: PMC6699827.
  15. Lu G, DeGuzman FR, Hollenbach SJ, Karbarz MJ, Abe K, Lee G, Luan P, Hutchaleelaha A, Inagaki M, Conley PB, Phillips DR, Sinha U. A specific antidote for reversal of anticoagulation by direct and indirect inhibitors of coagulation factor Xa. Nat Med. 2013 Apr;19(4):446-51. doi: 10.1038/nm.3102. Epub 2013 Mar 3. PMID: 23455714.
  16. Desmurs-Clavel H, Huchon C, Chatard B, Negrier C, Dargaud Y. Reversal of the inhibitory effect of fondaparinux on thrombin generation by rFVIIa, aPCC and PCC. Thromb Res. 2009 Mar;123(5):796-8. doi: 10.1016/j.thromres.2008.07.007. Epub 2008 Sep 3. PMID: 18771795.
  17. Frontera JA, Lewin JJ 3rd, Rabinstein AA, Aisiku IP, Alexandrov AW, Cook AM, del Zoppo GJ, Kumar MA, Peerschke EI, Stiefel MF, Teitelbaum JS, Wartenberg KE, Zerfoss CL. Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage: A Statement for Healthcare Professionals from the Neurocritical Care Society and Society of Critical Care Medicine. Neurocrit Care. 2016 Feb;24(1):6-46. doi: 10.1007/s12028-015-0222-x. PMID: 26714677.
  18. G. Gómez-Moreno, A. Aguilar-Salvatierra, M. Ángel Martín-Piedra, J. Guardia, J. L. Calvo-Guirado, M. Cabrera, C. López-Gallardo, T. Castillo. Dabigatran and rivaroxaban, new oral anticoagulants. new approaches in dentistry. J Clin Exp Dent. 2010;2(1):e1-5. doi:10.4317/jced.2.e1.
  19. Kaufman RM, Djulbegovic B, Gernsheimer T, Kleinman S, Tinmouth AT, Capocelli KE, Cipolle MD, Cohn CS, Fung MK, Grossman BJ, Mintz PD, O’Malley BA, Sesok-Pizzini DA, Shander A, Stack GE, Webert KE, Weinstein R, Welch BG, Whitman GJ, Wong EC, Tobian AA; AABB. Platelet transfusion: a clinical practice guideline from the AABB. Ann Intern Med. 2015 Feb 3;162(3):205-13. doi: 10.7326/M14-1589. PMID: 25383671.
  20. Swan D, Loughran N, Makris M, Thachil J. Management of bleeding and procedures in patients on antiplatelet therapy. Blood Rev. 2020 Jan;39:100619. doi: 10.1016/j.blre.2019.100619. Epub 2019 Oct 15. PMID: 31648803.
  21. Zakko L, Rustagi T, Douglas M, Laine L. No Benefit From Platelet Transfusion for Gastrointestinal Bleeding in Patients Taking Antiplatelet Agents. Clin Gastroenterol Hepatol. 2017 Jan;15(1):46-52. doi: 10.1016/j.cgh.2016.07.017. Epub 2016 Jul 25. PMID: 27464591
  22. Altman R, Scazziota A, M DELH, Gonzalez C. Recombinant factor VIIa reverses the inhibitory effect of aspirin or aspirin plus clopidogrel on in vitro thrombin generation. J Thromb Haemost. 2006;4(9):2022 -7
  23. Desborough MJ, Oakland KA, Landoni G, Crivellari M, Doree C, Estcourt LJ, Stanworth SJ. Desmopressin for treatment of platelet dysfunction and reversal of antiplatelet agents: a systematic review and meta-analysis of randomized controlled trials. J Thromb Haemost. 2017 Feb;15(2):263-272. doi: 10.1111/jth.13576. Epub 2017 Feb 8. PMID: 27893176.

SITOGRAPHY

  1. https://go.drugbank.com/
  2. https://pixabay.com/
  3. https://www.uptodate.com/

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

ECG Case n°1

A 75-year-old man is brought in Emergency Department by ambulance complaining of breathlessness and dyspnoea.

Medical History: Former smoker, COPD.

BP 133/77 mmHg, SpO2 96% room air, RR 22/min, GCS 15.

HR is fixed at 215 bpm. Is this SVT? ANRT? AVNRT? Atrial flutter? 

ECG. 1A-B

ABG room air: pH 7.391, pO2 95.4, pCO2 41.3, Hb 15.8 g/dL, K+ 5.3, Na+ 135, Ca2+ 1.14, Lac 2.2, Glu 152, HCO3- 25.

ECG ANSWER and INTERPRETATION

Rate:

  • 215

Rhythm:

  • Regular without P waves

Axis:

  • +90°

Intervals:

  • PR – No visible P waves
  • QRS – Normal (<120ms)
  • QT – 280ms (QTc Bazett 440ms)

Segments:

  • ST depression V3-6 and DIII-aVF

DIFFERENTIAL DIAGNOSIS

AVNRT– Regular 
– Rate ~140-280 bpm
– QRS complexes have a morphology that is usual for the subject under examination
– Narrow QRS complexes (< 120 ms) unless there is co-existing bundle branch block, accessory pathway, or rate-related aberrant conduction
– P waves if visible exhibit retrograde conduction with P-wave inversion.
– P waves if visible exhibit retrograde conduction with P-wave inversion in leads II, III, aVF. They may be buried within (more frequently), visible after, or very rarely visible before the QRS complex
– The atrial and ventricular rates are the same
– ST-segment depression may be observed
AVRT– Regular
– Rate 200-300 bpm
– QRS complexes have a morphology that is usual for the subject under examination
– Narrow QRS complexes (< 120 ms) unless there is co-existing bundle branch block, accessory pathway, or rate-related aberrant conduction
– P waves if visible exhibit retrograde conduction with P-wave inversion.
– Retrograde P waves are usually visible, with a long RP interval (P-QRS > QRS-P)QRS < 120ms unless pre-existing bundle branch block, or rate-related aberrant conduction
– The atrial and ventricular rates are the same
– ST-segment depression may be observed
Atrial Flutter– Narrow complex tachycardia
– Regular atrial activity at ~250-300 bpm (more frequently ~300 bpm)
– “Saw-tooth” pattern of P waves (typically in II, III, aVF, V1)
– Upright flutter waves in V1 that may resemble P waves
– Ventricular rate depends on AV conduction ratio; QRS rate is a fraction of the atrial rate (1/2 = 150 bpm; 1/3 = 100 bpm: 1/4 = 75 bpm)

OUTCOME

Flutter waves are not clearly seen (flutter with a 1:1 block?); Alternatively, this may just be rapid SVT (AVNRT/AVRT).

Given doubt regarding the rhythm, and a fixed heart rate of 220 bpm that is often seen in atrial flutter, we chose to administer adenosine to assist in differentiating/ treating the cause.

6 mg of adenosine was administered without benefit.

Then 12 mg of adenosine was administered.

ECG 2.

Rhythm strip reveals flutter waves. The patient does not cardiovert to sinus rhythm following adenosine administration; instead, the degree of AV block is increased, revealing sawtooth flutter waves.

Verapamil 5 mg 1 fl + Normal Saline 250 ml was administered, with good rate control

ECG 3.

INTERPRETATION:

ECG 1 A-B: Atrial Flutter 1:1 Block

ECG 3: Atrial Flutter 2:1 Block

  • Narrow Complex Tachycardia
  • Ventricular rate 120 bpm
  • Sawtooth flutter waves are seen in the inferior leads II, III, aVF.
  • Upright flutter waves in V1 appear either as pseudo-P waves or as notches in the T wave.
  • There is a clear 2:1 relationship between the flutter waves (300 bpm) and QRS complexes (120 bpm).

TRICKS

IMG. 1: Mechanism and electrocardiographic pattern of typical atrial flutter (left) and reverse typical atrial flutter (right). (1) 
 
Anticlockwise Reentry (typical atrial flutter) (2): (90% of cases of atrial flutter). Retrograde atrial conduction produces:
Inverted flutter waves in leads II,III, aVF
Positive flutter waves in V1 — may resemble upright P waves
 
 Clockwise Reentry (reverse typical atrial flutter) (2): This variant produces the opposite pattern:
Positive flutter waves in leads II, III, aVF (ECG. 1A-B,2,3)

AUTHORS

Dr. Lorenzo Pelagatti

Emergency Department – Nuovo Ospedale di Prato S. Stefano – Prato, Tuscany, Italy

High Dependency Unit – AOU Careggi – Florence, Tuscany, Italy


Dr. Franco Lai

Emergency Department – Nuovo Ospedale di Prato S. Stefano – Prato, Tuscany, Italy

REFERENCES

  1. F. García Cosío, A. Pastor, A. Núñez et al. Atrial Flutter: an Update Rev Esp Cardiol. 2006;59(8):816-31. DOI: 10.1016/S1885-5857(07)60047-4.
  2. Marine et al. Different Patterns of Interatrial Conduction in Clockwise and Counterclockwise Atrial Flutter. Circulation. 2001;104:1153–1157
  3. Jabbour F, Grossman SA. Atrioventricular Reciprocating Tachycardia. 2021 Aug 29. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 30969587.

SITOGRAPHY

  1. Dr Smith’s ECG Blog – Atrial Flutter
  2. https://litfl.com – Atrial Flutter, SVT, AVRT

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

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