The advent of direct-acting oral anticoagulants (DOACs) has transformed the care of patients requiring prevention and treatment for thrombotic disease. Many randomized clinical trials have demonstrated the efficacy and safety of these agents and their comparative advantages over conventional anticoagulants such as vitamin K antagonists (VKAs). While historically clinicians and patients raised questions about the reversal of DOAC-associated bleeding, federal approval in recent years of targeted DOAC reversal agents, along with adjunctive modalities, has given clinicians reliable pharmacologic options. Yet, optimal reversal strategies for bleeding at specific anatomic locations and in specific clinical scenarios remains uncertain. We present here a narrative review of the literature on the reversal of DOAC-associated bleeding or for urgent procedures. The totality of the reversal literature synthesized here yields several clear conclusions: (1) targeted DOAC reversal with specific agents demonstrates superior efficacy for both bleeding and urgent surgical indications when compared to the use of non-specific agents, such as prothrombin complex concentrates (PCCs); (2) at the same time, high-quality data suggest potentially increased thrombotic risks, particularly for ischemic stroke, when using the specific targeted agent andexanet; (3) in all cases of life-threatening bleeding, timely reversal is of the essence; (4) in particular, there is growing consensus that DOAC-associated intracranial hemorrhage (ICH) should be reversed promptly, with a goal door-to-reversal time of 60 min; (5) future research will focus on optimizing clinical pathways for reversal to address “calls to action” from professional groups on this critical topic.

Background: While the role of sex-based differences in acute myocardial infarction-related cardiogenic shock (AMI-CS) is well described, their relevance among patients with non-acute myocardial infarction-related CS (nonAMI-CS) is less well known. Methods: Adult patients treated for cardiogenic shock (CS) between 2016 and 2022 across eleven hospitals within our health system were included. NonAMI-CS etiologies were classified as heart failure or secondary CS (valvular and arrhythmia-triggered). Stratification by sex was used to compare characteristics, management strategies, and outcomes between men and women. Logistic regression models were used to examine the effect of clinical characteristics and management strategies on hospital mortality by sex, along with the effect of sex on different management strategies. Results: Of 2256 patients, women comprised the minority (36%) and also exhibited older age and more comorbidities. Both sexes displayed similar presenting shock stages, according to those established by the Society for Cardiovascular Angiography and Interventions (SCAI). Valvular shock was the only etiology which was more prevalent in women. Women received fewer invasive interventions, including treatment with pulmonary artery catheters (44% vs. 53%; p < 0.01) and mechanical circulatory support devices (15% vs. 22%; p < 0.01). While sex was not independently associated with increased mortality (OR = 1.16, 95% CI = 0.68–1.96), women were more likely to be discharged to skilled nursing facilities (SNF). Conclusions: Although women with nonAMI-CS exhibit a higher risk profile and undergo fewer invasive procedures, their survival rate is comparable to that of men. However, women are more likely to require SNF care upon discharge.

A patient in his 40s with no known cardiac history presented to the emergency department with midsternal chest pain worse on inspiration for the past 1 week. He also complains of recent weight loss...

Early revascularization improves survival in patients with ST-elevation myocardial infarction–related cardiogenic shock (STEMI-CS). However, lower rates of invasive management are seen in states with public reporting of outcomes for percutaneous coronary intervention and coronary artery bypass grafting surgery. The reasons for this remain speculative. We aim to report contemporary treatment patterns and examine the reasons for deferral of invasive management in patients with STEMI-CS in a New York cohort. All patients with STEMI-CS in the Northwell-Shock Registry, a retrospective study of cardiogenic shock across 11 hospitals in New York, treated between January 2016 and August 2022, were included. Clinical variables and outcomes were compared between patients managed invasively and conservatively. Reasons for deferral of invasive management were collected manually from clinical documentation. Multivariable logistic regression was performed to examine the factors associated with a conservative management strategy. Invasive management was performed in 87% of patients, revascularization with percutaneous coronary intervention in 63% and coronary artery bypass grafting surgery in 8%. Hospital mortality was 27% for patients managed invasively and 81% for those managed conservatively. The most cited reasons for deferring invasive management were unclear neurologic status (35%), patient or family preference (29%), and complicating medical conditions (25%). Meanwhile, the factors independently associated with conservative management were older age, higher creatinine, cardiac arrest, and higher Society for Cardiovascular Angiography & Interventions (SCAI) stages. Although rates of invasive management were high in this contemporary cohort of STEMI-CS patients in New York, risk aversion seems to still play a role in the deferral of invasive management in many patients.

The Brugada pattern is associated with a genetic disorder characterized by ST-segment elevation in the right precordial leads on electrocardiogram (EKG) in the absence of structural heart disease. Patients with the Brugada pattern have an increased risk for ventricular tachyarrhythmia and sudden cardiac death. Loss-offunction mutations in the SCN5A gene which encodes the alpha subunit of the cardiac sodium channel have been associated with Brugada syndrome (BrS). We report a case of a patient who was found to have a spontaneous type 1 Brugada pattern on a routine EKG done prior to travel. He underwent electrophysiological testing (EPS) which provoked ventricular tachycardia and underwent implantable cardioverter defibrillator (ICD) placement. His family history revealed a history of sudden cardiac death, abnormal EKG, syncope, dilated cardiomyopathy, and BrS. Genetic testing revealed a variant of uncertain significance (VUS) in the SCN5A gene in the proband and six of his relatives. The SCN5A VUS in this clinical context and segregation with the disease in his family supports its reclassification to pathogenic.

A female in her 30s with no known past medical conditions presented to North Shore University Hospital with three weeks of intermittent fevers, fatigue, and malaise. She also reports generalized body pain, myalgias, ear pain, throat pain, and joint pain. She denies rash. She also reports nausea, vomiting, and diarrhea and a 10-pound weight loss in one week. She had a miscarriage at 16 weeks of gestation. She met systemic inflammatory syndrome criteria on admission as she was febrile to 102.9 Fahrenheit, tachycardic to 120 beats per minute, tachypneic to 22 breaths/minute, and had leukopenia with white blood cell count of 2,470 per cubic milliliter. Labs were significant for pancytopenia, elevated transaminases, low C3 complement level, double stranded DNA > 1000 IU/mL, anti-nuclear factor positive 1:1280, and positive antiphospholipid serology. She was treated with steroids and hydroxychloroquine and was started on warfarin.